Guidelines Preventivehealth

Preventive Health Care Guidelines -
Adult/Adolescent/Pediatric –
In Primary Care Setting –
Clinical Practice Guideline (CPG)
Target Population:
Individuals from birth to geriatrics,
who are average risk and asymptomatic.
ACKNOWLEDGEMENT
This guideline was initially developed and produced through partnership between Unity
Health Insurance and Physicians Plus Insurance Corporation in 2002. Since 2005 this
document has been produced as a collaborative effort between clinicians and quality
improvement staff of Unity Health Insurance, Physicians Plus Insurance Corporation,
University of Wisconsin Medical Foundation, the Department of Family Medicine and Group
Health Cooperative. The guidelines are reviewed, revised and approved on an annual basis.
This version was reviewed and approved in January 2013.
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Chair of Preventive Health Care Guidelines
Name: Sally Kraft MD
Phone Number: (608) 821-4900
Email address: sakraft@wisc.edu
CPG Contact for Content Questions or Changes:

Name: Cheryl Schutte/Lee Vermeulen
Phone Number: (608) 262-7537
Email address: lc.vermeulen@hosp.wisc.edu
CPG Contact for Physicians Plus:

Jody Jardine, BSN, RN, CDE
Phone Number: (608) 417-4548
Email address: jody.jardine@pplusic.com
Guideline Author(s), Coordinating Team Members, and Review
Individuals/Bodies: See appendix A for detailed list
Committee Approvals/Dates:
Immunization Task Force: May 2012
Steering Committee: September 21, October 8, 13, 2012
Clinical Knowledge Management Council: December 20, 2012
Physicians Plus QUM Committee: March 27, 2013
Release Date: January 2013
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Table of Contents
Executive Summary…………………………………..4
Scope……………………………………………………6
Methodology…………………………………………...8
Evidence Rating……………………………………….9
Introduction …………………………………………..12
Recommendations …………………………………..12
Section 1 - Preventive Health Guideline for
Prenatal and Postpartum Care…………………….12
Section 2 – Preventive Health Guideline for
Neonatal Care...………………………………………16
Section 3 - Preventive Health Guideline for
Infant-Child Care……………………………………. 17
Adolescent Care…………………………………….. 22
Adult Care……………………………………………..27
References for Supporting Evidence………….... 37
Benefits/Harms of Implementation…………….... 44
Implementation Strategy……………………………45
Implementation Tools/Plan…………….…………..45
Disclaimer……………………………………………..45
Appendix A…………………………………………....46
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Executive Summary
Guideline Title:
Preventive Health Care Guideline
Guideline Overview
Preventive health services recommendations for screening, counseling
and education for patients from birth to geriatrics.
Practice Recommendations
Health care providers need to screen, counsel and educate patients on
preventive health services.
Companion Documents
TWEAK Questionnaire/ UW Health Alcohol Assessment
http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/InstrumentPDFs/74_TW
EAK.pdf
Health Professionals Guide to Newborn Screening

http://www.slh.wisc.edu/newborn/guide/
Forward Health Portal

https://www.forwardhealth.wi.gov/WIPortal/Default.aspx
Edinburgh Questionnaire/UW Health Guideline Diagnosing and Treating

Depression
http://www.testandcalc.com/etc/tests/edin.asp
Childhood and Adolescent Screening Schedule

http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
Badger Care Lead Screening Guidelines

http://www.dhs.wisconsin.gov/lead/doc/1pgScreeningRecom.pdf
4
Center for Epidemiological Studies Depression Scale for Children-CES-DC
http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc
Patient Health Questionnaire- PHQ-9

http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf
CRAFFT Tool
http://knowledgex.camh.net/amhspecialists/Screening_Assessment/screening/sc
reen_CD_youth/Pages/CRAFFT.aspx
Centers for Disease Control Growth Charts

http://www.cdc.gov/growthcharts/
Wisconsin Essential Diabetes Mellitus Care Guidelines

http://www.dhs.wisconsin.gov/diabetes/guidelines.htm
Benefits and Harms Prostate-Specific Antigen-David Jarrard MD

https://uconnect.wisc.edu/servlet/Satellite?cid=1119365719365&pagename=B_E
XTRANET_UWHC_MANUALS%2FFlexMemberManual%2FShow_Manual_Detai
l&c=FlexMemberManual
Get up and Go Test

http://www.aan.com/practice/guideline/uploads/273.pdf
2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons

http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summ
ary.Guide.pdf
FRAX Osteoporosis Risk Calculation

http://www.shef.ac.uk/FRAX/tool.jsp?country=9#notes
Alcohol Use Disorders Identification Test-AUDIT

http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf
Alcohol, Smoking and Substance Involvement Screening Test-ASSIST

http://www.who.int/substance_abuse/activities/assist_technicalreport_phase2_fin
al.pdf
SIP-AD or Severity of Dependence Scale-SDS

http://www.who.int/substance_abuse/research_tools/severitydependencescale/e
n/index.html
United States Preventive Services Task Force

http://www.uspreventiveservicestaskforce.org/uspstf05/brcagen/brcagenrs.htm#cl
inical
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Pertinent Physicians Plus Provider Care Guidelines
Alcohol Assessment and Intervention Guidelines
Depression Screening Guidelines
Guideline for the Treatment of Hypertension
http://www.pplusic.com/providers/care-guidelines
Pertinent UWHC Policies & Procedures

UW Health Alcohol Assessment and Intervention Guidelines
UW Health Depression Screening Guidelines
UW Health Guideline for the Treatment of Hypertension
UW Health Guideline for the Diagnosis and Management of Dyslipidemia
UW Health Alcohol Assessment and Intervention Guideline
https://uconnect.wisc.edu/servlet/Satellite?cid=1126652026690%26p
agename=B_UWHC_WORKGROUPS_ADMIN%2FFlexMemberManual%2F
Show_Manual_Detail%26c=FlexMemberManual
Scope
Adult Disease/Condition(s):
Preventable diseases or conditions, such as:
 Tobacco or alcohol use/abuse
 Myocardial infarction and stroke (aspirin chemoprophylaxis)
 Infectious diseases, such as pneumococcal pneumonia, influenza,
tetanus, diphtheria, pertussis, hepatitis B, herpes, zoster/shingles,
human papillomavirus, poliomyelitis, measles, mumps, rubella,
varicella
 Cervical cancer, colorectal cancer, breast cancer, prostate cancer
 Hypertension
 Vision and hearing impairment
 Chlamydia
 Dyslipidemia
 Folic acid deficiency
 Depression
 Obesity
 Osteoporosis and osteoporotic fractures
 Abdominal aortic aneurysm
Children Disease/Condition(s):
Preventable diseases or conditions, such as:
 Tobacco or alcohol use/abuse
 Infectious diseases, such as pneumococcal pneumonia, influenza,
tetanus, diphtheria, pertussis, hepatitis B, varicella, human
papillomavirus, poliomyelitis, measles, mumps, rubella, varicella,
hepatitis A, rotovirus, haemophilus influenza type B, poliomyelitis
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 Chlamydia
 Dyslipidemia
 Folic acid deficiency
 Depression
 Obesity
 Sudden Infant Death Syndrome (SIDS)
 Injuries
 Dental and periodontal disease (oral health)
Clinical Specialty:
 Family Practice
 Geriatrics
 Internal Medicine
 Obstetrics and Gynecology
 Pediatrics
 Preventive Medicine
Intended Users:
 Advanced Practice Nurses
 Allied Health Personnel
 Health care providers
 Health Plans/Managed Care Organizations
 Hospitals
 Nurses
 Physician Assistants
 Physicians
 Medical Assistants
Clinical Practice Guideline (CPG) objective(s):

 To provide a comprehensive approach to the provision of preventive
services, counseling, education and disease screening for average risk
individuals from birth through geriatrics.
 To assist in the prioritization of screening, maneuvers, tests and
counseling opportunities.
 To increase the rate of patients who are up to date with preventive
services.
 To provide guidelines for decision support tools in Health Link such as
Health Maintenance and Best Practice Alerts.
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Target Population:
Individuals from birth to geriatrics who are average risk and asymptomatic.
Please Note: there are occasional exceptions to this for high risk
populations where noted.
This guideline is not intended to diagnose or treat any condition. Once a

health issue or condition has been uncovered, other guidelines will take
precedence during any further diagnosis and management.
Interventions and Practices Considered:

 Prevention/Risk Assessment/Screening/Counseling
 Patient centered, team based approach and shared decision making.
 Using nearly every patient contact to identify and address preventive
service needs.
Screening
Screening including:
 Neonatal screening
 Chlamydia screening
 Colorectal, breast and cervical cancer screening
 Obesity and lipid screening
 Tobacco and alcohol screening
 Hypertension
 Depression and mental health screening
 Immunization screening
Counseling
 Breast feeding
 Injury prevention
 Sudden infant death syndrome (SIDS)
 Oral health
 Domestic violence
Major Outcomes Considered
 Effectiveness of screening tests
 Effectiveness of counseling and education
 Effectiveness of immunization and chemoprophylaxis
 Predictive value of screening tests
Methodology
Description of Methods Used to Collect/Select the Evidence:
The work group reviewed previous guideline recommendations and came to
consensus on the content to be included in the guideline. Searches of
electronic data bases as well as hand searches were conducted to update
and verify content. Randomized, controlled trials and meta-analysis/systemic
reviews and guidelines were included.
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Methods Used to Assess the Quality and Strength of the Evidence:
This clinical practice guideline will be using the Grading of
Recommendations, Assessment, Development and Evaluation (GRADE) as
defined by U.S. Preventive Services Task Force (USPSTF) which assigns
one of five letter grades to each of its recommendations (A, B, C, D, or I)
(Tables 1 and 2).
Table 1: Rating Scheme for the Strength of the Evidence:
Grade Definition Suggestions for Practice

