Preventive Care of Adults Ages 19 Years and Older

S AND PRINCIPLES: Guidelines and principles are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines and principles should be followed in most cases. However, there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. PURPOSE: This guideline documents standards for preventive health services for adults. It is the expectation that primary care physicians will provide these services for their patients. These services can be completed as part of an age appropriate history and physical or during the course of routine office visits. These guidelines were developed for care of patients in the absence of symptoms or disease. While these guidelines will be applicable to asymptomatic patients under most circumstances, the clinician must consider whether special conditions require a different standard for a particular patient. This guideline does not replace the role of a comprehensive history and physical examination and it does not address the preventive health needs of pregnant women or individuals with chronic disorders, nor does it define benefits or reimbursement. KEY MESSAGES: Many cancer deaths can be prevented and the number of new cases can be reduced with early screening and treatment. Premature mortality, morbidity, and disability due to both cancer and chronic illnesses can be prevented by promoting healthy behaviors and encouraging modification of risk factors (i.e. tobacco use, nutrition, and exercise.) Immunization is a very simple and effective way to prevent serious illness and death in adults, and is one of the safest and most cost-effective preventive measures available. HIGH RISK POPULATIONS: All practitioners need to be aware that there are racial and ethnic disparities in the delivery of adult preventive health services. Minorities are more likely to be diagnosed with late-stage breast cancer and colorectal cancer compared with whites. African Americans and poorer patients have higher rates of avoidable hospital admissions (i.e., hospitalizations for health conditions that, in the presence of comprehensive primary care, rarely require hospitalization). METRICS: There are a number of HEDIS (Health Plan Employer Data and Information Set) measures which reflect adult preventive care, including: Colorectal Cancer Screening the percentage of adults 50-80 years of age who had appropriate screening for colorectal cancer. Page 1 of 10

Advising Smokers to Quit the percentage of adults 18 years and older (current smokers or recent quitters) who were seen by practitioner, who received advice to quit smoking. REFERENCES: These guidelines are based primarily on recommendations from the United States Preventive Services Task Force (USPSTF). Scientific evidence indicates that these interventions are effective in improving health outcomes and can reduce the incidence of illness, disease and accidents. In cases where the USPSTF concluded that an intervention is clinically valuable, but did not recommend the screening interval, we have established a frequency based on expert opinion. The guidelines are also based on recommendations from The Advisory Committee on Immunization Practices Recommended Adult Immunization Schedule (October 2004- September 2005), The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) (2002), Consensus Opinion of the North American Menopause Society (2001) and the American Academy of Family Physicians Policy Recommendations for Periodic Health Examinations (1996). FOR DISTRIBUTION TO: Internists, Family Practice Physicians, General Practice Physicians, Pediatricians and Obstetrician/Gynecologists. LAST REVISED BY: Paul Frame, MD, Family Medicine; David Gandell, MD, Obstetrics and Gynecology; Steven Goldberg, MD, Family Medicine; Jamie Kerr, MD, Internal Medicine; Kathy Riegel, MPH; Paul Rapoza, MD, Family Medicine; S. Ramalingam, MD, Family Medicine; Lisa D. Smith, RN, FNP, MSN. LAST APPROVED BY: The Rochester Health Commission s Community-Wide Clinical Guidelines Steering Committee on May 16, 2005. Next scheduled update by May 2007. Page 2 of 10

GRADING SYSTEM STRENGTH OF RECOMMENDATIONS: The Rochester Community-wide Clinical Guidelines Steering Committee on behalf of the Rochester Health Commission (RHC) grades its recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms). A RHC strongly recommends that clinicians provide [the service] to eligible patients. There is good evidence that [the service] improves important health outcomes to conclude that benefits substantially outweigh harms. B RHC recommends that clinicians provide [this service] to eligible patients. There is at least fair evidence that [the service] improves important health outcomes to conclude that benefits outweigh harms. C RHC makes no recommendation for or against routine provision of [the service]. There is at least fair evidence that [the service] can improve health outcomes to conclude that the balance of benefits and harms is too close to justify a general recommendation. D RHC recommends against routinely providing [the service] to asymptomatic patients. There is at least fair evidence that [the service] is ineffective or that harms outweigh benefits. I RHC concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined. QUALITY OF EVIDENCE: The quality of the overall evidence for a service is on a 3-point scale (good, fair, poor). Good Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes. Fair Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes. Poor Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes. Page 3 of 24

