2020 Adult Preventive Care Guidelines
MHQP’s 2020 guidelines were developed by a collaborative group of Massachusetts healthcare organizations. These are recommendations for providing preventive care to adult patients from the general population. These guidelines should not supplant clinical judgment or the needs of individual patients. These guidelines are intended as quality-practice recommendations and are not intended as a description of benefits, conditions of payment, or any other legal requirements of any particular health plan or payor. Each health plan or payor makes its own determination of coverage and benefits. In the event that these practice recommendations are inconsistent with any applicable laws or regulations, such laws or regulations take precedence.
Click here to access a PDF version of the Adult Preventive Care guidelines.
PERIODIC HEALTH EVALUATION
- Obtain initial/interval medical and family history.
- Perform age-appropriate physical exam.
- Provide preventive screenings and counseling as outlined below.
- Update immunizations. For current immunization schedules, refer to the U.S. Centers for Disease Control and Prevention 2019 Adult Immunization Guidelines.
- For pneumococcal vaccine refer to Pneumococcal Vaccine Timing for Adults resource.
- For Zoster vaccine refer to Zoster (Shingles) ACIP Vaccine Recommendations.
- Recommend Tdap vaccine to any person who has not been previously vaccinated and who will have close contact with a baby ≤ 12 months.
- Refer to CDC Influenza ACIP Vaccine Recommendations for current influenza vaccine recommendations.
- Annually for ages 18-21.
- Every 1-3 years, depending on risk factors, for ages 22-29.
- Every 1-3 years, depending on risk factors.
- Every 1-3 years, depending on risk factors.
LABS AND CANCER SCREENINGS
- Consider performing clinical breast exam at all periodic health evaluations.
- Screen for patients with an increased risk for BRCA gene mutations using appropriate screening tools. Offer genetic counseling for women with positive screening results. The tools evaluated by the USPSTF include the Ontario Family History Assesment Tool, Manchester Scoring System, Referral Screening Tool, Pedigree Assessment Tool, and FHS-7.
- Only with patients at high risk, use shared decision making to discuss the risks and benefits of initiating mammography or other screening exams.
- Using shared decision making, including patient risk factors, discuss the risks and benefits of biennial mammography.
- Conduct mammography every two years, or more frequently based on risk factors and shared decision making.
- Determine need of further mammography based on shared decision making.
Age, first degree relative (parent, sibling, or child) with breast, ovarian, tubal, or peritoneal cancer, genetic predisposition, personal history of ovarian cancer or high risk breast biopsy result, and history of chest radiation therapy at a young age.
- Note that the USPSTF states these recommendations do not apply to women with high grade precancerous lesions or cervical cancer or in utero DES exposure or a compromised immune system, including women with HIV.
- Omit cervical cancer screening test if a woman has had a hysterectomy for benign disease with removal of cervix and does not have a history of high-grade pre-cancerous lesion or cervical cancer.
- No cervical cancer screening is indicated.
- Screen with cervical cytology alone every three years (pap or liquid cytology).
- Screen every three years with cytology alone; or
- Screen every five years with hrHPV testing or co-testing (hrHPV and cytology).
- Discontinue cervical cancer screening after age 65 if there is documented evidence of consistently negative results.
Infection with HPV (human papillomavirus), personal history of cervical dysplasia, smoking, history of other sexually transmitted diseases (including HIV/AIDS), compromised immune system, and in utero diethylstilbestrol (DES) exposure.
- Screening are not routine except for patients at high risk.
- Starting at age 45 for African American adults without risk factors and at age 50 for non-African American adults without risk factors. Note the ACS recommends screening starting at age 45 in all adults.
- Screen for colon cancer, and use shared decision making to select one of the following methods/screening intervals
- Colonoscopy every 10 years or
- Annual FIT
- If patient is unable to follow either of these screening regimens then select one of the following methods/screening intervals:
- Computed tomographic colonography every 5 years
- FIT– fecal DNA every 3 years
- Flexible sigmoidoscopy every 5–10 years
- If patient cannot follow any of these recommendations: capsule colonoscopy every 5 years
- Screening is not recommended, but individual patients may use shared decision making to determine need of further screening.