A Recommend the service. There Offer or provide this service.
is high certainty that the net
benefit is substantial.
B Recommend the service. There Offer or provide this service.
is high certainty that the net
benefit is moderate or there is
moderate certainty that the net
benefit is moderate to
substantial.
C Note: The following statement is Offer or provide this service only if other
undergoing revision. considerations support the offering or
Clinicians may provide this providing the service in an individual patient.
service to selected patients
depending on individual
circumstances. However, for
most individuals without signs or
symptoms there is likely to be
only a small benefit from this
service.
D Recommend against the service. Discourage the use of this service.
There is moderate or high
certainty that the service has no
net benefit or that the harms
outweigh the benefits.
I Statement Conclude that the current Recommendation Statement. If the service
evidence is insufficient to assess is offered, patients should understand the
the balance of benefits and uncertainty about the balance of benefits
harms of the service. Evidence is and harms.
lacking, of poor quality, or
conflicting, and the balance of
benefits and harms cannot be
determined.
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Table 2: Levels of Certainty Regarding Net Benefit
Level of Description
Certainty*
High The available evidence usually includes consistent results from well-
designed, well-conducted studies in representative primary care populations.
These studies assess the effects of the preventive service on health
outcomes. This conclusion is therefore unlikely to be strongly affected by the
results of future studies.
Moderate The available evidence is sufficient to determine the effects of the preventive
service on health outcomes, but confidence in the estimate is constrained by
such factors as:
 The number, size, or quality of individual studies.
 Inconsistency of findings across individual studies.
 Limited generalizability of findings to routine primary care
practice.
 Lack of coherence in the chain of evidence.
As more information becomes available, the magnitude or direction of the
observed effect could change, and this change may be large enough to alter
the conclusion.
Low The available evidence is insufficient to assess effects on health outcomes.
Evidence is insufficient because of:
 The limited number or size of studies.
 Important flaws in study design or methods.
 Inconsistency of findings across individual studies.
 Gaps in the chain of evidence.
 Findings not generalizable to routine primary care practice.
 Lack of information on important health outcomes.
More information may allow estimation of effects on health outcomes.
* The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is
defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level
based on the nature of the overall evidence available to assess the net benefit of a preventive service.
Description of the Methods Used to Analyze the Evidence:

Weighting according to the rating scheme given.
Description of Methods Used to Formulate the Recommendations:

Review of published studies, meta-analyses and expert opinions.
Cost Analysis:
No cost analysis.
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Description of Method of Guideline Validation:
Specialty workgroups made up of specialists and primary care physicians
reviewed the evidence of controversial topics and made a recommendation
based on evidence or formed a consensus guideline which was reviewed by
the Steering Committee.
The expert contributors made up of physicians and staff in a specialty area

reviews the recommendations by specialty workgroups and the entire
Preventive Health Care Guideline for content.
The Steering Committee is made up of primary care physicians, Ob-

Gynecologists, representatives from HMO groups (Physician, Plus, Group
Health Cooperative and Unity), Health link analyst and members from the
quality department. They reviewed the recommendations from the specialty
workgroups and the expert contributors.
Council for Clinical Knowledge Management will review and give final
approval for the Preventive Health Care Guidelines.
See flow diagram below of the process.
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Preventive Health Care Guidelines Specialty workgroups, expert contributors and the
steering committee follow the CPG guiding principles as well as those listed below:
 Members will serve as a representative of their discipline/department. They

will inform colleagues of the goals and report on feedback from colleagues.
They will represent concerns and provide suggestions for resolution.
 Recommendations are based on the highest levels of evidence
Recognize there maybe conflict or controversy
Refer to levels of evidence
 Create a consensus statement for the Preventive Health Care Guidelines
with input from specialty experts.
 Steering Committee can make recommendations for and against for
building tools in Health Link, based on the evidence
 Committee will update the guidelines as needed if new evidence comes
forward or if there is concern that arises between the 2 year periodic
reviews.
INTRODUCTION
This guideline contains recommendations designed to assist clinicians in delivering and
supporting preventive health care services.
RECOMMENDATIONS
Major Recommendations:
Section 1. Preventive Health Guideline for Prenatal

and Postpartum Care
FREQUENCY OF PRENATAL VISITS
GESTATIONAL AGE FREQUENCY OF VISITS
4 - 32 weeks Every 4 weeks
32 - 36 weeks Every 2 weeks
37+ weeks Every week
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PRENATAL / POSTPARTUM PREVENTIVE CARE TIMELINE
FIRST
DURING AFTER
SCREENINGS PRE-PREGNANCY PRENATAL
PREGNANCY PREGNANCY
VISIT
• Screen for HIV. • Screen for • Urine testing at  Screen for

 Screen for gonorrhea and 12 – 16 weeks postpartum
depression. 5 chlamydia, with urinalysis to depression.5
 Screen for alcohol syphilis, and HIV include leukocyte  Screen for
use.6 (if not done pre- esterase and alcohol use.6
conceptually) urine culture to
• Offer screen for screen for
cystic fibrosis to asymptomatic
appropriate ethnic bacteriuria.
groups. • Screen for
• Screen for blood Group B
type and Indirect Streptococcus
Coombs antibody late in
testing. pregnancy3 (35-
(Grade A 37 weeks).
Recommendation, • Screen for
USPSTF). indirect Coombs
• Pap test. antibody testing
• African- if not previously
American women done.
should be tested • Screen for
for sickle cell gestational
disease. diabetes at 26-30
• Recommend weeks or sooner
offering carrier if risk factors.4
screening for  Screen for
hemglobinopathies depression.5
to women of  Screen for
southeast Asian, alcohol use.6
African or
Mediterranean
descent.
• Screen for iron
deficiency.
TREATMENT Daily prenatal vitamin Provide Rh (D) • Administer Rh (D)

STANDARDS containing 0.4 – 0.8 immune globulin immune globulin to
mg folic acid for to all Rh negative un-sensitized
women planning women at postpartum Rh
pregnancy.1 Begin at 28 weeks. negative women
least 1 month prior to within 72 hours of
conception and birth, if fetus is Rh
continue during positive or
pregnancy. unknown.
• Check-up within
4 – 6 weeks after
delivery.
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FIRST
DURING AFTER
VACCINATIONS PRE-PREGNANCY PRENATAL
PREGNANCY PREGNANCY
VISIT
• Screen for rubella • Screen for • During flu • Varicella

or vaccination if no rubella (if not season offer vaccination if no
previous immunity at done pre- vaccine to all previous
least 4 weeks prior to conceptually). women regardless immunity.
becoming pregnant. • Screen for of trimester. • Rubella
• Screen for varicella hepatitis B2 Pregnant women vaccination if no
or vaccination if no should only previous
previous immunity 8 receive inactivated vaccination.
weeks prior to flu vaccine. • Screen family
becoming pregnant.
•Give Tdap members and
• Screen for family
between 27-36 close contacts for
members and close
weeks. Screen Tdap and
contacts for Tdap and
family members administer if not
administer.7
and close contacts given previously.7
for Tdap and
administer if not
given previously.7
1. Folic Acid –
Women with history of a prior child with a neural tube defect or family
history of neural tube defect should be offered a higher dose of 4 mg per day
of folic acid. (Grade A Recommendation, USPSTF)1
All prescription prenatal vitamins have 1 mg folic acid. All OTC vitamins have
0.4 mg folic acid.
2. Hepatitis B –
Mothers who are at high risk of contracting hepatitis B and who are HBsAg
negative may receive a hepatitis B immunization series anytime during
pregnancy.
Such mothers should be retested for hepatitis B prior to delivery. (Grade A
Recommendation, AAFP)2
3. Group B Strep –
Risk-based treatment is only appropriate if screening has not been done or
culture results are not known.3
4. Gestational Diabetes-
Screen sooner if macrosomia, maternal obesity or history of gestational
diabetes.
5. Depression –
Screen for prenatal depression and assess medications for depression.
Screen for depression during pregnancy and postpartum. Please refer to
Physicians Plus Depression Guidelines at: http://www.pplusic.com listed
under Clinical Practice Guidelines.
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6. Alcohol –
Screen and address alcohol use both prior to and during pregnancy. (Grade B
Recommendation, USPSTF).4 Assess alcohol use using the quantity-
frequency questions. If any alcohol use exists, use the TWEAK questionnaire
and advise to abstain from alcohol. Assist as appropriate; if necessary,
arrange treatment or follow-up. For additional information on alcohol
screening and the TWEAK questions, refer to the Physicians Plus Alcohol
Assessment and Intervention Guideline at: http://www.pplusic.com/ listed
under Clinical Practice Guidelines.
7. Tdap –
Administer a dose of Tdap during each pregnancy in the third trimester,
between 27 and 36 weeks gestation, irrespective of the patient’s prior history
of receiving Tdap. If Tdap is not administered during pregnancy, Tdap
should be administered immediately postpartum.5,6,7,8
8. Hemoglobinopathies –
Recommend offering carrier screening for hemoglobinopathies to women of
Southeast Asian, African or Mediterranean descent.9
PRENATAL HEALTH EDUCATION AND COUNSELING

1. Discuss diet, substance abuse, current or history of depression or anxiety,
domestic violence, safety and environment.
2. Reduce or stop tobacco use for those who use, and discuss availability of
nicotine replacement therapies and medications as an adjunct to counseling.
(Grade A Recommendation, USPSTF)10
3. Discuss benefits of breastfeeding during prenatal visits.