SCREENING AVERAGE RISK PROCEDURE WOMEN MEN Age Appropriate At each preventive health visit. History and Physical Exam, Risk Assessment 1&2 Blood Pressure 3 At least every 2 years (A). Age 65 and older - every 1-2 years. Height and Weight 4 Obesity Screening 5 Lipid Screening 6 Cervical Cancer Screening 7 Breast Cancer Screening 8 Colorectal Cancer Screening 9 Prostate Cancer 10 Depression Screening 11 Osteoporosis Screening 12 Visual Impairment 13 Hearing Impairment 14 At each preventive health visit Screen for obesity (B). Use height and weight to calculate BMI. Age 20 and older- Screen every 5 years. Obtain a fasting lipid profile. Within 3 years of onset of sexual activity or age 21 (whichever comes first), at least every 3 years (A). Age 40-69 - screening mammography, with or without clinical breast examination (CBE), every 1-2 years (B). Age 70 and older based on life expectancy. Age 50 and older (A). After the age of 80 based on life expectancy. Age 50 and older - counsel patients on known harms and potential benefits of screening (I) with PSA and Digital Rectal Exam. Screen for depression (B) (assuming systems are in place to assure accurate diagnosis, effective treatment, and followup) Age 60 - Routine screening for women at increased risk for osteoporotic fractures (B). Age 65 and older - Routine screening for all women (B). Age 65 and older - Perform Snellen testing and refer for periodic eye exam. Age 65 and older - Periodically question about hearing. Counsel about availability of treatment when appropriate. Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Bold italicized letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved May 16, 2005. Next scheduled update by May 2007. Page 4 of 10

SCREENING AT RISK PROCEDURE WOMEN MEN Diabetes 15 Screen adults with hypertension or dyslipidemia (B). Abdominal Aortic Aneurysm 16 At age 65-75 - one time screening by ultrasonography for men who have ever smoked (B). STD Testing Based on Screen those at increased risk. (A,B) Risk 17-20 (e.g. Chlamydia, HIV) Tuberculosis 21 Screen those at increased risk. (A). IMMUNIZATIONS PROCEDURE WOMEN MEN See attached Adult Immunization Table (CDC/ACIP). PROPHYLAXIS PROCEDURE WOMEN MEN Aspirin 22 Discuss ASA chemoprevention with adults who are at increased risk for CHD (A). COUNSELING PROCEDURE WOMEN MEN Folate 23 During childbearing years, encourage 0.4mg/day. Calcium 24 Assess dietary intake, encourage supplementation when appropriate. Hormone Replacement Therapy 25 Recommend against routine use of estrogen and progestin for prevention of chronic conditions in postmenopausal women (D). Tobacco Use 26 Screen for tobacco use and provide interventions (counseling, pharmacotherapy) for those who use tobacco products (A). Alcohol Misuse 27 Screen for alcohol misuse. Counsel those with risky/hazardous or harmful consumption (B). Injury Prevention 28 Counsel regarding accidental injury prevention including (as appropriate): lap/shoulder belt use, bicycle safety, motorcycle helmet use, smoke detectors, poison control center number, and driving while intoxicated. Sexual Health 29 Counsel regarding the risks for sexually transmitted diseases (STDs) and how to prevent them. Dental Health 30 Diet Counseling 31 Obesity Counseling 32 Advance Care Planning 33 Encourage oral hygiene and visit to dental care provider. For those with hyperlipidemia or other known risk factors for cardiovascular and diet-related chronic conditions - counsel (intensive) or refer regarding diet (B). For obese patients - counsel (intensive) or refer regarding diet, exercise or both (B). Age 18 and older - counsel all individuals regarding completion of advance directives. Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Bold italicized letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved May 16, 2005. Next scheduled update by May 2007. Page 5 of 10

