Disease Prevention Guidelines from the U.S. Preventive Services Task Force

This issue marks the first of a series of articles describing the state of the art and science of disease prevention, as interpreted by the U.S. Preventive Services Task Force (USPSTF). I write to introduce Annals readers to the USPSTF and to describe this journal's role in the guidelines field. In 1983, Dr. Edward Huth, editor of Annals from 1970 to 1993, published a medical practice guideline on the management of diabetes mellitus (1). It was the product of a new American College of Physicians program, the Clinical Efficacy Assessment Program, which began in 1980 under the direction of Dr. Robert Moser (then the Executive Vice President of the College). The College was one of the first professional organizations to establish a guidelines program. CEAP, as it was known then, set a standard that the best guidelines programs still strive to emulate. The basic approach was to review the literature on a topic, describe the pertinent findings from the very best articles, develop recommendations based on that evidence, and publish the recommendation in Annals. The guideline appeared in a short article, called the position paper. A longer accompanying article, the background paper, described the evidence. Annals subjected the background paper to peer review, but the position paper stood as the College's statement on the clinical question at hand. The College has published a book, Common Screening Tests (2), and guidelines that helped to frame the dialog on cholesterol screening (3, 4) and prostate cancer screening (5-7), among other controversial screening topics. The model for both the USPSTF and the College's guidelines program is the Canadian Task Force on the Periodic Health Examination, which released its first report in 1979. Dr. J. Michael McGinnis, who was then Director of the Office of Disease Prevention and Health Promotion in the U.S. Department of Health and Human Services, convened the first USPSTF in 1984. From the beginning, the Task Force has been federally funded but independent. Most of the USPSTF members have been primary care physicians with expertise in the evaluation of evidence. The first USPSTF issued its report in 1989 in the form of a book titled Guide to Clinical Preventive Services (8). This book sold very well and established the Task Force as an authoritative source of guidance about evidence-based preventive medicine. In 1990, the second USPSTF convened to update the guidelines of the first Task Force. In 1995, it issued a much-expanded set of guidelines in the second edition of its report (9). The third USPSTF convened in 1998 under the sponsorship of the Agency for Healthcare Research and Quality. This agency contracts with Evidence-Based Practice Centers in North Carolina and Oregon to review the literature, cull the best studies, collate the evidence, and draft the evidence reports. The staff of these centers consists of experts in the tasks of evaluating research. The members of the third Task Force include representatives of internal medicine, family practice, pediatrics, obstetrics-gynecology, and nursing, as well as experts on behavioral medicine and cost-effectiveness analysis. The College, the Canadian Task Force, and the USPSTF have been leaders in the field of evidence-based guidelines for disease prevention. Although the three organizations are independent of one another, their recommendations have usually agreed closely; this concordance testifies to the robustness of a rigorous evidence-based approach to practice guideline development. With two strong organizations specializing in guidelines for disease prevention, the College guidelines program has decided to focus on other topics. Therefore, by publishing USPSTF guidelines that pertain to adults, Annals will give its readers a view of disease prevention that they would not get from the College's guideline program. The USPSTF plans to publish its reports in medical journals. We do not have a formal understanding with the Task Force; they are free to publish elsewhere, and we are free to decide which topics have the highest claim on our readers' attention. In a manner that is analogous to the College's guideline program, most Task Force reports will consist of two articles. The Task Force members write a brief clinically oriented summary (Recommendations and Rationale). Members of the Evidence-Based Practice Centers write the background article, which contains a systematic review of the evidence. In the interest of conserving expensive page space, we may publish some of the longer tables only on www.annals.org, the Annals Web site. The Task Force is trying many strategies to disseminate the preventive services guidelines. We will do our part by placing their reports on the public-access part of our Web site so that anyone can access the electronic version of both articles. The Task Force will also publish the articles on their Web site (www.ahrq.gov/clinic/uspstfix.htm) and on the National Guideline Clearinghouse Web site (www.guidelines.gov). Dr. Christine Laine, our senior deputy editor, will be the editor for this series. We will send all articles for external peer review. Dr. Cynthia Mulrow and I have both been Task Force members, and we are coauthors on some Task Force background articles. Accordingly, we will recuse ourselves from discussions of work in which we participated as authors. Annals will publish USPSTF reports because we believe that internists should have convenient access to the best evidence about disease prevention, a core activity for most internists. Publishing USPSTF reports will help to make Annals a must read for health professionals and for the public, which is exactly the role that we seek to play.