(Grade B Recommendation, USPSTF)11
4. Offer amniocentesis or chorionic villi sampling for women 35 years or older.
5. Offer genetic screening in first or second trimester. Offer quad marker screen to
detect chromosome (Down syndrome), brain and spinal cord abnormalities.
Offer a choice of quad screen for Down syndrome or first trimester screen. If
first trimester screen is elected for screening for Down Syndrome, need to offer
AFP screening for neural tube defect in the second trimester. If quad screen is
elected for Down’s screening, it will automatically screen for neural tube defect.
6. Recommend that all close family contacts and care givers of infants be up to
date with immunizations, especially Tdap.7
7. Recommend routine screening for iron deficiency anemia in asymptomatic

pregnant women. (Grade B recommendation, AAFP)12
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Section 2. Preventive Health Guideline for Neonatal Care
Car
Administration
 Intramuscular injection of vitamin K within 1 hour of birth to prevent
hemolytic disease of the newborn.
 Ophthalmic antibiotic topically to eyes within 1 hour of birth.
 Hepatitis B vaccine to infants prior to discharge from the hospital.
 Hepatitis B vaccine within 12 hours of birth to infants born to HBsAg
positive mothers or to whom mother’s status is unknown.
 Hepatitis B Immune Globulin (HBIG) within 12 hours of birth to all infants
born to HBsAg positive mothers and to infants under 2000 grams birth
weight born to previously untested mothers whose hepatitis B status is
unlikely to be determined within 12 hours of birth. HBIG can be deferred
up to 7 days in infants over 2000 grams birth weight born to previously
untested mothers while awaiting the mother's HBsAg test results.
 Vitamin D within the first few days of life. Recommend all exclusively
breast-fed or formula fed babies receiving less than 1000 mL of formula
per day within first few days of life begin to receive vitamin D supplement
400 IU. Vitamin supplementation is also recommended for breastfed
babies who are receiving formula supplementation.
Screening
 Hearing loss using current medical techniques.
 Congenital heart disease using pulse oximeter within 24-48 hours of birth.
 The State of Wisconsin statutes for newborn screening.14 Screening is
currently conducted for 48 disorders and diseases. The complete list is
available at: http://www.slh.wisc.edu/newborn/guide Health Professionals
Guide to Newborn Screening: Table of Contents. Testing should be
conducted after 24 hours of life. Infants should be tested before discharge
from the neonatal nursery, and if discharged before 24 hours of age,
should be re-tested by 2 weeks of age. Premature infants and those with
illnesses optimally should be tested at or near 7 days of age, but in all
cases before discharge from the newborn nursery.
Education
 Sudden Infant Death Syndrome (SIDS) prevention. Endorse the safe to
sleep program.
 Benefits of breastfeeding. Provide support and follow-up.
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Section 3. Preventive Health Guideline for Infant-Child Care
Car
INFANT-CHILD CARE TIMELINE

BIRTH TO 2 4 6 9 12 15 18 30
24 MO 3-6 YR 7-10 YR
1 MO MO MO MO MO MO MO MO MO2
Only for
Within 48
Badger
WELL CHILD hours of At least
Care Plus
VISIT1 discharge Once Once Once Once Once Once Once Once Annually every 1-2
eligible
and 1 years
children
month
Once
DEVELOPMENTAL Once
SCREENING Once Once (24-30 Once
(ASQ)1 months)
AUTISM SCREEN
Once Once
(M-CHAT)1
BP SCREEN At each At each

clinic visit clinic visit
BLOOD LEAD
Once if at Once if at
LEVEL Once risk and risk and
SCREEN Once
if at not not
(FOR THOSE AT if at risk previously previously
risk
RISK)2 checked checked
ANEMIA If at If at If at If at
SCREENS risk risk Once risk risk
Annual
HEARING Annual
screen at
Birth screen at
SCREEN4 ages 8 and
ages 4-6
10
Risk
assessment
VISION annually
Once Once Once Once Once Once Once Once Once Once Annually
SCREEN5 and vision
screen at
8,10,
BMI6 Once Once Annually Annually
Universal
screening
at 9-10 yrs
LIPIDS7 If at
If at risk If at risk with non-
risk
fasting
cholesterol
and HDL
17
TUBERCULOSIS8 If at If at If at If at If at If at
risk risk risk risk risk If at risk If at risk If at risk
risk
SCREEN FOR
POSTPARTUM Once Once
DEPRESSION9
1. Health Check -
All infants discharged on the first or second postpartum day need to be seen
within 48 hours of discharge. Breastfeeding infants need to be seen within 48
hours of discharge. This is a State recommendation for children who are
Medicaid or HealthCheck eligible. For the Medical Assistance (BadgerCare
Plus) Health Check go to: www.forwardhealth.wi.gov/WIPortal/Default.aspx
Developmental surveillance is recommended at all Well Child visits. Universal

developmental screening with a standardized validated developmental
screening tool (such as the Ages and Stages Questionnaire) is recommended
for all children at 9, 18, and 24-30 months of age, as well as targeted
screening at any age when developmental concerns are identified by
developmental surveillance. 15 Autism screening with M-CHAT is
recommended at 18 and 24 months of age, and any other time when parents
raise a concern about a possible Autism Spectrum Disorder (ASD).16
2. Blood Lead Screening –

Perform lead test on children at 12 and 24 months if the answer to any of the
following is ‘yes’ or ‘don’t know’:
QUESTION TEST IF THE ANSWER IS
1. Does the child live in or visit a building constructed Yes / Don't know
before 1950? Has the child in the past?
2. Does the child live in or visit a building constructed Yes / Don't know
before 1978 with recent or ongoing renovation? Has the
child in the past?
3. Does the child have a brother, sister or playmates that Yes / Don't know
has or has had lead poisoning?
4. Is the child eligible for Medicaid, Health Check or WIC? Yes / Don't know
For MA (Badge Care Plus) Lead Screening Guidelines go to

http://dhfs.wisconsin.gov/lead/doc/1pgScreeningRecom.pdf
18
3. Anemia Screening -
CBC w/o diff at one year of age. At ages 9-12 months and at ages 15-18
months, assess infants and young children for risk factors for anemia.
Screen the following children:
 Preterm or low-birth weight infants
 Infants fed a diet of non-iron-fortified infant formula for greater than 2
months
 Infants introduced to cow's milk before age 12 months
 Breast-fed infants who do not consume a diet adequate in iron after age 6
months (i.e., who receive insufficient iron from supplementary foods)
 Children who consume greater than 24 oz daily of cow's milk
 Children who have special health-care needs (e.g., children who use
medications that interfere with iron absorption and children who have
chronic infection, inflammatory disorders, restricted diets, or extensive
blood loss from a wound, an accident, or surgery)
Recommend routine iron supplementation for asymptomatic children aged 6

to 12 months who are at increased risk for iron deficiency anemia.
4. Hearing Screening -
Recommend annual screening 4-6 years of age and 8 and 10 years of age
with 2-3 pure tones. Test each ear at 20dB with four frequencies (500,
1000, 2000 and 4000 Hz.)17
5. Vision Screening –
Children should have an assessment for eye problems. These should be
age-appropriate evaluations; visual acuity measurement is recommended
for all children starting at 3 years of age. (Grade B Recommendation,
USPSTF)18
All children who are found to have an ocular abnormality and who fail valid
vision screening should be referred to a pediatric ophthalmologist or an eye
care specialist appropriately trained to treat pediatric patients.
6. Obesity/BMI –
For CDC clinical growth charts with BMI go
to:http://www.cdc.gov/growthcharts. Screen individuals age 2-17 for
obesity. As appropriate, provide counseling for persons 2 years and older
for nutrition and physical activity. Document BMI. Provide counseling for
individuals who are greater than or equal to 85th percentile. Offer them or
refer them to comprehensive, intensive behavioral interventions to promote
improvement in weight status. (Grade B Recommendation, USPSTF)19
19
7. Lipids Screening –
Universal screening at 9-11 years of age with non fasting cholesterol and
HDL. Screen once with fasting lipid profile for at risk patients after 2 years
of age. Risk factors: patients with a positive family history of dyslipidemia
or premature (55 years of age for men and 65 years of age for women)
CVD, for whom family history is not known or those with other CVD risk
factors, such as overweight (BMI 85th percentile), obesity (BMI 95th
percentile), hypertension (blood pressure 95th percentile), cigarette
smoking, or diabetes mellitus.
8. Tuberculosis - 20
Screen for risk factors and test if at risk. Tuberculin skin test (TST) or
interferon gamma release assays (IGRA) should be done on anyone at risk
with positive screening questionnaire. IGRA recommended as screening
test after 5 years old. In children 2 to 4 years of age there is limited data
about the usefulness of IGRAs in determining TB infection but IGRA can be
performed if disease is suspected. TST should not be done before 3 months
of age. Risk factors include:
 Contacts with people with confirmed or suspected TB, radiographic or
clinical findings suggesting TB.
 Contacts with people immigrating from countries with endemic
infection (Asia, Middle East, Africa, Latin America, countries of the
former Soviet Union, including international adoptees).
 Children with travel histories to countries with endemic infection and
substantial contact with indigenous people.
 Children with HIV infection and other medical conditions such as
diabetes, chronic renal failure, malnutrition, congenital or acquired
immunodeficiency and children receiving TNF should have annual
TST or IGRA.
9. Postpartum Depression –
Recommend using Edinburgh Postnatal Depression Scale (EPDS) at 1 and 4
months. If there is a personal or family history of depression, anxiety or
other mood disorders or psychosocial risk factors such as social isolation/lack
of social support, domestic violence and/or substance abuse then follow up
screening at subsequent visits maybe warranted. Please refer to the
Physicians Plus Guideline Diagnosing and Treating Depression in Adults in
Primary Care http://www.pplusic.com listed under Clinical Practice
Guidelines.
20
INFANT-CHILD IMMUNIZATIONS
Please refer to the Recommended Childhood and Adolescent Immunization
Schedule approved by the Advisory Committee on Immunization Practices, the
American Academy of Pediatrics and the American Academy of Family Physicians.
The Schedule is provided in its entirety at the Centers for Disease Control website
at http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html for infants and
children.21 Families choosing not to immunize or who do not follow the
recommended immunization schedule need to sign a vaccine refusal form.
INFANT-CHILD HEALTH EDUCATION AND COUNSELING