SCREENING - USUAL RISK: Preventive Care of Adults Ages 19 Years and Older ANNOTATIONS 1 Age Appropriate History and Physical Exam: There are no studies comparing the efficacy of various schedules for preventive care visits. The intervals suggested below are based on a combination of various medical opinions and the frequency required by certain preventive services: 19-40 years: Every 5 years 41-50 years: Every 3 years 51-59 years: Every 2 years 60 years and over: Every 1-2 years 2 Risk Assessment: When conducting periodic health exams, consider leading causes of mortality and morbidity for the age group along with individual risk factors. 3 Blood Pressure: Normotensive adults should receive blood pressure measurements at least every 2 years if their last diastolic and systolic blood pressure readings were below 85 and 140 mm Hg, respectively (A). USPSTF 2003. Because prevalence rises with age, measurements are recommended every 1-2 years for those 65 and older. Expert Opinion. 4 Height and Weight: Height and weight should be measured at each preventive health examination. USPSTF 1996. 5 Obesity Screening: Screen all adults for obesity (B). Body mass index (BMI), calculated as weight in kilograms divided by height in meters squared is reliable and valid for identifying adults at increased risk for mortality and morbidity due to overweight and obesity. 6 Lipid Screening Routine cholesterol testing should begin in young adulthood ( 20 years of age). Lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) is the preferred initial test. In young adults, above-optimal LDL cholesterol levels deserve clinical attention through therapeutic lifestyle changes. The value of routine drug treatment for hyperlipidemia under the age 0f 35 has not been established. The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) 2002. 7 Cervical Cancer Screening: Screen for cervical cancer in women who have been sexually active and have a cervix. Screening with cervical cytology (Pap smears) reduces incidence of and mortality from cervical cancer. Indirect evidence suggests most of the benefit can be obtained by beginning screening within 3 years of onset of sexual activity or age 21 (whichever comes first) and screening at least every 3 years (A). Routine screening is not recommended for women who have had a total hysterectomy for benign disease and for women older than age 65 who have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer (D). USPSTF 2003. Use of monolayer technology is preferred given the sensitivity, specificity, and cost-effectiveness of this technology. Expert opinion and literature review. 02/05. Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Bold italicized letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved May 16, 2005. Next scheduled update by May 2007. Page 6 of 10

8 Breast Cancer Screening: Screening mammography, with or without clinical breast examination (CBE), is recommended every 1-2 years for women aged 40 and older (B). Evidence for benefit is also generalizable to women aged 70 and older (who face a higher absolute risk for breast cancer) if their life expectancy is not compromised by comorbid disease. Evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer, or to recommend for or against teaching or performing routine breast self-examination (I). USPSTF 2002. 9 Colorectal Cancer Screening: Screen men and women 50 years of age or older for colorectal cancer. Several screening methods are effective in reducing mortality from colorectal cancer. Potential options include home FOBT, flexible sigmoidoscopy, the combination of home FOBT and flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema. Each option has advantages and disadvantages that may vary for individual patients and practice settings. The choice of specific screening strategy should be based on patient preferences, medical contraindications, patient adherence, and available resources for testing and follow-up. Clinicians should talk to patients about the benefits and potential harms associated with each option before selecting a screening strategy. Neither digital rectal examination (DRE) nor the testing of a single stool specimen obtained during DRE is recommended as an adequate screening strategy for colorectal cancer. 10 Prostate Cancer Screening: The evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE) (I). Given the uncertainties and controversy surrounding prostate cancer screening, clinicians should not order the PSA test without first discussing with the patient the known harms and potential benefits of screening. Harms include false-positive and false negative results, unnecessary anxiety and biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. Men should be informed of the gaps in the evidence, and they should be assisted in considering their personal preferences and risk profile before deciding whether to be tested. USPSTF 2002. 11 Depression Screening: Screening adults for depression is recommended in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up (B). Benefits from screening are unlikely to be recognized unless such systems are functioning well. Many formal screening tools are available (e.g., the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire [GHQ], Center for Epidemiologic Study Depression Scale [CES-D]). Asking two simple questions about mood and anhedonia ("Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?") may be as effective as using longer instruments. USPSTF 2002. (Refer to guideline Identification and Treatment of Major Depression in Primary Care for Adults Age 18 and Older for available treatment options and follow-up care.) 12 Osteoporosis Screening: Women aged 65 and older should be screened routinely for osteoporosis (B). Routine screening should begin at age 60 for women at increased risk for osteoporotic fractures (B). The risk for osteoporosis and fracture increases with age and other factors. Bone density measurements accurately predict the risk for fractures in the short-term, and treating asymptomatic women with osteoporosis reduces their risk for fracture. The exact risk factors that should trigger screening in this age group are difficult to specify based on evidence. Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density. Low weight and no current use of estrogen therapy are incorporated with age into the 3-item Osteoporosis Risk Assessment Instrument (ORAI). There is less evidence to support the use of other individual risk factors (for example, smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake) as a basis for identifying high-risk women younger than 65. At any Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Bold italicized letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved May 16, 2005. Next scheduled update by May 2007. Page 7 of 10

given age, African-American women on average have higher bone mineral density (BMD) than white women and are thus less likely to benefit from screening. USPSTF 2002. 13 Visual Impairment: USPSTF 1996. 14 Hearing Impairment: Screening for older adults is recommended through periodically questioning them about their hearing, counseling them about the availability of hearing aid devices, and making referrals for abnormalities when appropriate. USPSTF 1996. SCREENING - AT RISK: 15 Diabetes: The evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose (I). Screening is recommended for type 2 diabetes in adults with hypertension or hyperlipidemia (B). The ADA recommends the fasting plasma glucose (FPG) for screening over other options. USPSTF 2003. 16 Abdominal Aortic Aneurysm: One-time screening by ultrasonography is recommended in men aged 65 to 75 who have ever smoked [*at least 100 cigarettes in person s lifetime] (B). There is no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked (C). The USPSTF recommends against routine screening for AAA in women (D). One-time screening to detect an AAA using ultrasonography is sufficient. There is negligible health benefit in re-screening those who have normal aortic diameter on initial screening. USPSTF 2005. 17 Chlamydia: Routinely screen all sexually active women aged 25 years and younger and other asymptomatic women at increased risk for infection. (A) Age is the most important risk marker. Other patient characteristics associated with a higher prevalence of infection include being unmarried, African-American race, having a prior history of sexually transmitted disease (STD), having new or multiple sexual partners, having cervical ectopy, and using barrier contraceptives inconsistently. USPSTF 2001. 18 HIV: Clinicians should assess risk factors for HIV infection in all patients by obtaining a careful sexual history and inquiring about drug use. There is insufficient evidence to recommend for or against routine HIV screening in persons without identified risk factors (C). Counseling and testing for HIV should be offered to all persons at increased risk for infection (A): those seeking treatment for sexually transmitted diseases; men who have had sex with men after 1975; past or present injection drug users; persons who exchange sex for money or drugs and their sex partners; women and men whose past or present sex partners were HIV-infected; bisexuals; or injection drug users and persons with a history of transfusion between 1978 and 1985. USPSTF 1996. 19 Syphilis: Screening persons at increased risk for syphilis infection and pregnant women is strongly recommended (A). Persons at increased risk because of high-risk sexual activities include commercial sex workers, persons who exchange sex for drugs, those with other sexually transmitted diseases (STDs) including HIV, and contacts of persons with active syphilis. USPSTF 2004. 20 Gonorrhea: Routine screening of men or women is not recommended in the general population of low-risk adults (D) Routine screening for gonorrhea is recommended for asymptomatic women at high risk of infection (B). High-risk groups include commercial sex workers (prostitutes), persons with a history of repeated episodes of gonorrhea, and young women (under age 25) with two or more sex partners in the last year. There is Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Bold italicized letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved May 16, 2005. Next scheduled update by May 2007. Page 8 of 10

