Title: General Health Maintenance: Adult Health Maintenance

Date: November 2005

Rationale for Guideline:

“These guidelines are informational only and are not intended or designed to substitute the reasonable exercise of independent clinical judgment by providers in any particular set of circumstances for each patient encounter. The guidelines are flexible and are intended to be used as a resource for integration with a sound exercise of clinical judgment. They can be used to create an approach to care that is unique to the needs of each individual patient. The implementation of this guideline is not intended to conflict with any agreed upon health plan benefits nor is it intended to prevent access to care that the practitioner believes is warranted based on clinical judgement.”

Adult health maintenance guidelines were developed in 1989 and regularly reviewed and revised since that time. The rationale for these guidelines is to support consistent, appropriate and effective assessment, screening, immunizations and counseling for adult asymptomatic members. Guidelines are based on the most current scientific evidence, consensus statements of expert panels, recommendations of the United States Preventive Services Task Force and recommendations of medical specialty organizations when appropriate.

All guidelines are population based. It is our position that they be evidence rather than expert based. It is our intent to use guidelines to guide care decision, rather than deny care recommended by expert panels, inform our members of the lack of evidence supporting recommendations when appropriate and provide preventive services with shared decision making in areas where there are recommendations but no evidence.

Target Population:

All asymptomatic adult members (ages 18 and older), primarily but not exclusively, delivered through primary care.

Responsible Parties: Eric France, MD, Elizabeth Gay, Primary Care Quality Council.

Approval: Departments of Internal Medicine, Family Practice, OB/GYN.

Review Date: Initial adoption, January 1991 Reviewed 8/94, 7/97, 7/99, 8/01, 8/03, 11/05.

Recommendations: Attached

Source of Evidence:

US Preventive Services Task Force Recommendation

Recommendations of appropriate medical specialty organizations

Literature review on efficacy of screening tests

Visit frequency recommendations from primary care departments at KP

Setting for Application:

Primarily but not exclusively adult primary care departments. Preventive care should be integrated with primary care at all visit types when feasible.

Methods for Measuring Compliance:

Annual HEDIS measures for mammography, pap smears

Annual influenza administrative audit

Regular compliance audits with other recommendations such as tobacco use, blood pressure assessment, lipid measurers, immunizations.

KAISER PERMANENTE 2005

MEN’S HEALTH RECOMMENDATIONS—PREVENTIVE MEDICINE PROCEDURES

AGE * / PREVENTIVE
PROCEDURE / KAISER PERMANENTE
RECOMMENDATIONS
18-39 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Tetanus booster
Meningococcal conjugate vaccine / Every 2 years†
Body Mass Index (screening for overweight) every 2-5 years†
Fasting lipid profile at least once
At least once between ages 18 and 49
Adults 18-21
40-49 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2-5 years†
Every five years, with fasting lipid profile
At least once between ages 18 and 49
50-64 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Colorectal cancer screening
Influenza vaccine
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Every five years, with fasting lipid profile
Flexible sigmoidoscopy every 10 years and fecal occult blood test every 1-2 years
Every year
At least once
65-75 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Abdominal aortic aneurysm screening
Colorectal cancer screening
Influenza vaccine
Pneumonia vaccine
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Every five years, with fasting lipid profile
Once for men who ever smoked
Flexible sigmoidoscopy every 10 years and fecal occult blood test every 1-2 years
Every year
Once after age 65
At least once if no booster since age 50
Over 75 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Colorectal cancer screening
Influenza vaccine
Pneumonia vaccine
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Individualize need for cardiac risk assessment and fasting lipid profile
Flexible sigmoidoscopy every 10 years and fecal occult blood test every 1-2 years, to age 80 as health permits
Every year
Once after age 65
At least once if no booster since age 50

Screening for prostate cancer with digital rectal exam and PSA is of uncertain benefit. Men who are interested in prostate cancer screening between ages 40 and 70 should understand the potential risks of testing and treatment and the lack of evidence supporting these tests.