Injury Prevention
 Water safety: bathtub and pool supervision at all times and a barrier
or fence. Suggest CPR training for pool owners, parents, and care
takers.
 Falls: window guards in high-risk buildings. Use of gates. Never leave
infant unattended on changing table.
 Firearm safety: firearms properly stored – locked up and not loaded –
at all times
 Bicycling: use of approved helmets
 ATVs and Motorcycles: Children under age 16 should not operate off-
road motorized vehicles (i.e. ATV, personal watercraft, snowmobiles or
mini bikes)
 Poison Prevention- child-proof containers kept out of reach and limit
number of tablets per package. Keep National Poison Control Number
readily available.
 Burn Prevention- smoking cessation, flame-retardant clothing, hot
water heaters set to <120 degrees Fahrenheit, and properly installed
and tested smoke detectors and carbon monoxide detectors.
 Motor Vehicle Safety-Advocate use of infant and rear facing child car
seats until 2 years of age, booster seats and seat belt until child is
4’9”. Recommend against children 12 years of age and under riding in
the front seat.
 Encourage sun avoidance or use of protective clothing while in the sun.
(Grade B Recommendation, USPSTF) .22 Use SPF 15 or greater when in
the sun.
Education
 Promote a balanced diet high in fruits, vegetables, grains and fiber and
encourage adequate calcium intake (4 or more servings per day). After
age two recommend a diet low in saturated fat and cholesterol.
 Promote an active lifestyle with regular exercise. Limit screen time to
no more than two hours of quality programming per day for children
two years and older. No screen time for children less than two years
of age. (Screen time includes television, video games and computers)
21
 Provide oral hygiene education at each well child visit. Refer to dental
home by age 2-3.
 Counsel parents not to smoke. Discuss availability of nicotine
replacement therapies and medications as an adjunct to counseling.
Counsel on risks of second and third hand smoke.
Section 4. Preventive Health Guideline for Adolescent Care
ADOLESCENT CARE TIMELINE
11 12 13 14 15 16 17
WELL CHILD
VISIT Annually* Annually* Annually* Annually* Annually* Annually* Annually*
*BASED ON PPLUS
RECOMMENDATIONS
BP SCREENING At each clinic At each At each At each At each At each clinic At each clinic
visit clinic visit clinic visit clinic visit clinic visit visit visit
VISION
Once Once
SCREENING
CHLAMYDIA, Based on
GONORRHEA, Based on Based on Based on Based on Based on risk Based on risk
risk
HIV SCREEN2 risk factors risk factors risk factors risk factors factors factors
factors
ALCOHOL
TOBACCO AND
DRUG USE Annually Annually Annually Annually Annually Annually Annually
SCREEN3
BMI4 Annually Annually Annually Annually Annually Annually Annually
non-fasting
cholesterol
LIPIDS 5 and HDL if Universal
not Screening
previously
tested
HEARING6 For those at For those For those at For those at For those at For those at
For those at risk
risk at risk risk risk risk risk
TUBERCULOSIS7 If at risk If at risk If at risk If at risk If at risk If at risk If at risk
DEPRESSION
SCREENING9 Once Once Once Once Once Once
22
1. Health Check -
Screen adolescents for hypertension, eating disorders, sexual activity,
abuse, and school performance at each health visit. Screen children 11-18
years of age for mental health disorders. Ensure systems are in place for
accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal)
and follow-up. Use appropriate screening resources. Address readiness
for transition to adult care.
2. Chlamydia, Gonorrhea Infection and HIV –

Screen all sexually active females at least annually (Grade A
Recommendation, USPSTF)23 and at risk males. Risk factors include being
sexually active.
Screen for human immunodeficiency virus (HIV) for all adolescents at
increased risk for HIV infection.
(Grade A Recommendation, USPSTF)24.
Consider screening sexually active young men and adolescent males in
clinical settings associated with high chlamydia prevalence (e.g., adolescent
clinics, correctional facilities, and STD clinics.)
Annual screening for men who have sex with men. Recommend screening
all males whose partners have chlamydia, those who attend STD clinics or
clinics in communities where prevalence rates are high. Males younger than
30 years of age who are in the military and those in jail should be
screened; as should males in juvenile justice facilities or Job Corps.
CDC recommends that everyone between the ages of 13 and 64 get tested
for HIV at least once as part of routine health care. Please note that this
recommendation differs from current USPSTF recommendations However
USPSTF issued draft recommendations 11/20/12 that all individuals ages
15-65 should have at least one screening for HIV. (Grade A
Recommendation, USPSTF in draft).24
An HIV test is recommended once a year for people at increased risk—such
as gay and bisexual men, injection drug users, or people with multiple sex
partners. Sexually active gay and bisexual men may benefit from more
frequent testing (e.g., every 3 to 6 months).
3. Alcohol, Tobacco and Drug Use – Screen adolescents using the CRAFFT
screening tool:
C-Have you ever ridden in a car driven by someone (including yourself)
that was “high” or had been using alcohol or drugs?
R-Do you ever use alcohol or drugs to relax, feel better about yourself, or
fit in?
A-Do you ever use alcohol or drugs while you are by yourself, alone?
F-Do you ever forget things you did while using alcohol or drugs?
23
F-Do your family or friends ever tell you that you should cut down on your
drinking or drug use?
T-Have you ever gotten into trouble while you were using alcohol or
drugs?
Two or more yes answers suggest a significant problem, abuse, or
dependence. If positive for use, have brief intervention using motivational
interviewing techniques. Refer to specialist for treatment of dependence if
indicated. Screen for tobacco use annually.
4. Obesity/BMI – For CDC clinical growth charts with BMI go to:

http://www.cdc.gov/growthcharts . As appropriate, provide counseling for
persons 11-17 years of age for nutrition. For persons eleven years and
older, counsel for nutrition and physical activity as appropriate. Document
BMI. Provide counseling for individuals who are greater than or equal to
85th percentile.
Refer them to comprehensive, intensive behavioral interventions to
promote improvement in weight status.
5. Lipid Screening – 28-37

Screen at 11 if not done at 9-10 years of age. Screen with non-fasting
cholesterol and HDL. Universal screening once from 17-21 years of age.
Screen with fasting lipid profile for at risk patients. Risk factors: patients
with a positive family history of dyslipidemia or premature (55 years of age
for men and 65 years of age for women) CVD, for whom family history is
not known or those with other CVD risk factors, such as overweight (BMI
85th percentile), obesity (BMI 95th percentile), hypertension (blood
pressure 95th percentile), cigarette smoking, or diabetes mellitus.
6. Hearing Screening-
Perform risk assessment with appropriate action if positive. Discuss loud
noise exposure.
7. Tuberculosis- 20
Screen for risk factors and test if at risk. Tuberculin skin test (TST) or
interferon gamma release assays (IGRA) should be done on anyone at risk
with positive screening questionnaire. IGRA recommended as screening
test after 5 years old. In children 2-4 years of age there is limited data
about the usefulness of IGRAs in determining TB infection but IGRA can be
performed if disease is suspected. TST should not be done before 3
months of age. Risk factors include:
24
 Contacts with people with confirmed or suspected TB, radiographic or
clinical findings suggesting TB.
 Contacts with people immigrating from countries with endemic
infection (Asia, Middle East, Africa, Latin America, countries of the
former Soviet Union, including international adoptees).
 Children with travel histories to countries with endemic infection and
substantial contact with indigenous people.
 Children with HIV infection and other medical conditions such as
diabetes, chronic renal failure, malnutrition, congenital or acquired
immunodeficiency and children receiving TNF should have annual TST
or IGRA.
8. Depression-
Screen for depression in adolescents aged 12-18 years for major
depressive disorder when staff assisted systems are in place to ensure
accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal),
and follow up.
(Grade B Recommendation, USPSTF) 26
ADOLESCENT IMMUNIZATIONS
Please refer to the Recommended Childhood and Adolescent Immunization
Schedule approved by the Advisory Committee on Immunization Practices, the
American Academy of Pediatrics and the American Academy of Family
Physicians. The Schedule is provided in its entirety at the Centers for Disease
Control website at http://www.cdc.gov/vaccines/schedules/hcp/child-
adolescent.html for children and adolescents.21
Families choosing not to immunize or who do not follow the recommended
immunization schedule need to sign a vaccine refusal form.
ADOLESCENT HEALTH EDUCATION AND COUNSELING

Injury Prevention
 Motor vehicle safety: Advocate use of seat belt. No texting while driving.
 Burn Prevention: smoking cessation, flame-retardant clothing, hot water
heaters set to <120 degrees Fahrenheit, and properly installed and tested
smoke detectors.
 Water safety: pool supervision at all times and a barrier or fence. Suggest
CPR training for pool owners, parents, and caretakers. Use personal flotation
devices with watercraft sports.
 Firearm safety: firearms properly stored – locked up and not loaded – at all
times
 Promote use of approved helmets for bicycling, snowboarding, skiing,
motorcycling.
25
 ATVs and Motorcycles: The American Academy of Pediatrics specific
recommendation is that children under 16 should not operate off-road
motorized vehicles (i.e. ATV, personal watercraft, snowmobiles or mini bikes).
 Encourage sun avoidance or use of protective clothing while in the sun.
(Grade B Recommendation, USPSTF)22 Use SPF 15 or greater when in the
sun.
Education
 Suggest regular dental visits, counsel on oral hygiene and address fluoride
supplement for those with inadequate fluoride
 Promote a balanced diet high in fruits, vegetables, grains and fiber and
encourage adequate calcium intake (4 or more servings per day).
Recommend a diet low in saturated fat and cholesterol.
 Promote an active lifestyle with regular exercise. Limit screen time to no
more than 2 hours daily of quality programming for children 2 years and
older. (Screen time includes television, video games and computers.)
 Advise tobacco users to stop; counsel non-smokers to never start. Counsel
parents not to smoke. Discuss availability of nicotine replacement therapies
and medications as an adjunct to counseling.
 Discuss the hazards of alcohol and other substance use. Strongly advise
against the use of alcohol, tobacco and other illicit drugs by youth. Avoidance
of contaminated injection equipment to prevent HIV.
 Encourage sexual abstinence or monogamous sexual relationships, use of
condoms, and birth control. Counsel on STI and pregnancy prevention.
Recommend behavioral counseling to prevent STIs for all sexually active
adolescents at increased risk of STIs. (Grade B Recommendation, USPSTF)23
26
Section 5. Preventive Health Guideline for Adult Care
ADULT PREVENTIVE CARE TIMELINE
MEN AND WOMEN 18-29 30-39 40-49 50-64 65-69
Blood Pressure1 Every 1-2 years beginning at age 18
Universal screening once between ages 17-21, then every 5 years.