insufficient evidence to recommend for or against screening high-risk men for gonorrhea (C). USPSTF 1996. 21 Tuberculosis (PPD): Screening for tuberculous infection by tuberculin skin testing is recommended for all persons at increased risk of developing tuberculosis (TB) (A). Asymptomatic persons at increased risk include persons infected with HIV, close contacts of persons with known or suspected TB (including health care workers), persons with medical risk factors associated with TB, immigrants from countries with high TB prevalence (e.g., most countries in Africa, Asia, and Latin America, medically underserved low-income populations (including high-risk racial or ethnic minority populations), alcoholics, injection drug users, and residents of long-term care facilities (e.g., correctional institutions, mental institutions, nursing homes). PROPHYLAXIS: 22 Aspirin: Discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease (CHD) (A). Men older than 40 years, postmenopausal women, and younger people with risk factors for coronary heart disease (e.g., hypertension, diabetes, or smoking) are at increased risk. Discussions with patients should address both the potential benefits and harms of aspirin therapy. Risk assessment should include asking about the presence and severity of the following risk factors: age, sex, diabetes, elevated total cholesterol levels, low levels of high-density lipoprotein (HDL) cholesterol, elevated blood pressure, family history (in younger adults), and smoking. USPSTF 2002. COUNSELING: 23 Folate: Daily multivitamins with folic acid to reduce the risk of neural tube defects are recommended for all women who are planning or capable of pregnancy. USPSTF 1996. 24 Calcium: Estimates of adequate intakes of calcium, vitamin D, and magnesium for peri-and postmenopausal women are based on evidence relating to osteoporosis prevention. At least 1,200 mg/day calcium is required for most women. A dietary intake of 400-600 IU of vitamin D is recommended, either through sun exposure or through dietary intake. There is no current evidence to support magnesium supplementation for most peri-and postmenopausal women who ingest a balanced diet. Consensus Opinion of The North American Menopause Society 2001. 25 Hormone Replacement Therapy: The routine use of estrogen and progestin for the prevention of chronic conditions in postmenopausal women is not recommended (D). The harmful effects of estrogen and progestin are likely to exceed the chronic disease prevention benefits in most women. The evidence is insufficient to recommend for or against the use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy (I). USPSTF 2002. 26 Tobacco Use: Screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products (B). Brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year. USPSTF 2003. 27 Alcohol Misuse: Screening and behavioral counseling interventions* to reduce alcohol misuse are recommended (B). Screening in primary care settings can accurately identify patients whose levels or patterns Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Bold italicized letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved May 16, 2005. Next scheduled update by May 2007. Page 9 of 10

of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality. Brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer. Alcohol misuse includes "risky/hazardous" and "harmful" drinking that places individuals at risk for future problems. "Risky" or "hazardous" drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. "Harmful drinking" describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet criteria for dependence. [*Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting, with further assistance and follow-up.] USPSTF 2004. 28 Injury Prevention: The AAFP Summary of Policy Recommendations for Periodic Health Examinations (RPHE), 1996. Last revised August 2004. 29 Sexual Health: The AAFP Summary of Policy Recommendations for Periodic Health Examinations (RPHE), 1996. Last revised August 2004. 30 Dental Health: Counseling patients to visit a dental care provider on a regular basis, floss daily, brush their teeth daily with a fluoride-containing toothpaste, and appropriately use fluoride for caries prevention and chemotherapeutic mouth rinses for plaque prevention is recommended. USPSTF 1996. 31 Diet Counseling: Medium- to high-intensity * counseling interventions can produce medium-to-large changes in average daily intake of core components of a healthy diet (including saturated fat, fiber, fruit, and vegetables) among adult patients at increased risk for diet-related chronic disease (B). [* greater than two contacts of 30 minutes or more.] Major diseases in which diet plays a role include coronary heart disease, some types of cancer, stroke, hypertension, obesity, osteoporosis, and non-insulin-dependent diabetes mellitus. Evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients (I). USPSTF 2003. 32 Obesity Counseling: High -intensity counseling* about diet, exercise, or both together with behavioral interventions aimed at skill development, motivation, and support strategies produces modest, sustained weight loss (typically 3-5 kg for 1 year or more) in adults who are obese (as defined by BMI > 30 kg/m 2 ) (B). [*more than 1 person-to-person (individual or group) session per month for at least the first 3 months.] The most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies to help patients acquire the skills and supports needed to change eating patterns and to become physically active. It is advisable to refer obese patients to programs that offer intensive counseling and behavioral interventions for optimal weight loss. USPSTF 2003. 