Improvements to the US Preventive Services Task Force Recommendation Statement

The mission of the US Preventive Services Task Force (USPSTF) is to improve the health of all Americans by making evidence-based recommendations about clinical preventive services. Critical to this mission is clear communication and dissemination of these recommendations.¹ While the principal audience for USPSTF recommendations remains primary care clinicians, other clinicians, public health officials, funders, and the general public are now also interested.

To better support implementation by primary care clinicians and to meet the needs of newer audiences, the USPSTF reevaluated the presentation of its Recommendation Statements. With the support of its partners, the Agency for Healthcare Research and Quality (AHRQ) and AHRQ’s contractors, the USPSTF engaged in formal and informal information gathering and analysis to guide these revisions. The USPSTF used the following goals, consistent with national standards,² to guide the revisions: (1) be clear and helpful for clinicians in practice; (2) convey trustworthiness through transparency in describing its methods and decision-making; and (3) describe the evidence on which the recommendations were made and any research gaps found.

The Recommendation Statement on screening for asymptomatic bacteriuria in adults³ reported in this issue of JAMA incorporates this revised approach.

To understand best practices for communicating and disseminating recommendations to clinicians, AHRQ’s Scientific Resource Center (SRC) conducted a literature review and interviews with experts in dissemination and implementation (D&I). In addition, the SRC interviewed family medicine and internal medicine clinicians about the structure, clarity, and usefulness of USPSTF Recommendation Statements. The methods and findings of this research are reported elsewhere,⁴ and key findings are summarized below.

Trusting the recommendation source is critical. According to D&I experts, it is essential for guideline developers to first establish trust and credibility with clinicians. Both D&I experts and clinicians agreed that the USPSTF is among the most trusted and respected sources for clinical preventive services recommendations.

D&I experts reported that clinicians typically scan recommendations to find the information most relevant for their clinical practice. Clinicians confirmed that once they trust a guideline developer, they generally only read the abstract or the “top-line recommendations.” Many clinicians reported that the information in some sections of USPSTF recommendations is repetitive. They also found the evidence section too detailed but appreciate that the evidence on which the recommendations are based is publicly available.

Using plain language makes recommendations easier to understand. The D&I experts suggested that the USPSTF reduce the amount of interpretation needed for clinicians to understand and implement the recommendations. The literature and interviews suggested that using concise action statements, plain language, and consistent denominators to compare risk between groups can help clinicians quickly and accurately comprehend the content.

Recommendations need to be easy to scan. The literature review revealed that clinicians want recommendations that have an easy-to-read format. Clinicians reported that they like the layout of USPSTF recommendations but want them to be easier to scan. They suggested presenting bulleted top-line recommendations up front and using bolding, callout boxes, colored text, and graphics.

Both D&I experts and clinicians suggested that the USPSTF include companion materials to assist clinicians with implementing recommendations, eg, infographics or pictograms for patients depicting absolute risk; shared decision-making tools and information; and tools to help fit recommendations into a clinical workflow, such as decision trees and flowcharts. Clinicians were largely unaware of existing companion tools, such as clinician and patient summaries, suggesting the need for additional promotion.

The USPSTF also solicited ideas for improving the Recommendation Statements from partners, including federal agencies and clinical professional organizations; AHRQ’s medical officers and Evidence-based Practice Centers; and the editors of JAMA, its publication partner. In addition, USPSTF members vetted early drafts of revised Recommendation Statements with primary care clinician colleagues for feedback.

The USPSTF incorporated these findings into its revisions of the Recommendation Statements, emphasizing the previously described principles. The Table summarizes the content of the new Recommendation Statement structure.

Emphasizing the summary of recommendations. First, the USPSTF will highlight the Summary of Recommendations (top-line recommendation) by formatting it as presented on the USPSTF website, including a color-coded letter grade along with concise text of the recommendation. Since clinicians reported that they primarily focus on this part of the Recommendation Statement, the USPSTF determined that it will highlight this information using a consistent look across dissemination modes.

Emphasizing the USPSTF rationale. The second change was to reformat the narrative paragraphs from what had been the “Rationale” section into a structured table. In this table, the USPSTF details the magnitude of net benefit by reviewing the specific benefits and harms, as well as reviewing the certainty of evidence supporting the intervention.

Streamlining the content to avoid repetition, make it easier to locate relevant information, and use clear language. The USPSTF has recommitted itself to the use of clear language in the recommendations. The USPSTF streamlined the Recommendation Statement content to avoid repetition and extraneous details. Formatting changes such as bolding, bullets, and headings make the sections easier to find and read.

The USPSTF kept more clinical information near the beginning of the Recommendation Statement and moved the “Research Needs and Gaps” section to after the summary of the current evidence. The USPSTF also moved the “Update of Previous USPSTF Recommendation” section earlier in the report to help clinicians better assess any changes.

The USPSTF renamed several sections to better reflect the content and help clinicians identify information of interest. For example, the USPSTF combined what was previously the “Clinical Considerations” and “Other Considerations” sections into a single section named “Practice Considerations.” This section provides a concise summary of the clinical information and definitions needed to implement the recommendations and now includes a subsection called “Additional Tools and Resources” that lists materials available to help clinicians with implementation.

The USPSTF consolidated the background contextual information from the “Rationale” and “Discussion” sections into an “Importance” section near the beginning of the recommendation. The USPSTF renamed the “Discussion” section to “Supporting Evidence,” which will now minimize duplication of information in the accompanying evidence summaries. The USPSTF grade definitions and level of certainty tables were moved to an online supplement and also are available on the USPSTF website for reference at any time.

Along with the changes in the Recommendation Statement, the abstract in JAMA will highlight the recommendations while providing a brief rationale, indicating whether it is a new or updated recommendation, specifying the population affected by the recommendation, and providing a brief overview of the evidence. The USPSTF also redesigned and streamlined its Clinician Summary document—a formatted summary of the essential aspects of the Recommendation Statement, including what information is new, meant for quick reference use by clinicians.

The USPSTF hopes that its new Recommendation Statements and accompanying materials will more clearly communicate its recommendations to clinicians and other interested parties, so they can implement them more effectively. The USPSTF is committed to regular review of its methods and processes to fulfill its mission of recommending evidence-based clinical preventive services to improve the health of all Americans.

Corresponding Author: John W. Epling, MD, MSEd, Department of Family and Community Medicine, Carilion Clinic, Virginia Tech Carilion School of Medicine, One Riverside Cir, Ste 102, Roanoke, VA 24016 (jwepling@carilionclinic.org).

Conflict of Interest Disclosures: None reported.

Funding/Support: The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF. The literature review and interviews were supported by AHRQ through contract HHSA-290-2016-00006-C.

Disclaimer: The findings and conclusions in this document are those of the authors, who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or the US Department of Health and Human Services.

Additional Contributions: We thank and acknowledge the contributions of the rest of the USPSTF Dissemination and Implementation Workgroup who were instrumental in conducting this work: Alex H. Krist, MD, MPH; Michael J. Barry, MD; Michael Cabana, MD, MA, MPH; Chyke A. Doubeni, MD, MPH; Michael Silverstein, MD, MPH; Melissa A. Simon, MD, MPH; Chien-Wen Tseng, MD, MPH, MSEE; and John B. Wong, MD. We also thank all USPSTF members, Quyen Ngo-Metzger, Tracy Wolff, AHRQ medical officers, Meghan Woo, Tana Brummer, and Meaghan Hunt for their insights and assistance.