Lipid Screening2
lo,
High Sensitivity Fecal Occult
Blood Test annually
or
Sigmoidoscopy every 5 years
or
Colorectal CT Colonography (Virtual)
every 5 years*
Screening 3
or
Optical Colonoscopy
every 10 years
50-75 years of age
*Requires prior authorization
Screening for Pre Screen all people beginning at age 45. If

diabetes and normal and person has no risk factors, retest
Diabetes4 in 3 years.
Tobacco, Alcohol
All adults
and Depression5
BMI6 All adults
Hepatitis C Virus Not recommended at this

Screening7 time.
HIV Screening8 Screen all adults at increased risk.
Begin screening
Fall Screening9
at age 65.
MEN ONLY 18-29 30-39 40-49 50-69 70 AND OLDER
Once for 65
Abdominal Aortic yrs-75 men
Aneurysm10 who have
ever smoked.
27
Counsel men at least once
Prostate
regarding screening for
Screening11
prostate cancer.
Chlamydia and
Not recommend routine screening.
Gonorrhea12
WOMEN ONLY 18-29 30-39 40-49 50-64 65-69
Chlamydia and
Annually for all sexually active women age 24 and younger and others
Gonorrhea
at increased risk
Screening13
Begin
screening
low risk
Screen low risk populations every 3
Cervical Cancer populations
years with cytology only or 5 years with
Screening14 at age 21,
cotesting (cytology and high risk HPV).
every 3
years with
cytology.
Routine screening mammography every 1-2 years

for women aged 50-74. A baseline screening
mammogram should be obtained in average risk 40-
49 year old women, preferably at age 40.
Mammogram (with Recommend additional screening mammography
or without clinical for women age 40-49 every 1-2 years based on a
breast exam)15 discussion of the risks and benefits of
mammography in this age group. Recommend
screening every 1-2 years for women age 75-85
based on a discussion of the risks and benefits
of screening mammography in this age group.
Screen for
65 and older
Osteoporosis16
Screen women of childbearing age for

Screen for Violence17
intimate partner violence.
1. Hypertension –
Refer to the Physicians Plus Guideline for the Treatment of Hypertension for
detailed screening and treatment recommendations at
http://www.pplusic.com listed under Clinical Practice Guidelines. (Grade A
Recommendation, USPSTF)2
28
2. Dyslipidemia – 28-37
Universally screen once for adults age 17-21.
(Grade B Recommendation, National Heart Lung and Blood Institute)
Test with a fasting lipid panel (total cholesterol, LDL, HDL and
Triglycerides) or non-fasting total cholesterol and HDL once every 5 years.
Based on the judgment of the provider, if LDL and TG levels are low and
overall cardiovascular risk is low, subsequent screening maybe delayed
and considered every 10 years. If non-fasting study is performed and total
cholesterol is >200mg/dl or HDL is <40 mg/dl, follow up with lipoprotein
profile for LDL management. May stop screening at age 75.
3. Colorectal Screening -
Acceptable screening includes fecal occult blood testing, sigmoidoscopy or
colonoscopy. (Grade A Recommendation, USPSTF)35
Traditional also known as endoscopic or optical colonoscopy is
recommended every 10 years. Virtual is recommended every 5 years and
Physicians Plus requires prior authorization for coverage. Follow-up is based
on test findings. Recommend screening men and women age 50-75 years
for colorectal cancer. (Grade A Recommendation, USPSTF)38
4. Diabetes –
Physicians Plus refers to the American Diabetes Association (ADA)
Standards of Medical Care in Diabetes for specific screening, diagnosis and
treatment recommendations for patients with diabetes.39 This guideline is
available at http://www.pplusic.com listed under Clinical Practice
Guidelines.
The UW Health Preventative Health Care Guideline refers to the Wisconsin

Essential Diabetes Mellitus Care Guidelines for specific screening, diagnosis
and treatment recommendations for patients with diabetes.39 They are
available through U-Connect at https://uconnect.wisc.edu listed under
Clinical Practice Guidelines.
Screen all people with BMI less than 25 beginning at age 45. If normal and
person has no risk factors, retest in 3 years.
If BMI is greater than or equal to 25 with no or at least one additional risk
factor, begin screening sooner and perform annually. Screening can be
done with a fasting plasma glucose or A1C.
USPSTF recommends screening for type 2 diabetes in asymptomatic adults
with sustained blood pressure (either treated or untreated) greater than
135/80 mm Hg.
29
5. Tobacco, Alcohol and Depression -
Recommend that clinicians ask all adults about tobacco use and provide
tobacco cessation interventions for those who use tobacco products.
Provide alcohol-screening and behavioral counseling interventions to reduce
alcohol misuse by adults, including pregnant women in primary care
settings.
Screen adults for depression when staff assisted depression care supports
are in place to assure accurate diagnosis, effective treatment, and follow
up. No specific interval was recommended. (Grade B Recommendation,
USPSTF)43
Please refer to the Physicians Plus Guideline Diagnosing and Treating
Depression in Adults in Primary Care listed under Clinical Practice
Guidelines at http://www.pplusic.com
6. Obesity/BMI –
Screen all adult patients for obesity and offer intensive counseling and
behavioral interventions to promote sustained weight loss for obese adults.
7. Chronic Hepatitis C Virus (HCV) Infection –

CDC recommends adults born between the years 1945-1965 should receive
one time testing without prior ascertainment of risk of infection. Any patient
identified with HCV infection should receive a brief alcohol screening and
intervention if indicated, followed by referral to specialty care for HCV
infection and related conditions. 45
However, USPSTF recommends against routine screening for hepatitis C
virus (HCV) infection in asymptomatic adults who are not at increased risk
for infection.
(Grade D Recommendation, USPSTF, Update in Progress)46
8. HIV Screening -
Recommend clinicians screen for human immunodeficiency virus (HIV) for
all adults at increased risk for HIV infection.
(Grade A Recommendation, USPSTF) 47
9. Falls Risk Screening -

Screen all older individuals if they have fallen (in the past year).
The multifactorial fall risk assessment should be followed by direct
interventions tailored to the identified risk factors, coupled with an
appropriate exercise program.
30
(Grade A Recommendation, AGS)48
The components most commonly included in efficacious interventions were:
a) Adaptation or modification of home environment
b) Withdrawal or minimization of psychoactive medications
(Grade B Recommendation, AGS)48
c) Exercise, particularly balance, strength, and gait training
Primary care clinicians can consider the following factors to identify older
adults at increased risk for falls: a history of falls, a history of mobility
problems, and poor performance on the timed Get-Up-and-Go test
(observing the time it takes a person to rise from an armchair, walk 3
meters (10 feet), turn, walk back, and sit down again, <10 seconds).
(USPSTF and American Geriatrics Society/ British Geriatrics Society Clinical
Practice Guideline for Prevention of Falls in Older Persons)
http://www.uspreventiveservicestaskforce.org/uspstf11/fallsprevention/falls
prevrs.pdf
Recommend exercise or physical therapy and vitamin D supplementation to
prevent falls in community dwelling adults aged 65 years and older who are
at increased risk for falls.
(Grade B Recommendation, USPSTF) 49
http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm
10. Abdominal Aortic Aneurysm -

Recommend one time screening by ultrasonography in men aged 65-75 who
have ever smoked.
51-57
11. Prostate Cancer Screening –
Counsel men age 40-69, at least once regarding prostate cancer screening.
Discuss the potential benefits and harms of prostate specific antigen (PSA)
testing and treatment and consider patient risk factors. Risk factors for
increased prostate cancer mortality include African American ancestry or
having a first degree relative (father, brother or son), diagnosed with prostate
cancer at 65 years of age or younger. Do not recommend screening for men
70 years and older.
The USPSTF currently does not recommend PSA screening for prostate cancer.
(Grade D Recommendation, USPSTF)
The American Cancer Society and the American Urological Association
recommend discussion of the potential benefits and harms of PSA testing and
deciding with the patient whether to do PSA testing.
31
12. Chlamydia and Gonorrhea Screening for Men-
Annual screening for men who have sex with men. Recommend screening all
males whose partners have Chlamydia; those who attend sexually
transmitted infection clinics or clinics in communities were prevalence rates
are high. Males younger than 30 years of age who are in the military and
those in jail, males in juvenile justice facilities or Job Corps or anyone who
requests testing annually should be screened. Although evidence is
insufficient to recommend routine screening for C. trachomatis in sexually
active young men because of several factors (including feasibility, efficacy,
and cost-effectiveness) , the screening of sexually active young men should
be considered in clinical settings with a high prevalence of chlamydia (e.g.,
adolescent clinics, correctional facilities, and STD clinics) CDC 2010 STD
Guideline.58
13. Chlamydia and Gonorrhea Screening for Women -

At least annually for all sexually active woman age 24 and younger and for
older non pregnant women who are at increased risk for infection.
(Grade A Recommendation, USPSTF)59 Risk factors include having more than
one sexual partner, having had a sexually transmitted infection in the past, or
not using condoms consistently or correctly. Recommends screening for
human immunodeficiency virus (HIV) all adults at increased risk for HIV
infection.
14. Cervical Cancer Screening – 60-66