33 Advance Care Planning: Advance Care Planning is a process that requires conversation and results in the completion of an Advance Care Directive. An Advance Care Directive allows patient preferences and goals to drive care and to guide shared medical decision making in the event the patient is unable to communicate. Studies have demonstrated that physician counseling markedly increases the completion rate of Advance Care Directives. Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Bold italicized letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved May 16, 2005. Next scheduled update by May 2007. Page 10 of 10

Recommended Adult Immunization Schedule, by Vaccine and Age Group UNITED STATES, OCTOBER 2005 SEPTEMBER 2006 Vaccine Age group 19 49 years 50 64 years > 65 years Tetanus, diphtheria (Td) 1 * 1-dose booster every 10 yrs Measles, mumps, rubella (MMR) 2 * 1or 2 doses 1 dose Varicella 3 * 2 doses (0, 4 8 wks) 2 doses (0, 4 8 wks) Vaccines below broken line are for selected populations Influenza 4 * 1 dose annually 1 dose annually Pneumococcal (polysaccharide) 5,6 1 2 doses 1 dose Hepatitis A 7 * 2 doses (0, 6 12 mos, or 0, 6 18 mos) Hepatitis B 8 * 3 doses (0, 1 2, 4 6 mos) Meningococcal 9 1 or more doses NOTE: These recommendations must be read along with the footnotes. *Covered by the Vaccine Injury Compensation Program. For all persons in this category who meet the age requirements and who lack evidence of immunity (e.g., lack documentation of vaccination or have no evidence of prior infection) Recommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications) This schedule indicates the recommended age groups and medical indications for routine administration of currently licensed vaccines for persons aged >19 years. Licensed combination vaccines may be used whenever any components of the combination are indicated and when the vaccine s other components are not contraindicated. For detailed recommendations, consult the manufacturers package inserts and the complete statements from the ACIP (www.cdc.gov/nip/publications/acip-list.htm). Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a VAERS report are available by telephone, 800-822-7967, or from the VAERS website at www.vaers.hhs.gov. Information on how to file a Vaccine Injury Compensation Program claim is available at www.hrsa.gov/osp/vicp or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Madison Place, N.W., Washington D.C. 20005, telephone 202-357-6400. Additional information about the vaccines listed above and contraindications for vaccination is also available at www.cdc.gov/nip or from the CDC-INFO Contact Center at 800-CDC-INFO (232-4636) in English and Spanish, 24 hours a day, 7 days a week. Department of Health and Human Services Centers for Disease Control and Prevention

Recommended Adult Immunization Schedule, by Vaccine and Medical and Other Indications UNITED STATES, OCTOBER 2005 SEPTEMBER 2006 Vaccine Indication Pregnancy Congenital immunodeficiency; leukemia; 10 lymphoma; generalized malignancy; cerebrospinal fluid leaks; therapy with alkylating agents, antimetabolites, radiation, or highdose, long-term corticosteroids Diabetes; heart disease; chronic pulmonary disease; chronic liver disease, including chronic alcoholism Asplenia 10 (including elective splenectomy and terminal complement component deficiencies) Kidney failure, end-stage renal disease, recipients of hemodialysis or clotting factor concentrates Human immunodeficiency virus (HIV) infection 2,10 Healthcare workers Tetanus, diphtheria (Td) 1 * 1-dose booster every 10 yrs Measles, mumps, rubella (MMR) 2 * 1 or 2 doses Varicella 3 * 2 doses (0, 4 8 wks) 2 doses Influenza 4 * 1 dose annually 1 dose annually 1 dose annually Pneumococcal (polysaccharide) 5,6 1 2 doses 1 2 doses 1 2 doses Hepatitis A 7 * 2 doses (0, 6 12 mos, or 0, 6 18 mos) Hepatitis B 8 * 3 doses (0, 1 2, 4 6 mos) 3 doses (0, 1 2, 4 6 mos) Meningococcal 9 1 dose 1 dose 1 dose NOTE: These recommendations must be read along with the footnotes. *Covered by the Vaccine Injury Compensation Program. For all persons in this category who meet the age requirements and who lack evidence of immunity (e.g., lack documentation of vaccination or have no evidence of prior infection) Recommended if some other risk factor is present (e.g., based on medical, occupational, lifestyle, or other indications) Contraindicated Approved by the Advisory Committee on Immunization Practices (ACIP), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP)

