Abstract
Objective To summarize the best available age-appropriate, evidence-based guidelines for prevention and screening in Canadian adults.
Quality of evidence The Canadian Task Force on Preventive Health Care recommendations are the primary source of information, supplemented by relevant US Preventive Services Task Force recommendations when a Canadian task force guideline was unavailable or outdated. Leading national disease-specific or specialty-specific organizations’ guidelines were also reviewed to ensure the most up-to-date evidence was included.
Main message Recommended screening maneuvers by age and sex are presented in a summary table highlighting the quality of evidence supporting these recommendations. An example of a template for use with electronic medical records or paper-based charts is presented.
Conclusion Whether primary care providers use a dedicated preventive health visit or opportunistic preventive counseling and screening in their patient encounters, this summary of evidence-based recommendations can help maximize efficiency and prevent important omissions and unnecessary screening.
Useful charting tools for preventive care have been published in the past1–4 but not all such resources are regularly updated. There is a lack of recent comprehensive guides to facilitate delivery and charting of appropriate evidence-based primary care. Recommendations for screening come from various organizations and are constantly changing, rendering health promotion and disease prevention a daunting task. Currently, navigating the plethora of available information in a search of prevention guidelines is overwhelming. There is a need for regular updates through systematic literature reviews. Piecing together these guidelines into a single summary table for practical use in a busy clinical setting simplifies access to information and allows practitioners to provide preventive care in an efficient, evidence-based manner.
Chronic disease management is an economic burden to the health care system.5 Savings through prevention have been explored by several sources, with emphasis on quality of life and increase in years lived.6,7 The Choosing Wisely movement is publicizing the disadvantages of causing harm with tests that are not evidence based.8 By facilitating opportunities for prevention through easy access to best-practice guidelines, the incidence of chronic disease might decrease, resulting in improved patient-centred care and savings to the health care system.
We performed a review of the literature and created a concise table summarizing the findings, as well as charting tools to aid in documentation. After reading this article, providers will be able to list the evidence-based recommendations for preventive maneuvers in healthy adults of different ages and sexes.
Quality of evidence
A review of the literature from 2009 to 2014 was conducted with the assistance of librarians from the Canadian Library of Family Medicine. The PubMed database was searched for articles, in English or French, indexed with a combination of the following sets of medical subject headings: preventive health services, primary prevention, secondary prevention, osteoporosis, prostatic neoplasms, breast neoplasms, colonic neoplasms, hyperlipidemias, mass screening or screening, and practice guidelines as topic or publication type, or guideline, or similar text words or associated text. We also searched the main national guidelines databases CMA Infobase, the US National Guideline Clearinghouse, and the UK National Institute for Health and Care Excellence guidelines for guidelines with combinations of the first 2 sets of terms cited above. The initial search found 289 articles, and articles not relevant to Canadian, office-based preventive primary care and those related to preventive care of children were excluded. A full review of 69 articles was completed using the methods outlined below. The final selection included 40 articles.
Published guidelines from many sources relevant to adult preventive care are developed using various methods. The quality of evidence supporting the recommendations was assessed by applying the methods used by Rourke et al4 in the development of the Rourke Baby Record, and the approach used by authors of the Preventive Care Checklist Form2,3 in the development of the last aid for the periodic health examination endorsed by the College of Family Physicians of Canada at the time of writing.3
Both of these groups initially used the old Canadian Task Force on Preventive Health Care (CTFPHC) method of grading recommendations in which recommendations with the highest quality of evidence received an A and those with fair evidence received a B. The US Preventive Services Task Force (USPSTF) is also currently using this method.9 The new CTFPHC adopted the GRADE (grading of recommendations, assessment, development, and evaluation) method in 2010,10 making it challenging to present all recommendations in a unified classification system. The GRADE system11 uses the quality of evidence to evaluate the strength of a recommendation, also taking into account factors in line with family medicine principles: the balance between desirable and undesirable effects, patient values and preferences, and resource allocation. In the GRADE system recommendations are either strong or weak.
The only reference found blending these 2 systems was the 2014 update of the Rourke Baby Record.12 For the most part they followed the system outlined below, which we adopted.
A recommendation is classified as good (presented in boldface) if according to the older CTFPHC method there is good evidence to recommend the clinical preventive action or if according to the GRADE system it is a strong recommendation.
A recommendation is classified as fair (italic type) if according to the old CTFPHC method there is fair evidence to recommend the clinical preventive action or if according to the GRADE system it is a weak recommendation.
A recommendation is classified as inconclusive or based on consensus (plain type) if according to the older CTFPHC method the existing evidence is conflicting and does not allow for making a recommendation for or against use of the clinical preventive action (although other factors might influence decision making) or if the recommendation is based on consensus only.