Screen women age 21-29 with cytology alone every 3 years. High risk
patients may require more frequent screening. High risk patients include:
HIV positive, immunocompromised (including transplant patients), have a
history of DES exposure or prior history of CIN 2, 3 or cervical cancer.
(Grade A Recommendation, USPSTF)
Screen women age 30-65 with a combination of cytology and high risk HPV
every 5 years OR screen with cytology only every 3 years.
(Grade A Recommendation, USPSTF)
Do not screen women younger than 21 years of age. Stop screening at age
65 if 3 normal cytology results OR 2 negative high risk HPV results in the last
decade AND no history of CIN 2, 3 or cervical cancer in the last 20 years. No
screening should be done after hysterectomy with removal of the cervix,
unless there is a history of CIN 2 or greater in the last 20 years. Patients
who have had supracervical hysterectomy should continue to have routine
screening.
32
15. Mammography Screening –
Asymptomatic women are those who currently do not have any breast
complaints. This excludes women who have symptoms which include but are
not limited to breast pain, nipple discharge and breast skin changes such as
dimpling, and/or new masses.
Women who are high risk and therefore do not meet the guidelines above are those
with:
High Risk Factor Screening Recommendation

Personal History of Breast Cancer Annual unless indicated by oncology
(includes invasive ductal, lobular and physicians
DCIS)
Breast Biopsy with Atypia or LCIS Annual unless indicated by oncology
physicians
First Degree relative with invasive 5 years earlier than the affected family
breast cancer member or at age 40; mammograms
every 1-2 years
Prior Chest Wall Radiation between Annual at 8 years post therapy or age 40
ages 10 and 30 for treatment of cancer
such as Hodgkins
Known BRCA 1 or 2 genetic mutation Annual at age 25
Family history of 2 family members Annual mammogram beginning 5 years
with breast cancer at any age from the prior to the earliest diagnosis or age 40
same side of the family (maternal or
paternal)
The following is a list of moderate risk factors for breast cancer. They may play a
role in determining when to obtain mammograms for screening but are still
undergoing investigation to determine how important a role they play in the
screening process:
1. Moderate to extreme breast density based on a screening mammogram
2. Obesity-BMI greater than 30
3. Alcohol intake on average of two drinks per day
4. Nulliparity
5. First birth after age 30
6. Menstrual cycles that started prior to age 12
7. Menopause that ended after age 55
33
8. Genetic Risk Factors
a. Family history of one family member with epithelial ovarian cancer
(maternal or paternal)
b. Family history of a male with breast cancer
c. Ashkenazi Jewish Heritage
d. Family history with one individual with breast cancer and any
additional individuals with cancers such as thyroid, sarcoma,
endometrial, pancreatic, gastric, lymphoma/leukemia
If a woman has one or several of these risk factors these factors should be
considered in the shared decision making discussion regarding the use of
screening mammography in the 40-49 and 75-85 age ranges and should be
factored into the shared decision making for annual mammography for
women in the 50-74 year old age range.
16. Osteoporosis –
Recommend women aged 65 and older be screened routinely. Recommend
routine screening for women who are post menopausal but under age 65 if
they are at increased risk for osteoporotic related fractures.(Grade B
Risk factors include but are not limited to: family history of osteoporosis or
personal history of fractures, low body weight, diabetes, steroid use,
rheumatoid arthritis, alcohol and tobacco use. May use FRAX calcualation to
estimate 10 year risk for major fracture.
68
http://www.shef.ac.uk/FRAX/tool.jsp?country=9#notes
17. Screen for Violence –

Screen women of childbearing age for intimate partner violence, such as
domestic violence and provide or refer women who screen positive to
intervention services. (Grade B Recommendation, USPSTF) 69
ADULT IMMUNIZATIONS
Please refer to the Recommended Adult Immunization Schedule, by Vaccine
and Medical and Other Indications approved by the Advisory Committee on
Immunization Practices, and the American Academy of Family Physicians and
the American College of Obstetricians and Gynecologists, the American
College of Physicians, and the American College of Nurse-Midwives. The
Schedule is provided in its entirety at the Centers for Disease Control website
at: http://www.cdc.gov/vaccines/schedules/hcp/adult.html70
34
ADULT HEALTH EDUCATION AND COUNSELING
Injury Prevention
 Urge avoidance of driving after use of alcohol, illicit drugs or non-prescribed
addictive drugs.
 Advocate use of seat belts, air bags and avoid texting while driving, as well
as use of a helmet when biking, skiing, snowboarding or motorcycling. Use
personal flotation devices for watercraft sports.
 Encourage avoidance of sun, or use of protective clothing and sunscreen (at
least SPF 15) while in the sun.
EDUCATION/COUNSELING
 Advise tobacco users to stop; counsel non-smokers to never start. Discuss
availability of nicotine replacement therapies and medications as an adjunct
to counseling. Please refer to the Physicians Plus Tobacco Cessation Guideline
at http://www.pplusic.com listed under Clinical Practice Guidelines.(Grade A
Recommendation)71
 Ask about alcohol use using the “quantity-frequency” questions; if the patient
is at risk for developing alcohol-related problems ask the questions for:
AUDIT http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf
ASSIST
http://www.who.int/substance_abuse/activities/assist_technicalreport_phase2_final.
pdf
SIP-AD or SDS
http://www.who.int/substance_abuse/research_tools/severitydependencescale/en/in
dex.html
SIP-AD and SDS questions need to be administered together. Assess
answers to determine the severity of the problem and advise and assist as
appropriate; if necessary, arrange treatment or follow-up. For additional
information on alcohol screening, please refer to the Physicians Plus Alcohol
Assessment and Intervention Guideline at: http://www.pplusic.com listed
under Clinical Practice Guidelines. Recommend avoidance of heavy alcohol
consumption.
 Promote a balanced diet high in fruits, vegetables, grains and fiber while low
in fat and cholesterol, and encourage adequate, age-appropriate calcium
intake. Maintain caloric balance.
 Recommend an active lifestyle with regular exercise. (Grade C
 Suggest regular dental visits and regular brushing and flossing.
35
 Recommend the use of aspirin for men age 45 to 79 years when the potential
benefit due to a reduction in myocardial infarctions outweighs the potential
harm due to an increase in gastrointestinal hemorrhage. (Grade A
Recommendation, USPSTF)73 Recommend the use of aspirin for women age
55 to 79 years when the potential benefit due to a reduction in stroke
outweighs the potential harm due to an increase in gastrointestinal
hemorrhage.
 Recommend women whose family history is associated with an increased risk
(breast or ovarian cancer) for deleterious mutations in BRCA1 or BRCA2
genes are referred for genetic counseling and evaluations for BRCA testing.
(Grade B Recommendation, USPSTF)74 Additional information under Clinical
Considerations
http://www.uspreventiveservicestaskforce.org/uspstf05/brcagen/brcagenrs.htm#clinical
 Recommend high-intensity behavioral counseling to prevent sexually
transmitted infections (STIs) for all sexually active adults at increased risk of
STIs.75 (Grade A Recommendation, USPSTF)
WEB SITES
If you are unable to access the Physicians Plus website, you can find a similar
copy of this guideline on these Web sites:
Unity Health Insurance: http://www.unityhealth.com/ under Providers, Practitioner
Resources, Clinical Guidelines
Group Health Cooperative: https://ghcscw.com/clinical_practice_guidelines.asp
Or, you can contact Physicians Plus at (608) 282-8900 to request this guideline
sent to your email or mailed in hard copy format.
36
References for Supporting Evidence
1. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Services
Task Force. Folic Acid to Prevent Neural Tube Defects. 2009.
<http://www.uspreventiveservicestaskforce.org/uspstf. Accessed December
2012.
2. Kirkham, Colleen, Susan Harris, et al. "Evidence-Based Prenatal Care: Part II.
Third-Trimester Care and Prevention of Infectious Diseases." American Family
Practice. 71.8 (2005): 1555-1560. Print.
<http://www.aafp.org/afp/2005/0415/p1555.html>.
3. "FAQ Group B Streptococcus and Pregnancy." American College of
Obstetricians and Gynecologists. FAQ 105. (2011): n. page. Print.
<http://www.acog.org/~/media/For
Patients/faq105.pdf?dmc=1&ts=20121210T1620390680>. Accessed November
2012.
Task Force. Screening and Behavioral Counseling Interventions in Primary Care
to Reduce Alcohol Misuse. 2004.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm>. Accessed
December 2012.
5. Department of Health and Human Services. Centers for Disease Control and
Prevention. Updated recommendation. 2012. Print.
<http://www.cdc.gov/vaccines/recs/provisional/downloads/Tdap-pregnant-Oct-
2012.pdf>.
Prevention. Advisory Committee on Immunization Practices (ACIP). Updated
Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and
Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have
or Anticipate Having Close Contact with an Infant Aged <12 Months. Morbidity
and Mortality Weekly Report (MMWR), 2011.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6041a4.htm?s_cid=mm6041a
4_e&source=govdelivery>.
37
7. "Update on Immunization and Pregnancy: Tetanus, Diptheria, and Pertussis
Vaccination." The American College of Obstetricians and Gynecologists
Committee Opinion. 521. (2012): n. page. Print.
<http://www.acog.org/~/media/Committee Opinions/Committee on Obstetric
Practice/co521.pdf?dmc=1&ts=20120423T1657138649>.
Prevention. Guidelines for Vaccinating Pregnant Women. 2011. Print.
<http://www.cdc.gov/vaccines/pubs/preg-guide.htm>.
9. "Practice Bulletin Hemoglobinopathies." American Congress of Obstetricians and
Gynecologists. (2007): n. page. Print.
Task Force. Counseling and Interventions to Prevent Tobacco Use and Tobacco-
Caused Disease in Adults and Pregnant Women. 2009. Print.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspstbac2.htm>.
Task Force. Primary Care Interventions to Promote Breastfeeding. 2008. Print.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrfd.htm>.
12. "U.S. Preventive Services Task Force." American Academy of Family Practice.
74.3 (2006): 461-464. Print. <http://www.aafp.org/afp/2006/0801/p461.html>.
Task Force. Universal Screening for Hearing Loss in Newborns. 2008. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsnbhr.htm>.
14. Wisconsin State Laboratory of Hygiene. Health Professionals Guide to Newborn
Screening. 2011. Web. <http://www.slh.wisc.edu/newborn/guide/>.
15. Policy Revision Committee. "Identifying Infants and Young Children with
Developmental Disorders in the Medical Home: An Algorithm for Developmental
Surveillance and Screening." American Academy of Pediatrics. 118. (2006): n.
page 405-420. Print.
16. Johnson, Chris, and Scott Myers. "Identification and Evaluation of Children with
Autism Spectrum Disorders." Pediatrics Journal. 120. (2007): 1183-1215. Print.
17. "Clinical Report—Hearing Assessment in Infants and." American Academy of
Pediatrics. 124. (2009): 1252-1263. Web. 11 Dec. 2012.
38
18. Agency for Healthcare Research and Quality (AHRQ). U.S. Preventive Health
Services. Screening for Visual Impairment in Children Ages 1 to 5 Years . 2011.
Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsvsch.htm>.
Services Task Force. Screening for Obesity in Children and Adolescents . 2011.
Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspschobes.htm>.
20. American Academy of Pediatrics. Red Book Atlas of Pediatric Infectious
Diseases. 1. 2007. Table 3.76. Print.
Prevention. Child, Adolescent & "Catch-up" Immunization Schedules. Web.
<http://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html>.
Task Force. Behavioral Counseling to Prevent Skin Cancer. 2012. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsskco.htm>.
Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted
Infections. 2008. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm>.
Services Task Force. Screening for HIV . 2005. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm>.
Services Task Force. Screening for Obesity in Children and Adolescents. 2010.
Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspschobes.htm>.
Services Task Force. Major Depressive Disorder in Children and Adolescents.
2009. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspschdepr.htm>.
Services Task Force. Screening for High Blood Pressure in Adults. 2007. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspshype.htm>.
39
Lipid References 28-37
28. Cooper, Neil, J Betteridge, et al. "European Heart Journal."Reductions in all-
cause, cancer, and coronary mortality in statin-treated patients with heterozygous
familial hypercholesterolaemia: a prospective registry study. 29.21 (2008): 2625-
2633. Web. 27 Nov. 2012.
<http://eurheartj.oxfordjournals.org/content/29/21/2625.full>.
29. Marks, Dayla, David Wonderling, et al. "BMJ Group." Cost effectiveness
analysis of different approaches of screening for familial hypercholesterolaemia.
324.7349 (2002): n. page. Web. 27 Nov. 2012.
<http://www.bmj.com/content/324/7349/1303>.
30. Marks, D, M Thorogood, et al. National Institute of Health. National Center for
Biotechnology Information. . Comparing costs and benefits over a 10 year period
of strategies. J Public Health Med, 2003. Web.
<http://www.ncbi.nlm.nih.gov/pubmed/12669918>.
31. McCrindle, Brian, Patrick McBride, et al. "Pediatrics." Guidelines for Lipid
Screening in Children and Adolescents: Bringing Evidence to the Debate. 130.2
(2012): 353-356. Web. 27 Nov. 2012.
<http://pediatrics.aappublications.org/content/130/2/353.full.pdf html>.
32. Nherera, L, D Marks, et al. "Heart and Education in Heart." Probabilistic cost-
effectiveness analysis of cascade screening for familial hypercholesterolaemia
using alternative diagnostic and identification strategies. 97.14 (2011): n. page.
Web. 27 Nov. 2012. <http://heart.bmj.com/content/97/14/1175.long>.
33. Nherera, L, NW Calvert , et al. "Current Medical Research and Opinions." Cost
effectivenessanalysis of the use of a high intensity statin compared to a low-
intensity statin in the management of patients with familial
hypercholesterolaemia. 26.3 (2010): 529-536. Web. 27 Nov. 2012.
<http://informahealthcare.com/doi/abs/10.1185/03007990903494934>.
34. Rodenburg, Jessica, Maude Vissers, et al. "American Heart Association
Circulation."Statin treatment in children with familial hypercholesterolemia: the
younger, the better. 116. (2007): 664-668. Web. 27 Nov. 2012.
<http://circ.ahajournals.org/content/116/6/664.abstract>.
35. Wiegman, Albert, Barbara Hutten, et al. "The Journal of American Medical
Association."Efficacy and safety of statin therapy in children with familial
hypercholesterolemia: a randomized controlled trial. 292.3 (2004): 331-337. Web.
27 Nov. 2012. <http://jama.jamanetwork.com/article.aspx?articleid=199118>.
36. Wonderling, D, MA Umans, et al. "Semiars in Vascular Medicine." Cost-
effectiveness analysis of the genetic screening program for familial
hypercholesterolemia in The Netherlands 4.4 (2004): 97-104. Print.
40
37. U.S. Department of Health and Human Services. National Heart Lung and Blood
Institute. Third Report of the Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). 2002.
Print. http://www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm
Services Task Force. Screening for Colorectal Cancer. 2008. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm>.
39. Division of Public Health. Wisconsin Essential Diabetes Mellitus Care Guidelines
2012. 2012. Print. <http://www.dhs.wisconsin.gov/publications/P4/P49356.pdf
Services Task Force. Screening for Type 2 Diabetes Mellitus in Adults. 2008.
Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm>.
Services Task Force. Counseling and Interventions to Prevent Tobacco Use and
Tobacco-Caused Disease in Adults and Pregnant Women. 2009. Web.
Services Task Force. Screening and Behavioral Counseling Interventions in
Primary Care to Reduce Alcohol Misuse. 2008. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm>.
Services Task Force. Screening for Depression in Adults. 2009. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsaddepr.htm>.
Services Task Force. Screening for and Management of Obesity in Adults. 2012.
Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsobes.htm>.
45. Smith, Bryce, Rebecca Morgan, et al. Department of Health and Human
Services. Centers for Disease Control and Prevention. Recommendations for the
Identification of Chronic Hepatitis C Virus Infection Among Persons Born During
1945–1965. 2012. Web. <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6104a1
Services Task Force. Screening for Hepatitis B Virus Infection in Nonpregnant
Adolescents and Adults. 2004. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspshepb.htm>.
Services Task Force. Screening for HIV. 2005. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspshivi.htm>.
48. American Geriatric Society. 2010 AGS/BGS Clinical Practice Guideline:
Prevention of Falls in Older Persons. (2010): n. page. Web. 10 Dec. 2012.
41
Services Task Force. Prevention of Falls in Community-Dwelling Older Adults.
2012. Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm>.
Services Task Force. Screening for Abdominal Aortic Aneurysm. 2005. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsaneu.htm>.
Prostate Cancer Screening References 51-57