*Counseling at all ages: tobacco use, nutrition, diet & exercise, weight management, alcohol & other drug use, injury prevention, sexual behavior, dental health.

† Frequency of blood pressure and BMI screening is based on recommended frequency of prevention office visits.

KAISER PERMANENTE 2005

WOMEN’S HEALTH RECOMMENDATIONS—PREVENTIVE MEDICINE PROCEDURES

AGE* / PREVENTIVE PROCEDURE / KAISER PERMANENTE

RECOMMENDATIONS

Younger than 18 years / Chlamydia screening (urine/cervical)
Pap smear
Other procedures / Annually for sexually active females.
PAP smears every 2 years, starting 3 years after becoming sexually active; more frequent if high risk2.
Refer to prevention recommendations for adolescents
18-39 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Pap smear1
Chlamydia screening (urine/cervical)
Tetanus booster
Meningococcal conjugate vaccine / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Fasting lipid profile at least once
PAP smears every 2 years, starting 3 years after becoming sexually active; more frequent if high risk2
Annually to age 26 for sexually active females.
At least once between ages 18 and 49
Adults age 18-21
40-49 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Pap smear1
Mammogram
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Every five years, with fasting lipid profile
Every 2 years, more frequent if high risk2
Offered with shared decision making, annual if high risk3
At least once between ages 18 and 49
50-64 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Pap smear1
Mammogram
Colorectal cancer screening
Osteoporosis Screening
Influenza vaccine
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Every five years, with fasting lipid profile
Every 2 years, more frequent if high risk2
Every 2 years, annual if high risk3
Flexible sigmoidoscopy every 10 years and fecal occult blood test every 1-2 years
BMD screening at age 60-64 if weight less than 132 lbs, or weight 132-154 lbs & no current hormone replacement; no screening if weight > 154 lbs
Every year
At least once
65-75 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Pap smear1
Mammogram
Colorectal cancer screening
Osteoporosis screening
Influenza vaccine
Pneumonia vaccine
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Every five years, with fasting lipid profile
Not recommended if long history of normal PAP smears and not high risk2
Every 2 years, annual if high risk3to age 69. Shared decision age 70+
Flexible sigmoidoscopy every 10 years and fecal occult blood test every 1-2 years, to age 80 as health permits
BMD screening at a frequency determined by BMD results
Every year
Once after age 65
At least once if no booster since age 50
Over 75 years / Blood pressure
Height and weight measurement
Cardiac risk assessment
Pap smear1
Mammogram
Colorectal cancer screening
Osteoporosis screening
Influenza vaccine
Pneumonia vaccine
Tetanus booster / Every 2 years†
Body Mass Index (screening for overweight) every 2 years†
Individualize need for cardiac risk assessment and fasting lipid profile
Not recommended if long history of normal PAP smears and not high risk2
Available with shared decision making
Flexible sigmoidoscopy every 10 years and fecal occult blood test every 1-2 years, to age 80 as health permits
BMD screening at a frequency determined by BMD results
Every year
Once after age 65
At least once if no booster since age 50

1Women who have had a hysterectomy for non-cancer reasons may choose to stop Pap smears

2Risk factors for cervical cancer (consider more frequent
Pap smears): / 3Risk factors for breast cancer (consider yearly
mammograms if over age 40):

High risk Human Papilloma Virus (HPV)

Breast cancer in mother, sister or daughter

Past history of abnormal Pap smear (CIN 2-3)

Previous breast cancer

No recent Pap smear (within 3 years)

Previous breast biopsy with “atypical hyperplasia” results

Positive HIV status

Genetic alteration associated with increased breast cancer risk

* Counseling at all ages: tobacco use, nutrition, diet & exercise, weight management, alcohol & other drug use, injury prevention, sexual behavior, dental health.

† Frequency of blood pressure and BMI screening is based on recommended frequency of prevention office visits.