When organizations mentioned using the old CTFPHC or GRADE systems, the methods used were reviewed to see if the process was modified or adapted.
Some sources did not use either of these systems. For these, the methods used were assessed and the recommendations were compared with guidelines from organizations in other countries that target primary care providers, such as the USPSTF or the National Institute for Health and Care Excellence guidelines13 from the United Kingdom. As well, some of these guidelines have been appraised by the CTFPHC.
Main message
Based on the literature review, we created tools for use during routine primary care visits to support the delivery of evidence-based preventive care to the adult population. The tools can function as lists summarizing potential appropriate preventive care as well as charting aids to be integrated into medical charts in electronic format or printed out for paper charts.
Table 1, the 2015 Primrose Preventive Screening Guidelines, is a 2-page summary of all evidence-based prevention recommendations for adults divided by age and sex.14–43 This table is to be used as a quick reference. Three age categories were used to divide the recommendations for asymptomatic patients without risk factors. The maneuvers that differ for women and men are listed in the lower portion of the table under the headings “Women” and “Men.” For the row “Physical Examination,” only elements found in the review that were evidence-based for a healthy patient with no risk factors are listed. Patients’ concerns and other considerations might influence the type of physical examination done. Six charting tools were created to allow for succinct documentation that can be adapted to paper-based or electronic charting systems. Figure 1 offers an example of one of these charting tools; the rest are available from CFPlus.*
Sample charting tool for age-appropriate primary prevention maneuvers for women aged 21 to 49 y*: Recommendations with good evidence are presented in boldface; those with fair evidence are presented in italic text; consensus recommendations are presented in plain text. These recommendations are intended for primary care prevention and screening. Additional testing or physical examination, as required, for pre-existing conditions and presenting complaints might be warranted.
BMI—body mass index; BP—blood pressure; FINDRISC—Finnish Diabetes Risk Score; HbA1c—hemoglobin A1c; HBV—hepatitis B virus; HPV—human papillomavirus; HT—height; MMR—measles-mumps-rubella; STI—sexually transmitted infection; Td—tetanus and diphtheria; Tdap—tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; VDRL—Venereal Disease Research Laboratory; WC—waist circumference; WT—weight.
*Additional templates for other age and sex categories are available from CFPlus.
The 2015 Primrose Preventive Screening Guidelines: Recommendations with good evidence are presented in boldface; those with fair evidence are presented in italic text; consensus recommendations are presented in plain text. These recommendations are intended for primary care prevention and screening. Additional testing or physical examination, as required, for pre-existing conditions and presenting complaints might be warranted.
The literature review identified updates for several common preventive maneuvers since the last 2012 update.3 Key recommendations that have changed recently or are up for debate are highlighted below.
Cervical cancer screening
Guidelines have changed in North America in the past few years.44 Currently there is a discrepancy between the CTFPHC recommendations on cervical cancer screening45 and all provincial guidelines on this topic. The CTFPHC recommends starting at 25 years of age or 3 years after first intercourse, while most provinces recommend starting at 21 years of age. These guidelines are similar in moving away from early screening and increasing the interval between Papanicolaou tests.
Prostate cancer screening
Screening for prostate cancer has been hotly debated since the prostate-specific antigen (PSA) test was developed.46 The 2014 CTFPHC recommendation states that available evidence does not conclusively show that PSA screening will reduce prostate cancer mortality but that it clearly shows an increased risk of harm.47 The task force recommends that the PSA test should not be used to screen for prostate cancer.48 Useful tools to discuss the issue with patients can be found on the CTFPHC website.49,50 The USPSTF recommends against screening with the PSA test.51 Both task forces reviewed the evidence provided by 2 randomized controlled trials that studied PSA screening prospectively.52,53 The reviewers were critiqued by the Canadian Urological Association and the American Urological Association.54,55 Evans’ video on PSA screening56 provides an interesting discussion of the evidence. In a commentary on the CTFPHC guideline in the CMAJ, Krahn suggests the CTFPHC might not have taken patient preferences, social values, and costs to the health care system into account but does conclude there is not enough evidence to recommend population screening with PSA testing.57
Breast cancer screening
Screening with mammography is controversial in the 40- to 49-year-old age group. The CTFPHC and USPSTF recommend against screening in this age group.58,59 The Canadian Association of Radiologists60 and the American College of Obstetricians and Gynecologists recommend it.61 We have opted to follow the organizations with a primary care perspective.58,59 Tools are available on the CTFPHC website to help explain this to patients.62
The CTFPHC also recommends not screening by provider physical examination or promoting breast self-examination in asymptomatic women.58 Information from the CTFPHC website is useful to reassure patients,62,63 underlining that there is no proof of benefit and that potential harms exist, such as but not limited to the removal of healthy breast tissue.
Colon cancer screening
At the time of our review, guidelines had last been published by the CTFPHC in 2001. Updated recommendations were provided from the 2008 USPSTF64 and the 2011 Scottish Intercollegiate Guidelines Network recommendations.65 Currently, cancer screening guidelines related to age, test, and interval of screening vary across Canada34; however, most recommendations suggest using the fecal occult blood test or fecal immunochemical test every 2 years for adults aged 50 to 75.34 The Canadian Association of Gastroenterology’s position paper on colon cancer screening from 2010 provides a review of the evidence.66 It recommends fecal immunochemical testing or fecal occult blood testing every 2 years or flexible sigmoidoscopy every 10 years. Colonoscopy is not recommended because of a current lack of evidence and because of possible harms, as well as a lack of resources in Canada.66 Updated CTFPHC colon cancer screening guidelines are anticipated and will include diet and lifestyle as part of the risk profiling guide.
Dyslipidemia screening
The CTFPHC has not recently reviewed the screening guidelines for dyslipidemia. The C-CHANGE (Canadian Cardiovascular Harmonization of National Guidelines Endeavour) initiative67 is very helpful for primary care providers, as it harmonizes recommendations between 8 specialty organizations. Most of the harmonized guidelines use GRADE or a modified version of GRADE. The C-CHANGE initiative has recently updated their harmonized guidelines for screening for cardiovascular disease and associated risk factors.19 Both C-CHANGE and the Canadian Cardiovascular Society recommend initiating screening of lipid levels at 40 years of age for men and 50 years of age or at the onset menopause for women.19,32 Earlier screening is recommended for high-risk groups such as aboriginal or Southeast Asian patients. Earlier screening is also suggested for anyone with the risk factors listed in Table 1.14–43
Weight management
In 2015, the CTFPHC released their first guidelines for the prevention of weight gain and management of patients who are overweight or obese.27,68 Recommendations include measurement of body mass index (BMI) and offering or referring individuals with BMI greater than 25 kg/m2 to structured behavioural interventions. The strongest recommendation is for those with a BMI between 30 and 40 kg/m2 who are at high risk of diabetes. It is suggested that interventions be longer than 12 months, be patient-centred, and include diet, exercise, and lifestyle modification.
Conclusion
The literature review has allowed us to update published recommendations. Synthesized findings in Table 1 allow easier, more efficient access to evidence-based recommendations.14–43 An important effect on population health might be achieved by capturing missed screening and health promotion opportunities, avoiding unnecessary diagnostic testing, and decreasing apprehension for patients exposed to the uncertainty and potential harm that further testing can cause. Potential exists to decrease the burden of chronic disease for patients and to decrease health care dollars spent.6
It is anticipated that by facilitating access to the current recommendations, delivery of preventive maneuvers will be improved. The USPSTF and CTFPHC websites address the above, but we have expanded upon this by incorporating additional evidence-based sources relevant to and used by Canadian primary care providers. Further research is needed to evaluate the utility and effectiveness of preventive care charting tools. Support for infrastructure to develop and maintain this tool is necessary, as many resources are needed to manage literature reviews, evidence analysis, and expert consensus on final conclusions.
Acknowledgments
We thank Dr Sharon Johnston for her comments on earlier drafts of this article.
Notes
EDITOR’S KEY POINTS
Navigating the many different guidelines and recommendations for preventive care can be a daunting task for primary care providers. The authors of this review completed an updated assessment of the best available evidence for prevention and screening among Canadian adults and provide a summary for primary care practitioners.
A concise table summarizes age- and sex-appropriate history taking, counseling, investigations, and screening tests. Updated recommendations are provided for cervical cancer, prostate cancer, breast cancer, colon cancer, and dyslipidemia screening, as well as weight management.
Sample charting tools were also created to aid practitioners with documentation at dedicated preventive health visits or as part of opportunistic screening.
Footnotes
↵* The 6 charting tools are available at www.cfp.ca. Go to the full text of the article online and click on CFPlus in the menu at the top right-hand side of the page.
This article is eligible for Mainpro-M1 credits. To earn credits, go to www.cfp.ca and click on the Mainpro link.
This article has been peer reviewed.
La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de février 2016 à la page e64.
Contributors
All the authors contributed to the literature review and analysis, and to preparing the manuscript for submission.
Competing interests
None declared
- Copyright© the College of Family Physicians of Canada
References
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