51. Agency for Healthcare Reseach and Quality. U.S. Preventive Services Task
Force. Screening for Prostate Cancer. 2012. Web.
<http://www.uspreventiveservicestaskforce.org/prostatecancerscreening.htm>.
Prevention. United States Cancer Statistics: 1999–2008 Incidence and Mortality
Web-based Report. Atlanta: U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention and National Cancer Institute; 2012.
Print. <http://apps.nccd.cdc.gov/uscs/>.
53. Etzioni, R, A Tsodikov, et al. National Institute for Health. National Center for
Biotechnology Information. The prostate cancer conundrum revisited: Treatment
changes and prostate cancer mortality declines. 2012. Web.
54. Etzioni, R, A Tsodikov, et al. National Institute for Health. National Center for
Biotechnology Information. Quantifying the role of PSA screening in the US
prostate cancer mortality decline. 2008. Web.
55. Ganz, P, and W Burke. U.S. Department of Health and Human Services.
National Institutes of Health. NIH State-of-the-Science Conference: Role of
Active Surveillance in the Management of Men With Localized Prostate Cancer.
NIH Consensus State Sci Statements:. 2011. Print.
<http://consensus.nih.gov/2011/prostate.htm>.
56. Hamilton, Ann, and Lynn Ries. U.S. Department of Health and Human Services.
National Cancer Institute. Cancer Survival Among Adults: U.S. Seer Program,
1988-2001. Betesda, MD: SEER Program, 2007. Print.
<http://seer.cancer.gov/publications/survival/>.
57. Hugosson, Jonas, Sigrid Carlsson, et al. "The LANCET Oncology." Mortality
results from the Göteborg randomised population-based prostate-cancer
screening trial. 11.8 (2010): 725-732. Web. 27 Nov. 2012.
<http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(10)70146-
7/abstract>.
Prevention. 2010 STD Treatment Guidelines. 2010. Print.
<http://www.cdc.gov/std/treatment/2010/>.
42
Services Task Force. Screening for Chlamydial Infection. 2007. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspschlm.htm>
Cervical Cancer Screening References 60-66
60. Agency for Healthcare Research and Quality. U.S. Preventive Services Task
Force. Screening for Cervical Cancer. 2012. Available at:
http://www.uspreventiveservicestaskforce.org/uspstf.
61. "The American College of Obstetricians and Gynecologists Women's Health
Care Physicians Committee Opinion." Letter 463 of Cervical Cancer in
Adolescents: Screening, Evaluation, and Management. 2010. Print.
<http://www.acog.org/Resources_And_Publications/Committee_Opinions/Commi
ttee_on_Adolescent_Health_Care/Cervical_Cancer_in_Adolescents_-
_Screening_Evaluation_and_Management>.
62. "New Cervical Cancer Screening Recommendations from the U.S. Preventive
Services Task Force and the American Cancer Society/American Society for
Colposcopy and Cervical Pathology/American Society for Clinical Pathology."
The American Congress of Obstetricians and Gynecologists. N.p., 12 2012. Web.
27 Nov 2012. <http://www.acog.org/About_ACOG/Announcements/New_Cervical
Cancer_Screening_Recommendations
63. Rijkaart, Dorien, and Johannes Berkhof. "The LANCET Oncology." Human
Papillomavirus testing for the detection of high-grade cervical intraepithelial
neoplasia and cancer: final results of the POBASCAM randomized controlled
trial. 13.1 (2011): 78-88. Print.
<http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(11)70296-
0/abstract>.
64. Saslow, Debbie, Diane Solomon, et al. “American Society for Colposcopy and
Cervical Pathology and American Society for Clinical Pathology Screening
Guidelines for the Prevention and Early Detection of Cervical Cancer.“ American
Society of Clinical Pathology. 137. (2012): 516-542. Print.
<http://ajcp.ascpjournals.org/site/misc/pdf/Screening_Guidelines.pdf>.
65. Xian Wen, Jin, Andrea Skion, et al, et al. "Cleveland Clinic Journal of Medicine."
Cervical Cancer Screening: Less testing, Smarter Testing. 78.11 n. page. Web.
27 Nov. 2012.
<http://www.clevelandclinicmeded.com/online/journal/11_November-
2011/0530972/>.
66. Whitlock, Evelyn, Kimberly Vesco, et al. "Annals of Internal Medicine." Liquid
Based Cytology and HPV Testing to Screen for Cervical Cancer: A Systematic
Review for the US Preventive Services Task Force. 155.10 (2011): 687-697.
Web. 27 Nov. 2012. <http://annals.org/article.aspx?articleid=1033158>.
43
Services Task Force. Screening for Osteoporosis. 2011. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsoste.htm>.
68. World Health Organization Collaborating Centre for Metabolic Bone Diseases.
University of Sheffield, UK : , Web.
<http://www.shef.ac.uk/FRAX/tool.jsp?country=9
Services Task Force. Screening for Family and Intimate Partner Violence. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsfamv.htm>.
70. Department of Health and Human Services, Centers for Disease Control and
Prevention. (2010). Adult immunization schedule Retrieved from
http://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm#hcp
Services Task Force. Counseling and Interventions to Prevent Tobacco Use and
Tobacco-Caused Disease in Adults and Pregnant Women. 2009. Web.
Services Task Force. Behavioral Counseling to Promote a Healthful Diet and
Physical Activity for Cardiovascular Disease Prevention in Adults. 2012. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsphys.htm>.
Services Task Force. Aspirin for the Prevention of Cardiovascular Disease. 2009.
Web. <http://www.uspreventiveservicestaskforce.org/uspstf/uspsasmi.htm>.
Services Task Force. Genetic Risk Assessment and BRCA Mutation Testing for
Breast and Ovarian Cancer Susceptibility. 2005. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsbrgen.htm>.
Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted
Infections. 2008. Web.
<http://www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm>.
44
Benefits/Harms of Implementation
Potential Benefits:
In general this guideline will provide a systematic approach to screening for and
identifying preventive diseases.
Specific potential benefits and potential harms of individual tests must be

discussed by the provider at the time of recommendation.
Appropriate use of comprehensive approach of preventive services, counseling

and education and disease screening for average risk, asymptomatic patients will
result in an increase in patients who are up to date with preventive services.
Potential Harms:
Aspirin chemoprophylaxis- aspirin therapy has been associated with an
increase in gastrointestinal bleeding and hemorrhagic stroke.
Prostate cancer screening is associated with potential harms including frequent

false positives, leading to undue anxiety, unnecessary biopsies, and
complications of treatment of some cancers that may have not affected the
patient’s health.
Breast cancer screening is associated with potential harms of false positive

mammograms, unnecessary biopsies and anxiety.
Screening tests may lead to potential harm (from the study itself or as a result of
the findings on the screening study). This guideline does not provide detailed
review of the potential harms of every screening study or recommendation.
References are provided for detailed information.
Qualifying Statements (optional)

This clinical guideline is designed to assist clinicians by providing an analytical
framework for the evaluation and treatment of patients and is not intended either
to replace a clinician’s judgment or to establish a protocol for all patients with a
particular condition. A guideline will rarely establish the only approach to a
problem.
Implementation Strategy
Distribute to physician leads, directors and clinic managers and encourage
discussion in staff meetings.
Publicize new guidelines in the Physicians Plus Provider Newsletter.
45
Implementation Tools/Plan
Update links to the guideline on Physicians Plus’ website.
Disclaimer
This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all
patients. It is understood that some patients will not fit the clinical condition
contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem. Screening should always be considered in
the context of comorbidities and anticipated life expectancy. Decisions could be
made on case by case basis and screening may be discontinued as appropriate.
46
Apendix A
Preventive Health Guideline Workgroup Members

2012
Physician Champion Clinical Center for Clinical Knowledge
Sally Kraft, MD Management
Cheryl Schutte, MBA
Steering Committee
 Deloris Emspak, MD  Sally Kraft, MD  Cheryl Schutte

 Mary Landry, MD  Irene Hamrick, MD  Anna Dopp
 Joel Buchanan, MD  Jonas Lee, MD  Lisa Sherven, RN
 Julie Fagan, MD  Richard Brown, MD  Kim Volberg, RN
 Juanita Halls, MD  Jennie Hounshell, MD  Heather Mantzke
 Prasanna Raman, MD  Jon Keevil, MD  Jake Aleckson
 Mihai Teodorescu,  Richard Roberts, MD  Pam Kittleson
MD  Elaine Rosenblatt, NP  Bryan Gladding
 David Feldstein, MD  Kim Miller, MD  Susan Marks
 Meghan Ogden, MD
Specialty Work Groups
Cervical Cancer Screening Adult and Pediatric Immunization Breast Cancer Screening
Workgroup Jim Conway, MD Workgroup-
Ann Evensen, MD Jon Temte, MD Lee Wilke, MD
Jim Eastman, MD Sandy Jacobson Bill Caplan, MD
Jimmie Stewart, MD Immunization Task Force Beth Burnside, MD
Julie Fagan MD Betsy Trowbridge, MD
Kim Miller MD,GYN PSA Screening Workgroup
Meghan Ogden MD, GYN David Jarrard, MD Pediatric Workgroup
Stephen Nakada, MD Steve Koslov, MD
Lipid Screening Jonas Lee, MD Jeff Sleeth, MD
Pat McBride, MD Juanita Halls, MD Prasanna Raman, MD
Irene Hamrick, MD Irene Hamrick, MD Jennie Hounshell, MD
Juanita Halls, MD David Feldstein, MD
47
Expert Contributors
Expertise Experts
Lung Cancer Screening Mark Schiebler, MD
Colon Cancer Screening Pat Pfau, MD
Perry Pickhardt, MD
Depression Screening Roseanne Clark, MD
Diabetes Screening Melissa Meredith, MD
Drug Policy Program Anna Dopp
Laboratory (Domain) Teresa Darcy, MD
Keith Hoerth
Radiology (Domain) Gina Greenwood
Nutrition (Domain) Jane Dunn
Respiratory (Domain) Anne Flaten (adult) Rhonda Yngsdal-Krenz (peds)
Quality Safety Innovation Michael Phillips Rianna Murray
(Domain)
Rehab Therapy (Domain) Noreen Poirer
Osteoporosis Screening Neil Binkley, MD
48

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Preventive Health Care Guidelines -

CPG Contact for Content Questions or Changes:

CPG Contact for Physicians Plus:

Health Professionals Guide to Newborn Screening

Forward Health Portal

Edinburgh Questionnaire/UW Health Guideline Diagnosing and Treating

Childhood and Adolescent Screening Schedule

Badger Care Lead Screening Guidelines

Patient Health Questionnaire- PHQ-9

Centers for Disease Control Growth Charts

Wisconsin Essential Diabetes Mellitus Care Guidelines

Benefits and Harms Prostate-Specific Antigen-David Jarrard MD

Get up and Go Test

2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons

FRAX Osteoporosis Risk Calculation

Alcohol Use Disorders Identification Test-AUDIT

Alcohol, Smoking and Substance Involvement Screening Test-ASSIST

SIP-AD or Severity of Dependence Scale-SDS

United States Preventive Services Task Force

Pertinent UWHC Policies & Procedures

Clinical Practice Guideline (CPG) objective(s):

This guideline is not intended to diagnose or treat any condition. Once a

Interventions and Practices Considered:

Table 1: Rating Scheme for the Strength of the Evidence:

Grade Definition Suggestions for Practice

Description of the Methods Used to Analyze the Evidence:

Description of Methods Used to Formulate the Recommendations:

The expert contributors made up of physicians and staff in a specialty area

The Steering Committee is made up of primary care physicians, Ob-

See flow diagram below of the process.

 Members will serve as a representative of their discipline/department. They

Section 1. Preventive Health Guideline for Prenatal

FREQUENCY OF PRENATAL VISITS

GESTATIONAL AGE FREQUENCY OF VISITS

4 - 32 weeks Every 4 weeks

32 - 36 weeks Every 2 weeks

37+ weeks Every week

• Screen for HIV. • Screen for • Urine testing at  Screen for

TREATMENT Daily prenatal vitamin Provide Rh (D) • Administer Rh (D)

• Screen for rubella • Screen for • During flu • Varicella

PRENATAL HEALTH EDUCATION AND COUNSELING

3. Discuss benefits of breastfeeding during prenatal visits.

4. Offer amniocentesis or chorionic villi sampling for women 35 years or older.

7. Recommend routine screening for iron deficiency anemia in asymptomatic

INFANT-CHILD CARE TIMELINE

BP SCREEN At each At each

BMI6 Once Once Annually Annually

Developmental surveillance is recommended at all Well Child visits. Universal

2. Blood Lead Screening –

QUESTION TEST IF THE ANSWER IS

For MA (Badge Care Plus) Lead Screening Guidelines go to

Recommend routine iron supplementation for asymptomatic children aged 6

INFANT-CHILD HEALTH EDUCATION AND COUNSELING

Section 4. Preventive Health Guideline for Adolescent Care

ADOLESCENT CARE TIMELINE

BMI4 Annually Annually Annually Annually Annually Annually Annually

TUBERCULOSIS7 If at risk If at risk If at risk If at risk If at risk If at risk If at risk

2. Chlamydia, Gonorrhea Infection and HIV –

4. Obesity/BMI – For CDC clinical growth charts with BMI go to:

5. Lipid Screening – 28-37

ADOLESCENT HEALTH EDUCATION AND COUNSELING

ADULT PREVENTIVE CARE TIMELINE

MEN AND WOMEN 18-29 30-39 40-49 50-64 65-69

Blood Pressure1 Every 1-2 years beginning at age 18