- After age 86, screening is not recommended.
Patients with risk factors (one first degree relative with colorectal cancer or advanced adenoma diagnosed before age 60 or patients with two first degree relatives with colorectal cancer or advanced adenoma at any age) should begin screening at age ten years less than age at diagnosis of 1st degree relative or at age 40, whichever is earlier, repeating every 5 years.
Patients with risk factors (one first degree relative with colorectal cancer, advanced adenoma or advanced serrated lesion over age 60) begin screening at age 40, with intervals same as average risk patients.
- Counsel current smokers to stop smoking and counsel that lung cancer screening does not replace the need to quit smoking.
- Use shared decision making to discuss the risks and benefits of low dose computed tomography (LDCT) screenings for patients meeting the following criteria:
- 30 pack year smoking history and
- either currently smoke or have quit within the past 15 years
- If the decision is made to pursue screening, screen annually at a facility equipped to perform screening and evaluate results.
- Discontinue screening when the length of time from quitting exceeds 15 years, or when life expectancy is limited or ability to undergo surgery is compromised.
Current smokers with a 30 pack-year smoking history, and patients who quit within the last 15 years who have a 30 pack-year smoking history.
- For high-risk patients only, use shared decision making to discuss prostate specific antigen (PSA) screening. High-risk men should be provided with the same screening education and options as men age 55-69, but starting at age 40 for African American men and 45 for all other men.
- Screening for prostate cancer with PSA test should not be performed or offered routinely without shared decision making, including a clear explanation and understanding of the benefits and harms.
- Only offer PSA screening for men who express a clear preference for screening after shared decision making and who have a life expectancy of >10 years.
- For men who have chosen PSA screening, screen every 2 years
- PSA screening is not recommended for men with a life expectancy of < 10 years.
- PSA screening and routine discussion of screening are not recommended.
African-American ancestry, and either a brother or father diagnosed with prostate cancer before age 65.
- Inspect skin for abnormalities when performing physical exam.
- Educate patients at-risk about skin cancer, including using the ABCDE guidelines to check moles.
- Counsel to limit exposure to the sun (especially between 10 A.M. and 4 P.M.), to fully cover skin with clothing and hats, and to use sun block (SPF 15 or greater), especially those over 24 with fair skin types.
- Discourage use of indoor tanning.
Age (65 and older), personal history of skin cancer or repeated sunburns early in life, family history of skin cancer, certain types and a large number of moles, fair skin, sun-sensitive skin, and chronic exposure to the sun.
GENERAL SCREENING, COUNSELING, AND GUIDANCE
- Review and assess known cardiovascular risks, and counsel on mitigating any risks. See sections on diet and nutrition, obesity and overweight, and physical activity for additional counseling and guidance.
- Consider using ASCVD Risk Estimator Plus to evaluate 30 year or lifetime risk in patients with low risk aged 18-59.
- Use a risk estimator for patients aged 40-79. For US White or Black non-Hispanics use ASCVD Risk Estimator Plus. For other groups this may over or under-estimate risk. In those patients consider other tools including the general Framingham CVD risk score, Reynolds risk score, SCORE and QRISK/JBS3 tools.
- Consider CAC scoring in patients with borderline to intermediate risk.
- Screen for lipid disorder (high cholesterol) with a total cholesterol and HDL. Recommend follow-up lipoprotein profile if total cholesterol is >200 mg/dl or HDL is <40 mg/dl.
- Consider statin use in patients without CV disease aged 40-75 who have at least one risk factor for CVD and a 10 year risk of developing CVD of 10% or higher based on ACC/AHA Pooled Cohort Equation (USPSTF B recommendation).
- Consider statin use in similar patients whose risk is 7.5% or higher based on ACC/AHA Pooled Cohort Equation (USPTF C Recommendation).
- Check blood pressure at every medical encounter.
- Perform blood pressure screening for hypertension once every two years.