Footnotes Recommended Adult Immunization Schedule, UNITED STATES, OCTOBER 2005 SEPTEMBER 2006 1. Tetanus and Diphtheria (Td) vaccination. Adults with uncertain histories of a complete primary vaccination series with diphtheria and tetanus toxoid-containing vaccines should receive a primary series using combined Td toxoid. A primary series for adults is 3 doses; administer the first 2 doses at least 4 weeks apart and the third dose 6 12 months after the second. Administer 1 dose if the person received the primary series and if the last vaccination was received >10 years previously. Consult ACIP statement for recommendations for administering Td as prophylaxis in wound management (www.cdc.gov/mmwr/preview/mmwrhtml/00041645.htm). The American College of Physicians Task Force on Adult Immunization supports a second option for Td use in adults: a single Td booster at age 50 years for persons who have completed the full pediatric series, including the teenage/young adult booster. A newly licensed tetanusdiphtheria-acellular pertussis vaccine is available for adults. ACIP recommendations for its use will be published. 2. Measles, Mumps, Rubella (MMR) vaccination. Measles component: adults born before 1957 can be considered immune to measles. Adults born during or after 1957 should receive >1 dose of MMR unless they have a medical contraindication, documentation of >1 dose, history of measles based on healthcare provider diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who 1) were recently exposed to measles or in an outbreak setting, 2) were previously vaccinated with killed measles vaccine, 3) were vaccinated with an unknown type of measles vaccine during 1963 1967, 4) are students in postsecondary educational institutions, 5) work in a healthcare facility, or 6) plan to travel internationally. Withhold MMR or other measles-containing vaccines from HIV-infected persons with severe immunosuppression. Mumps component: 1 dose of MMR vaccine should be adequate for protection for those born during or after 1957 who lack a history of mumps based on healthcare provider diagnosis or who lack laboratory evidence of immunity. Rubella component: administer 1 dose of MMR vaccine to women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Do not vaccinate women who are pregnant or might become pregnant within 4 weeks of receiving the vaccine. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the healthcare facility. 3.Varicella vaccination. Varicella vaccination is recommended for all adults without evidence of immunity to varicella. Special consideration should be given to those who 1) have close contact with persons at high risk for severe disease (healthcare workers and family contacts of immunocompromised persons) or 2) are at high risk for exposure or transmission (e.g., teachers of young children; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). Evidence of immunity to varicella in adults includes any of the following: 1) documented age-appropriate varicella vaccination (i.e., receipt of 1 dose before age 13 years or receipt of 2 doses [administered at least 4 weeks apart] after age 13 years); 2) born in the United States before 1966; 3) history of varicella disease based on healthcare provider diagnosis or self- or parental report of typical varicella disease for non U.S.-born persons born before 1966 and all persons born during 1966 1997 (for a patient reporting a history of an atypical, mild case, healthcare providers should seek either an epidemiologic link with a typical varicella case or evidence of laboratory confirmation, if it was performed at the time of acute disease); 4) history of herpes zoster based on healthcare provider diagnosis; or 5) laboratory evidence of immunity. Do not vaccinate women who are pregnant or might become pregnant within 4 weeks of receiving the vaccine. Assess pregnant women for evidence of varicella immunity. Women who do not have evidence of immunity should receive dose 1 of varicella vaccine upon completion or termination of pregnancy and before discharge from the healthcare facility. Dose 2 should be given 4 8 weeks after dose 1. 4. Influenza vaccination. Medical indications: chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus, renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression caused by medications or by HIV ); any condition (e.g., cognitive dysfunction, spinal cord injury, seizure disorder or other neuromuscular disorder) that compromises respiratory function or the handling of respiratory secretions or that can increase the risk of aspiration; and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. Occupational indications: healthcare workers and employees of long-term care and assisted living facilities. Other indications: residents of nursing homes and other long-term care and assisted living facilities; persons likely to transmit influenza to persons at high risk (i.e., in-home household contacts and caregivers of children birth through 23 months of age, or persons of all ages with high-risk conditions); and anyone who wishes to be vaccinated. Department of Health and Human Services Centers for Disease Control and Prevention