- Screen for abdominal aortic aneurysm once in men aged 65–75 who have ever smoked, and consider using shared decision making for others at risk.
- Consider low dose aspirin for adults aged 50 – 59 who have a 10% or greater 10 year risk of CVD, are not at risk for bleeding, have a life expectancy of 10 years or more and are willing to continue taking it for 10 years.
- Use shared decision making for adults with the same profile aged 60 and older.
Cardiovascular Disease: Age, male gender, hypertension, hyperlipidemia, low HDL, diabetes, tobacco use, obesity (BMI>30), history of preeclampsia, and family history of premature heart disease.
Abdominal Aortic Aneurysm: Male gender, tobacco use, family history of any aneurysm, atherosclerotic disease, and hypertension.
Note: If you use an application for risk calculation, make sure it is based on the ACC/AHA Pooled Cohort Equation.
- Counsel on the benefits of physical activity and a healthy diet. See sections on diet and nutrition and physical activity for further guidance.
- Screen every 3 years beginning at age 45 with fasting blood sugar, 2-hour oral glucose tolerance, or HbA1C test. Screen more often and beginning at a younger age for those who have risk factors.
- If test results in diagnosis of pre-diabetes, recommend screening again in 6 months to 1 year, and counsel or refer for counseling on diet and lifestyle changes to prevent the onset of Type-2 diabetes.
- Consider the CDC training program recommendation for diabetic and pre-diabetic patients.
- Emphasize that lifestyle changes that result in lower weight and increased physcial activity are critical in managing Type-2 diabetes and pre-diabetes, including the potential for remission.
- Refer for consideration of metabolic surgery if BMI is ≥40 (≥37.5 in Asian Americans).
- Refer for consideration of metabolic surgery if BMI is 35-39.9 (32.5-37.4 in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with reasonable nonsurgical methods.
Age (>45 years old), first-degree relative with diabetes, physical inactivity, overweight/obesity, race/ethnicity (African-American, Hispanic, Native American, Asian), high blood pressure (above 135/80mm Hg), history of vascular disease, elevated cholesterol/lipid levels, history of gestational diabetes or birth of a baby >9 lbs, impaired glucose tolerance, and polycystic ovary syndrome.
- Counsel on the benefits of physical activity and a healthy diet to maintain an appropriate weight for height. See sections on diet and nutrition and physical activity for further guidance.
- Screen for obesity at every periodic health evaluation visit using the CDC’s growth and BMI charts as a guide.
- Offer more focused evaluation and intensive counseling for obese adults (BMI ≥ 30), or overweight adults (BMI ≥ 25) with co-morbidities, to promote sustained weight loss. The USPSTF recommends that clinicians offer or refer patients with a BMI ≥ 30 to intensive, multicomponent behavioral interventions.
- Consider the CDC training program recommendation for diabetic and pre-diabetic patients. See diabetes section for diabetes-specific recommendations.
- Counsel on the importance of regular physical activity including aerobic, strength, and flexibility training.
- Advise that the CDC recommends 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity/week, and muscle-strengthening activities 2 days/week.
- Advise that any increase in physical activity can be beneficial in chronic disease prevention, even if not to the level of the CDC recommendation.
- Emphasize the importance of balance training for older adults at risk for falls.
- Counsel on the importance of a healthy diet in the prevention of disease. A healthy diet:
- Emphasizes fruits and vegetables, whole grains, low-fat dairy, lean proteins, nuts and legumes.
- Limits red and processed meat, saturated and trans fats, refined carbohydrates, and food and beverages with added sugar.
- Follows appropriate portion size.
- Screen for eating disorders by asking about body image and dieting patterns.
- Discuss contraception with female patients.
- Advise condom use for prevention of STIs and pregnancy
- Recommend consistent sleep and wake times throughout the week.
- Discourage exposure to blue light (including LED bulbs and electronic screens) for at least one hour before sleep onset.
- Recommend regular exercise to help promote sleep.
- Discourage alcohol, caffeine, and large meals before sleep.
- Discourage excess alcohol consumption throughout the day.
- Recommend 7 or more hours of sleep per night.
- Recommend 7 to 9 hours of sleep per night.
- Recommend 7 to 8 hours of sleep per night.
- Ask about tobacco, smoking, and vaping use at every visit.
- Advise all tobacco and nicotine users to quit, especially pregnant women.
- Assess readiness to quit.
- Assist tobacco and nicotine users in quitting by providing brief counseling, referring to Quitworks, and recommending the use of pharmacotherapy.
- Arrange follow-up.
- Discuss lung illnesses associated with use of vaping products and urge vapors to stop.
Family/personal history of depression or other psychiatric disorders, female gender, LGBT individuals, being in the postpartum period, older adults, other chronic illnesses or medical issues, stressful life events or recent traumatic experiences, and substance abuse.
- Consider screening for anxiety based on risk factors and individual presentation using the GAD-7 or other validated screening tool.
- Consider screening for other types of anxiety by asking these four questions:
- Have you had a spell attack where all of a sudden you felt frightened, anxious or uneasy? (Panic Disorder)
- Have you been bothered by nerves or feelings of anxious or on edge for 6 months? (Generalized Anxiety Disorder)
- Have you had a problem being anxious or uncomfortable around people? (Social Anxiety Disorder)
- Have you had recurrent dreams or nightmares of trauma or avoidance of trauma reminders? (Post Traumatic Stress Disorder)
Female gender, personal or family history of anxiety or other psychiatric disorders, traumatic or recent adverse life events, gay, bisexual, transgender, men who have sex with men, and chronic disease.
- Assess history of alcohol misuse and substance abuse, including prescription or over-the-counter drugs.
- Counsel about the effects of alcohol misuse and/or substance abuse.
- Provide brief behavioral counseling to people engaged in or at risk of developing alcohol/substance abuse disorders.
- Treat or refer for treatment if there is evidence of addiction.
- Advise family and friends of persons with opioid use or misuse to obtain NARCAN for emergency use.
- Discuss lung illnesses associated with use of vaping products.
- Recommend that prescription medications are stored in a secure place and that any unused prescription medication is properly disposed of.
- Counsel not to drive when under the influence of alcohol/substances, or ride with someone who is under the influence.
- Advise pregnant women to stop drinking alcohol and using harmful substances during pregnancy, and advise them of the harmful effects of substance use on fetal development.
Early onset of usage, binge drinking, family history of alcohol or substance misuse, mental health problems, history of trauma, using more addictive substance like stimulants and opioids, and LGBT individuals, especially under age 25.
- Counsel about ways to prevent household and recreational injuries. For example;
- Safe-keeping of prescription drugs or household chemicals
- Motor-vehicle safety/seatbelt use
- Helmet and other protective gear for cycling, skateboarding, scootering, and motorcycles
- Alcohol and substance use
- Intimate partner violence/abuse in the home
- Carbon monoxide risks and detectors
- Fall prevention measures in the elderly. For more information on fracture prevention refer to section on Osteoporosis.
- Advise about the dangers of firearms possession, particularly handguns, in the home. Recommend the removal of guns from the home or secure home storage with safety locks on.
- Advise to keep guns away from children, and discuss other ways to reduce accidental injury or death from guns.
- Asses and screen for physical and behavioral signs of abuse and neglect.
- Screen all women of child-bearing age for intimate partner violence.
- Consider asking the following questions:
- Have you ever been hurt or threatened by your partner, or anyone else (e.g. ex-partner, other family member)?
- Do you ever feel afraid, controlled, or isolated by your partner or anyone else?
- Ask about hearing and vision impairment, and counsel or refer for further diagnosis around any issues.
- Recommend eye exam at the following intervals:
- 40-54: 2-4 years
- 55-64: 1-3 years
- 65+: 1-2 years
Consider Glaucoma screening with a dilated eye exam every two years for:
- African Americans age 40 and over
- Everyone age 60 and over
African American descent, Latin American descent, and family history.
INFECTIOUS DISEASE SCREENING AND PREVENTION
Traveler’s Health (Vaccines, Medicines, Advice)
- Obtain sexual history.
- Counsel on effective ways to reduce the risk of infection based on patient’s sexual history and risk factors.
- Assess risks of STD in transsexual individuals based on current anatomy and sexual practices.
Chlamydia and gonorrhea
- Screen all sexually active female patients age 24 and younger annually.
- Starting at age 25, screen if at risk.
Inconsistent use of condoms, new or multiple sex partners, history of and/or current sexually transmitted infection, current partner has other sexual partner(s), and exchanging sex for money or drugs.
- Screen if at risk.
Living in an area with increased syphilis morbidity, history of and/or current infection of another sexually transmitted infection, having more than one sexual partner within the past 6 months, exchanging sex for money or drugs, and males who have sex with males.
- See cervical cancer screening section for screening recommendations.
- Counsel regarding schedule for HPV vaccine.
- Recommend HPV vaccination for females age 26 and under and males age 21 and under, if not previously vaccinated.
- Recommend vaccination for men engaging in sex with other men and for immuno-compromised patients, including patients with HIV through age 26, if not previously vaccinated.
- Counsel on risk factor reduction.
- Screen those at risk for hepatitis B who have not been vaccinated.
- Counsel on vaccination for patients not vaccinated and at high risk.
Immigration or parents emigrating from high-risk areas (born in area with HBsAg prevalence >2% or born in US but not vaccinated with parents born in area with HBsAg prevalence >8%), positive HIV infection status, injection drug users, men who have sex with men, persons receiving hemodialysis or cytotoxic immunosuppressive therapy, household contacts or sexual contacts of persons with chronic HBV infection, health care and public safety workers at risk for occupational exposure to blood or blood-contaminated body fluids. See MHQP’s Perinatal Guidelines for guidance for screening pregnant women.
- Counsel about risk factor reduction.
- CDC recommends a one-time screening for all adults born between the years 1945-1965, regardless of risk factors.
- Periodic testing of all patients at high risk.
All people born between 1945 and 1965, illicit injection drug use, receipt of blood product for clotting problems before 1987, receipt of a blood transfusion or solid organ transplant before July 1992 (if not previously tested), long-term kidney dialysis, HIV, and born to mother with Hepatitis C. The USPSTF also recommends testing the following: tattoo or body piercing by nonsterile needle, intranasal drug use, and incarceration.
- Counsel about risk factor reduction.
- CDC recommends routine HIV screening for all individuals 18 years of age and older and annual testing for those at increased risk.
- CDC recommends that individuals get tested at least once in their lifetimes.
- Assess risk in transsexual individuals based on current anatomy and sexual practices.
- CDC recommends pre-exposure prophylaxis for anyone who is currently HIV negative but is at significant risk for contracting HIV.
Injection-drug users and their sex partners, persons who exchange sex for money or drugs, sex partners of HIV-infected persons, men who have sex with men, and heterosexual persons who themselves or whose sex partners have had more than one sex partner since their most recent HIV test. Indications for pre-exposure prophylaxis: Ongoing sexual contact with partner who is HIV +, men who have sex with men, having anal intercourse without condoms or have had any STD within 6 months and are not in monogamous relationship, heterosexual men or women who have sex without condoms with partner of unknown HIV status, IV drug users who have shared IV drugs or needles within past 6 months, IV drug users who have had treatment within past 6 months and are still using.
- Screen all patients at high risk.Determine the need for repeat testing by the likelihood of continuing exposure to infectious TB.
- Administer tuberculin skin test (TST) for individuals with no past BCG vaccination.
- Consider IGRA for individuals who have received BCG vaccination or who are at risk for not returning for reading of the TST.
Born in or resident of a country with high rates of TB, live in or have lived in communities where prevalence of TB is high (prisons, shelters, migrant farm settings), immunosuppressed (HIV +, immunosuppressing drugs), contacts of patients with active TB, workers exposed to high risk populations, and patients with silicosis.
CDC: Tuberculosis (TB)
- Screen for Zika virus in women of child-bearing age based on risk factors. Please see Preconception Counseling section below for more details.
- Advise men who have been exposed to or have had Zika to avoid procreation for at least 3 months.
Symptoms of Zika virus (fever, rash, joint pain, red eyes), unprotected intercourse, and geographic locations (Africa, Southeast Asia, the Americas, the Caribbean, the Pacific).
Other Mosquito and Tick-Borne Illnesses
- Counsel on prevention of other mosquito-borne illnesses, including Eastern Equine Encephalitis (EEE) and West Nile Virus.
- Recommend that patients who are at risk of exposure to tick-borne diseases use insect repellents that provide protections for the amount of time they will be outdoors and to check skin and clothes for ticks every day.
SCREENING AND GUIDANCE FOR AGE-SPECIFIC CONDITIONS
(Note: See MHQP’s Perinatal Guidelines for complete recommendations on prenatal care.)
- Advise all women of child-bearing age to take a daily multivitamin containing 0.4 – 0.8 mg folate.
- Encourage scheduling a visit for preconception counseling to include review of appropriate immunization status, chronic illnesses, current medications, whether there is need to make any changes based on teratogenicity, and consideration of genetic testing.
- Inform patients on the impact of alcohol, drug, tobacco, and environmental exposures in early pregnancy, often before pregnancy is diagnosed.
- If patient has BMI >30, recommend weight loss before becoming pregnant.
- Recommend that patients with diabetes or pre-diabetes achieve optimal glycemic control prior to pregnancy.
- Counsel women of child-bearing age on the importance of oral health and routine dental care before pregnancy.
- Recommend HIV testing for patient and partner.
- Counsel on HIV prevention and ways to reduce HIV transmission during conception and pregnancy, and offer pre-exposure prophylaxis if indicated.
- Review travel restrictions during pregnancy and the preconception period, including avoiding travel to an area with active Zika virus transmission.
- Advise women who have been exposed to or have had Zika to avoid conception for 8 weeks from the last exposure or onset of symptoms.
- Advise men who have been exposed to or have had Zika to avoid procreation for at least 3 months from the last exposure or onset of symptoms.
- Counsel about preventive measures, including dietary calcium and vitamin D intake, weight-bearing exercise, and smoking cessation.
- Counsel frail patients on specific measures to prevent falls.
- Offer bone mineral density (BMD) testing to women over 65.
- Recommend exercise interventions to prevent falls in community-dwelling adults ≥65 who are at increased risk for falls.
- Consider offering multifactorial interventions to prevent falls in community-dwelling adults ≥65 who are at increased risk for falls.
- Offer bone mineral density (BMD) testing to post-menopausal women who are at high risk.
Age, female gender, family/personal history of fractures as an adult, race (Caucasian or Asian), small-bone structure and low body weight (under 127 lbs.), certain menopause or menstrual histories, lifestyle (tobacco use, little physical activity), and certain medications or chronic diseases.
- Counsel symptomatic women on the management of menopause, including the risks and benefits of hormonal and nonhormonal therapies.
- USPSTF recommends against the use of combined estrogen and progestin or estrogen only in most women.
DEFINITION OF PERIODIC HEALTH EVALUATION FOR MHQP’S GUIDELINES PROGRAM:
The periodic health evaluation (PHE) consists of one or more visits with a health care provider to assess patients’ overall health and risk factors for preventable disease, and it is distinguished from the annual physical exam by its incorporation of tailored clinical preventive services and laboratory testing as part of health risk assessment. Source: AHRQ
DEFINITION OF SHARED DECISION MAKING FOR MHQP’S GUIDELINES PROGRAM:
Shared decision making is an approach to care in which clinicians share educational resources with patients, and patients are encouraged to ask questions and to share their personal values and opinions about their condition and treatment options with the clinician. Factors to be considered during this process include the patient’s risk factors, co-morbidities;and health status; patient’s values and culture; as well as risks and benefits of screening or procedure. The final result of this process is a joint decision between the patient and the clinician about the patient’s health care. Adapted from definitions: AHRQ and Journal of General Internal Medicine