Footnotes Recommended Adult Immunization Schedule, UNITED STATES, OCTOBER 2005 SEPTEMBER 2006 For healthy nonpregnant persons aged 5 49 years without high-risk conditions who are not contacts of severely immunocompromised persons in special care units, intranasally administered influenza vaccine (FluMist ) may be administered in lieu of inactivated vaccine. 5. Pneumococcal polysaccharide vaccination. Medical indications: chronic disorders of the pulmonary system (excluding asthma); cardiovascular diseases; diabetes mellitus; chronic liver diseases, including liver disease as a result of alcohol abuse (e.g.,cirrhosis); chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection [vaccinate as close to diagnosis as possible when CD4 cell counts are highest], leukemia, lymphoma, multiple myeloma, Hodgkin disease, generalized malignancy, organ or bone marrow transplantation); chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids; and cochlear implants. Other indications: Alaska Natives and certain American Indian populations; residents of nursing homes and other long-term care facilities. 6. Revaccination with pneumococcal polysaccharide vaccine. One-time revaccination after 5 years for persons with chronic renal failure or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy); immunosuppressive conditions (e.g., congenital immunodeficiency, HIV infection, leukemia, lymphoma, multiple myeloma, Hodgkin disease, generalized malignancy, organ or bone marrow transplantation); or chemotherapy with alkylating agents, antimetabolites, or high-dose, long-term corticosteroids. For persons aged >65 years, one-time revaccination if they were vaccinated >5 years previously and were aged <65 years at the time of primary vaccination. 7. Hepatitis A vaccination. Medical indications: persons with clotting factor disorders or chronic liver disease. Behavioral indications: men who have sex with men or users of illegal drugs. Occupational indications: persons working with hepatitis A virus (HAV)-infected primates or with HAV in a research laboratory setting. Other indications: persons traveling to or working in countries that have high or intermediate endemicity of hepatitis A (for list of countries, visit www.cdc.gov/travel/diseases.htm#hepa) as well as any person wishing to obtain immunity. Current vaccines should be given in a 2-dose series at either 0 and 6 12 months, or 0 and 6 18 months. If the combined hepatitis A and hepatitis B vaccine is used, administer 3 doses at 0, 1, and 6 months. 8. Hepatitis B vaccination. Medical indications: hemodialysis patients (use special formulation [40 µg/ml] or two 20-µg/mL doses) or patients who receive clotting factor concentrates. Occupational indications: healthcare workers and public-safety workers who have exposure to blood in the workplace; and persons in training in schools of medicine, dentistry, nursing, laboratory technology, and other allied health professions. Behavioral indications: injection-drug users; persons with more than one sex partner in the previous 6 months; persons with a recently acquired sexually transmitted disease (STD); and men who have sex with men. Other indications: household contacts and sex partners of persons with chronic hepatitis B virus (HBV) infection; clients and staff of institutions for the developmentally disabled; all clients of STD clinics; inmates of correctional facilities; or international travelers who will be in countries with high or intermediate prevalence of chronic HBV infection for >6 months (for list of countries, visit www.cdc.gov/travel/diseases.htm#hepa). 9. Meningococcal vaccination. Medical indications: adults with anatomic or functional asplenia, or terminal complement component deficiencies. Other indications: first-year college students living in dormitories; microbiologists who are routinely exposed to isolates of Neisseria meningitidis; military recruits; and persons who travel to or reside in countries in which meningococcal disease is hyperendemic or epidemic (e.g., the meningitis belt of sub-saharan Africa during the dry season [Dec June]), particularly if contact with the local populations will be prolonged. Vaccination is required by the government of Saudi Arabia for all travelers to Mecca during the annual Hajj. Meningococcal conjugate vaccine is preferred for adults meeting any of the above indications who are aged <55 years, although meningococcal polysaccharide vaccine (MPSV4) is an acceptable alternative. Revaccination after 5 years may be indicated for adults previously vaccinated with MPSV4 who remain at high risk for infection (e.g., persons residing in areas in which disease is epidemic). 10.Selected conditions for which Haemophilus influenzae type b (Hib) vaccine may be used. Haemophilus influenzae type b conjugate vaccines are licensed for children aged 6 weeks 71 months. No efficacy data are available on which to base a recommendation concerning use of Hib vaccine for older children and adults with the chronic conditions associated with an increased risk for Hib disease. However, studies suggest good immunogenicity in patients who have sickle cell disease, leukemia, or HIV infection, or have had splenectomies; administering vaccine to these patients is not contraindicated. Approved by the Advisory Committee on Immunization Practices (ACIP), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP)