Supplement / Vol. 61 June 15, 2012
U.S. Department of Health and Human Services
Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report
Use of Selected Clinical Preventive Services
Among Adults — United States, 2007–2010
The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30333.
Suggested Citation: Centers for Disease Control and Prevention. [Title]. MMWR 2012;61(Suppl; June 15, 2012):[inclusive page numbers].
Centers for Disease Control and Prevention
Thomas R. Frieden, MD, MPH, Director
Harold W. Jaffe, MD, MA, Associate Director for Science
James W. Stephens, PhD, Director, Office of Science Quality
Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services
Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office
MMWR Editorial and Production Staff
Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series
Christine G. Casey, MD, Deputy Editor, MMWR Series
Teresa F. Rutledge, Managing Editor, MMWR Series
David C. Johnson, Lead Technical Writer-Editor
Catherine B. Lansdowne, MS, Jeffrey D. Sokolow, MA, Denise Williams, MBA
MMWR Editorial Board
William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Matthew L. Boulton, MD, MPH, Ann Arbor, MI
Virginia A. Caine, MD, Indianapolis, IN
Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA
David W. Fleming, MD, Seattle, WA
William E. Halperin, MD, DrPH, MPH, Newark, NJ
King K. Holmes, MD, PhD, Seattle, WA
Deborah Holtzman, PhD, Atlanta, GA
Timothy F. Jones, MD, Nashville, TN
Martha F. Boyd, Lead Visual Information Specialist
Maureen A. Leahy, Julia C. Martinroe,
Stephen R. Spriggs, Terraye M. Starr
Visual Information Specialists
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Information Technology Specialists
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Patrick L. Remington, MD, MPH, Madison, WI
John V. Rullan, MD, MPH, San Juan, PR
William Schaffner, MD, Nashville, TN
Dixie E. Snider, MD, MPH, Atlanta, GA
John W. Ward, MD, Atlanta, GA
Rationale for Periodic Reporting on the Use of Selected Adult
Clinical Preventive Services — United States ...........................................3
Recommended Use of Aspirin and Other Antiplatelet Medications
Among Adults — National Ambulatory Medical Care Survey
and National Hospital Ambulatory Medical Care Survey,
United States, 2005–2008 .............................................................................11
Control of Hypertension Among Adults — National Health and
Nutrition Examination Survey, United States, 2005–2008 ................19
Screening for Lipid Disorders Among Adults — National Health
and Nutrition Examination Survey, United States,
Characteristics Associated with Poor Glycemic Control Among
Adults with Self-Reported Diagnosed Diabetes —
National Health and Nutrition Examination Survey,
United States, 2007–2010 .............................................................................32
Tobacco Use Screening and Counseling During Physician
Office Visits Among Adults — National Ambulatory Medical
Care Survey and National Health Interview Survey,
United States, 2005–2009 .............................................................................38
Breast Cancer Screening Among Adult Women — Behavioral
Risk Factor Surveillance System, United States, 2010 .........................46
Prevalence of Colorectal Cancer Screening Among Adults —
Behavioral Risk Factor Surveillance System,
United States, 2010 .........................................................................................51
Prevalence of Undiagnosed HIV Infection Among Persons
Aged ≥13 Years — National HIV Surveillance System,
United States, 2005–2008 .............................................................................57
Influenza Vaccination Coverage Among Adults — National
Health Interview Survey, United States, 2008–09
Influenza Season ..............................................................................................65
Conclusions and Future Directions for Periodic Reporting
on the Use of Selected Adult Clinical Preventive Services —
United States .....................................................................................................73
MMWR / June 15, 2012 / Vol. 61 1
Thomas R. Frieden, MD, MPH
Corresponding author: Thomas R. Frieden, Director, CDC, 1600 Clifton Road, NE, MS D-14, Atlanta, GA 30333. Telephone: 404-639-7000; E-mail:
CDC has a long history of monitoring the use of clinical preventive services to provide public health agencies, health care providers
and their partners information needed to plan and implement programs that increase use of these services and improve the health
of the U.S. population. Better use of clinical preventive services could prevent tens of thousands of deaths each year. With passage
of the Patient Protection and Affordable Care Act of 2010 as amended by the Heathcare and Education Reconciliation Act of
2010, which expands health insurance coverage for the United States population and increases access to preventive services, there
are new opportunities to promote and improve use of these valuable and life-saving services. This report provides baseline data
prior to implementation of the provisions of the Affordable Care Act.
Public health and clinical medicine complement and enrich each other, but they must engage with each other to maximize their
impact. Synergies created through cooperation can amplify the impact that either might produce working alone. Public health
can also serve as an honest broker by providing unbiased and scientifically accurate information to policy makers, the health-care
community, and the public, and is well equipped to monitor health systems to facilitate increases in effectiveness and efficiency.
This MMWR Supplement on the Use of Selected Clinical Preventive Services Among Adults — United States, 2007–2010 is the first
in a periodic series of reports examining use of selected clinical preventive services. There are other important preventive health
services, such as screening and brief intervention for problem alcohol use and screening and effective treatment of depression,
but robust national data for these services are not currently available. For other important health problems, there are no proven,
recommended clinical preventive services at present. The report focuses on the following adult services:
•?Use of aspirin or antiplatelet therapy to prevent recurrent cardiovascular disease events among adults with a history of ischemic
vascular disease and use of aspirin in the general population among those at increased risk for cardiovascular disease,
•?control of blood pressure among adults with hypertension,
•?screening for lipid disorders,
•?control of blood glucose among adults who have had diabetes diagnosed,
•?screening for tobacco use in office-based ambulatory-care settings and tobacco cessation counseling and medication use among
current tobacco users,
•?screening using mammography for breast cancer among women,
•?screening for colorectal cancer in the adult population,
•?assuring awareness of human immunodeficiency virus-status among those who are infected, and
•? vaccination against influenza in adults.
The findings of this report indicate that tens of millions of people in the United States have not been benefitting from key
preventive clinical services, and that there are large disparities by demographics, geography, and health care coverage and access
in the provision of these services.
•?Slightly less than half of patients with diagnosed ischemic cardiovascular disease were prescribed aspirin or other antiplatelet
•?Despite improvements in hypertension treatment and control over the past10 years, slightly less than half of persons in the
United States with high blood pressure had it under control, and levels of control were particularly low for people who are
uninsured or do not have a usual source of heath care.
•?Only two thirds of adults (68%) had their cholesterol levels checked during the preceding 5 years, and among persons with
high LDL cholesterol levels, less than one third (31.6%) had it under control. More than one third (36%) of people in the
United States had elevated levels of low-density lipoprotein cholesterol.
•?More than one third (37.3%) of outpatient visits had no documentation of tobacco use status; just one in five (20.9%) who
screened positive for tobacco use received tobacco cessation counseling, and less than one in 13 (7.6%) tobacco users were
prescribed cessation medications. Rates of counseling were particularly low among younger smokers, despite a high level of
interest in quitting in this population; younger smokers have been shown to be more likely to try to quit but less likely
to succeed, hence could benefit particularly from improved counseling and treatment
2 MMWR / June 15, 2012 / Vol. 61
•?Approximately 2.3 million adults (12.9%) with diagnosed diabetes had poor glycemic control (A1c > 9.0).
•?Approximately one in five women age 50–74 years had not had a mammogram during the preceding 2 years.
•?Although there have been large increases in recent years, still approximately one third of adults aged 50–75 years were not
up-to-date with screening for colorectal cancer, which is the second leading cause of cancer death in the United States, the
leading cause of cancer death among nonsmokers, and which can be prevented through screening and follow-up.
•?Approximately one in five of the 1.1 million persons in the United States living with HIV had not been diagnosed.
•?Only approximately one in four (28%) of adults aged <65 years were vaccinated against influenza; 133 million adults were not
vaccinated, and vaccination rates were particularly low among the poor and those without health insurance or a medical home.
Improved clinical management of the ABCS — aspirin, blood pressure control, cholesterol management, and smoking cessation
— can significantly reduce the risk for cardiovascular disease, our nation’s leading killer, and could save approximately 100,000
lives each year. The Million Hearts initiative, which targets improvements in both clinical preventive practice (e.g., ABCS) and
community prevention (e.g., reducing smoking and exposure to secondhand smoke and decreasing sodium and artificial trans-
fat intake) by engaging public and private sectors, can prevent a million heart attacks and strokes over the next 5 years. This can
reduce the number of people who need treatment and the costs of health care to our society.
This report documents the potential benefits of selected clinical preventive services, the problem of their underuse, and effective
collaborative strategies to improve use. I hope the report will help increase use of these services and thereby help people in the
United States live longer, healthier, and more productive lives.
MMWR / June 15, 2012 / Vol. 61 3
Rationale for Periodic Reporting on the Use of Selected Adult Clinical
Preventive Services — United States
Ralph J. Coates, PhD1
Paula W. Yoon, ScD2
Stephanie Zaza, MD3
Lydia Ogden, PhD4
Stephen B. Thacker, MD5
1Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology, and Laboratory Services
2Division for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion
3Epidemiology and Analysis Program Office, Office of Surveillance, Epidemiology, and Laboratory Services
4Office of the Associate Director for Policy
5Office of the Director, Office of Surveillance, Epidemiology, and Laboratory Services
Corresponding author: Ralph J. Coates, PhD, Office of Surveillance, Epidemiology, and Laboratory Services, CDC, 1600 Clifton Rd., NE, MS E-97,
Atlanta, GA 30333. Telephone: 404-498-0080; Fax: 404-498-0595; E-mail: RCoates@cdc.gov.
This supplement introduces a CDC initiative to monitor and report periodically on the use of a set of selected clinical preventive
services in the U.S. adult population in the context of recent national initiatives to improve access to and use of such services.
Increasing the use of these services has the potential to lead to substantial reductions in the burden of illness, death, and disability
and to lower treatment costs. The majority of clinical preventive services are provided by the health-care sector, and public health
agencies play important roles in helping to support increases in the use of these services (e.g., by identifying and implementing policies
that are effective in increasing use of the services and by collaborating with stakeholders to conduct programs to improve use). Recent
health reform initiatives, including efforts to increase the accessibility and affordability of preventive services, fund community
prevention programs, and improve the use of health information technologies, offer opportunities to enhance use of preventive
services. This supplement provides baseline information on a set of selected clinical preventive services before implementation of these
recent reforms and discusses opportunities to increase the use of such services. This information can help public health practitioners
collaborate with other stakeholders that have key roles to play in improving public health (e.g., employers, health plans, health
professionals, and voluntary associations), understand the potential benefits of the recommended services, address the problem
of underuse, and identify opportunities to apply effective strategies to improve use and foster accountability among stakeholders.
Clinical Preventive Services
Optimal provision of clinical preventive services has the
potential to enable U.S. adults to live longer, healthier lives
by reducing the burden of illness, death, and disability (1–5).
These services include clinical interventions to reduce the
risk for an adverse health condition, screening to identify and
treat a condition early to reduce severity and duration, and
clinical interventions to reduce complications from a condition
or recurrence of a condition (6). Expert panels use multiple
methods and procedures to review and evaluate the evidence on
the benefits and harms from use of specific clinical preventive
services and to develop recommendations (5,7,8). The U.S.
Preventive Services Task Force (9), the Advisory Committee
on Immunization Practices (ACIP) (10), National Institutes
of Health consensus panels (11), and other committees (5)
supported by federal agencies make recommendations for
clinical preventive services. In addition, associations of health
professionals (e.g., the American College of Physicians) and
volunteer associations (e.g., the American Diabetes Association)
also organize and support panels to issue guidelines (5,12,13).
Approximately half of the U.S. adult population does not
use commonly recommended preventive services (1–4,14,15).
The Healthy People 2020 initiative, which identifies national
objectives for improving population health, reports low levels of
use of multiple clinical preventive services recognized as having
national importance (16). For example, in 2007, only 8% of
ambulatory care physician office visits included counseling or
education related to exercise. In 2008, less than half of primary
care physicians regularly assessed the body mass index of their
adult patients. During 2005–2008, of adults aged ≥18 years
with hypertension, 30% were not taking prescribed blood
The health-related costs of underuse of recommended
clinical preventive services are substantial. Researchers have
reported that increasing use of nine clinical preventive services
4 MMWR / June 15, 2012 / Vol. 61
to more optimal levels (i.e., levels achieved by high-performing
health plans) could prevent an estimated 50,000–100,000
deaths each year among adults aged <80 years (4). Another
study found that adopting 20 preventive services recommended
by the U.S. Preventive Services Task Force could prevent an
estimated annual loss in life expectancy for the U.S. population
as a whole of approximately 2 million years (3).
Role of Public Health in Clinical
With their focus on population health, public health
agencies have played and will continue to play important
roles in increasing use of recommended clinical preventive
services (17–22). Two long-standing roles for public health
are developing policies and plans to improve individual and
community health and ensuring provision of health care when
it is not otherwise available (17–19). For example, CDC-
supported panels make policy recommendations for a range
of clinical preventive services including vaccinations of adults
and children; counseling, screening, and prevention of human
immunodeficiency virus (HIV) and sexually transmitted
diseases; and prevention and control of health-care–associated
infections (23–25). In addition, public health agencies
improve access to clinical preventive services to the broader
population by providing services directly, funding the delivery
of services through nonprofit community public health clinics,
community organizations, or private practices and by providing
selected services in nonclinic settings (26–28).
Another important role of public health is identifying
community preventive services (i.e., policies, laws, programs
and initiatives, education programs, and health system
interventions) that are effective in increasing use of clinical
preventive services (19,22). To support this function, in 1996,
the U.S. Department of Health and Human Services initiated
the Community Preventive Services Task Force to examine
the effectiveness of a range of community preventive services.
The Community Preventive Services Task Force conducts
systematic literature reviews to evaluate evidence and uses
explicit criteria and procedures to make recommendations
(22). Among the community preventive services reviewed and
recommended by the Community Preventive Services Task
Force are policy and health system interventions that facilitate
the delivery of clinical preventive services. These interventions
act by reducing patients’ out-of-pocket costs (e.g., policies
that require no or reduced copayment for clinical preventive
services), reducing barriers to access (e.g., through changes in
clinic hours or providing services through mobile vans), and
using patient tracking systems to identify eligible patients
and provide decision support (e.g., patient and provider
reminders about the need for and timing of clinical services).
In addition, the Community Preventive Services Task Force
recommends ongoing surveillance to monitor, evaluate, and
report on performance in the use of clinical preventive services,
which is an effective and important means of increasing
service delivery by clinicians and health plans (22). The
Community Preventive Services Task Force also reviews and
makes recommendations about policy changes, public health
education programs, employee wellness programs, and changes
in the physical and social environment to promote use of
clinical preventive services and healthy behaviors (e.g., tobacco
avoidance, physical activity, weight control, and seatbelt use).
Community interventions to promote healthy behaviors have
the potential to reduce the need for certain clinical preventive
services (e.g., by reducing the prevalence of tobacco use and
obesity), thereby decreasing the need for counseling and other
Public health also plays a critical role in collaborating
with other stakeholders to implement effective community
interventions to increase use of clinical preventive services.
Population health is the outcome not only of services provided
by the health-care system and public health agencies but
also by the activities of private and voluntary organizations
and persons, including employers, health plans, and other
stakeholders (17–20). Each stakeholder can implement
interventions to increase use of clinical preventive services.
CDC has played a leading role in collaborating with
stakeholders at the national level and in supporting state and
local public health agencies to develop community coalitions
to engage in prevention and control programs, including, but
not limited to, increasing implementation of interventions
recommended by the Community Preventive Services Task
Finally, to help other stakeholders plan effective collaborations,
public health has a role in monitoring, evaluating, and
reporting on how well communities and stakeholders are doing
in increasing use of recommended community interventions as
well as use of clinical preventive services (20,32). An example
of such surveillance is CDC’s State Tobacco Activities Tracking
and Evaluation (STATE) System, which tracks state tobacco-
control policies (33). Monitoring the number and percentage
of employers whose employee health insurance policies provide
coverage for clinical preventive services recommended by the
National Business Group on Health (29) is another example of
the type of surveillance that could be conducted. To promote
accountability among stakeholders responsible for population
health, public health authorities will need to develop additional
performance-measurement systems that track specific, effective
actions by stakeholders (e.g., worksite wellness programs
MMWR / June 15, 2012 / Vol. 61 5
and use of patient tracking and reminder systems for clinical
preventive services) as well as health outcomes (e.g., lower
disease rates) (20,32).
Opportunities Offered by Recent
Changes to the U.S. Health-Care
Recent changes in the U.S. health-care system provide
opportunities to expand use of preventive services. The Patient
Protection and Affordable Care Act of 2010 as amended by
the Healthcare and Education Reconciliation Act of 2010
(referred to collectively as the Affordable Care Act [ACA])
emphasizes both population-based prevention and individual
clinical preventive services (34–38). Implementation of the
Affordable Care Act has the potential to lead to substantial
reductions in morbidity, premature mortality, and associated
health spending by expanding access to health insurance
and increasing use of preventive services (34–38). In 2009,
an estimated 58.5 million persons in the United States
lacked health insurance for at least some part of the previous
12 months; among adults aged 18–64 years, 25.6% were
uninsured for at least part of the year (39). The Congressional
Budget Office has estimated that implementation of the
Affordable Care Act will extend insurance coverage to 93% of
the nonelderly U.S. population by 2016 (38). Medicare now
covers adult clinical preventive services graded A (strongly
recommended) or B (recommended) by the U.S. Preventive
Services Task Force and immunizations recommended by
ACIP. These services, together with recommended preventive
services for children, youth, and women, will be covered at
no cost sharing by newly qualified private health plans in the
state-based insurance exchanges that are to start operating in
2014, when a competitive insurance marketplace will be set up
in the form of state-based insurance exchanges (ACA §1311).
These exchanges will allow eligible persons and small businesses
with up to 100 employees to purchase health insurance plans
that meet criteria outlined in the Affordable Care Act (34,37).
If a state does not create an exchange, the federal government
will operate it. Beginning in 2013, state Medicaid programs
that eliminate cost sharing for these clinical preventive services
might receive enhanced federal matching funds for them
(34,35). In addition, Medicare covers an annual wellness visit
(which includes a health-risk assessment and a personalized
prevention plan) at no cost to beneficiaries. In December 2011,
as required by the Affordable Care Act, CDC issued evidence-
based guidelines for individualized health-risk assessment (40).
Improved insurance coverage, expanded benefits, reduced
cost-sharing and improved access to health services can increase
use of clinical preventive services (22,29,35). The uninsured
are identified frequently as one of the population subgroups
with the lowest use of clinical preventive services (41). Even
for those who are insured, cost is often a barrier to service use
(42). The Affordable Care Act addresses cost impediments
to care through additional provisions, including eliminating
lifetime and annual limits on private insurance coverage
and providing premium rebates if insurers’ administrative
costs are too high, offering discounted prescription drugs for
seniors; providing tax credits for insurance coverage for those
from 100%–400% of the federal poverty limit and for small
businesses, and extending coverage for young adults up to
age 26 years through continued coverage under their parents’
The Affordable Care Act reauthorized the U.S. Preventive
Services Task Force (and for the first time authorized the
Community Preventive Services Task Force) to continue
updating and conducting new reviews, identify research gaps,
and make recommendations for evidence-based prevention
programs. In addition, the Affordable Care Act created and
provided funding for the Prevention and Public Health Fund,
which enables communities to prevent the leading causes
of death, strengthens state and local disease detection and
response, and produces information for action (34–36). In
Fiscal Year 2011, CDC was allocated $611 million from the
Prevention and Public Health Fund to strengthen prevention,
improve the health of the U.S. population, and bolster the
ability to detect and respond to both natural and deliberate
disease threats. The Affordable Care Act substantially expanded
funding for federally qualified community health centers
through the Health Resources and Services Administration
(HRSA), committing $11 billion over 5 years. It also
authorized demonstrations of new payment and care delivery
models (e.g., accountable care organizations and community
health teams) to promote a population health approach to
clinical care (43). Together, these provisions will work to
integrate primary care services into community-based mental
and behavioral health settings and will support the expansion
of the primary care workforce, which can increase access to
preventive services (34–36).
Recognizing the importance of broad collaboration for
prevention, Congress included the National Prevention
Strategy in the Affordable Care Act. Created by the National
Prevention, Health Promotion, and Public Health Council in
consultation with the public and an advisory group of outside
experts, the comprehensive plan, which was released on June
16, 2011, includes specific actions public and private partners
can take to help Americans stay healthy (44). The National
Prevention Strategy encourages partnerships among federal,
state, tribal, local, and territorial governments; business,
6 MMWR / June 15, 2012 / Vol. 61
industry, and other private sector partners; philanthropic
organizations; community and faith-based organizations;
and individuals to improve health through prevention. It
is a cross-sector, integrated national strategy that identifies
priorities for improving the health of the U.S. population.
Through these partnerships, the National Prevention Strategy
aims to improve public health by helping to create healthy
and safe communities, expand clinical and community-based
preventive services, empower people to make healthy choices,
and eliminate health disparities (44).
Other national initiatives that have been implemented in
recent years are also likely to increase use of preventive services.
The American Recovery and Reinvestment Act (ARRA) of
2009 invested in the expansion of community health centers
(45). The portion of ARRA known as the Health Information
Technology for Economic and Clinical Health (HITECH)
Act, as well as amendments to the Public Health Service
Act, support increased use of health information technology
as a means of improving the quality, efficiency, and safety
of health care (46,47). A draft national strategic plan for
health information technology published in 2011 for public
comment outlines multiple strategies that have the potential
to increase use of preventive services in health care through the
use of electronic information technologies (47). The Centers
for Medicare and Medicaid Services is offering incentives to
providers to increase their use of electronic health information
systems and has included selected clinical preventive services
as potential quality of care measures (48). Electronic health
information systems increase the ability of clinicians and health
plans to identify all patients in need of preventive services
more easily and systematically, deliver reminders to patients
and providers, and assist them in making informed decisions.
They also could contribute to evaluating and reporting on
the timeliness and quality of care. In addition, by facilitating
information exchange, such systems could support patient
self-management and improve coordination of care among
primary care professionals and specialists. Finally, the new
health information technologies together with the other health
reform initiatives create opportunities for greater sharing of
information and closer collaboration between public health
and clinical care professionals to improve the health of the
About This Surveillance Supplement
This surveillance supplement is the first of a series of
periodic reports from CDC to monitor and report on progress
made at the population level in increasing the use of a set of
clinical preventive services identified by CDC as public health
priorities. The audience for the report is the broad range of
stakeholders who shape the health of the U.S. population,
including public health practitioners, employers, health
plans, health professionals, and voluntary associations. Before
selecting a limited set of clinical preventive services to include
in this report, CDC considered a wide range of services and
surrogate measures of service use (e.g., proximal biologic
outcome measures) to indicate whether a disease is under
control. For example, CDC considered a set of adult clinical
preventive services that were identified by the Affordable Care
Act and that have been evaluated and recommended by the
U.S. Preventive Services Task Force or by ACIP (34). Also
reviewed were clinical preventive services for areas of public
health identified by CDC as priorities, including aspirin
therapy, blood pressure and cholesterol control, and smoking
cessation (the ABCS for heart disease and stroke prevention)
(49) as well as those related to food safety, immunizations,
health-care–associated infections, HIV, motor-vehicle injuries,
obesity, teen pregnancy, and tobacco use (50).
To select indicators important to the public, stakeholders,
and policy makers, CDC identified a set of clinical preventive
services that 1) address leading causes of illness, injury,
disability, or death; 2) are underutilized but have the potential
for substantial increases in use over the next few years with
focused effort; 3) have substantial effects on population health,
as measured by deaths prevented or healthy life years gained
(2–4); 4) are priorities of CDC public health programs and
the coalitions of stakeholders; and 5) have routinely collected
nationally representative surveillance data available for
measurement. Consideration also was given as to whether the
same or similar indicators were used by other national efforts
to monitor and promote progress in use of clinical preventive
services, including Healthy People 2020, the National Quality
Forum, and the National Committee for Quality Assurance
Using these criteria, CDC leadership initiated an iterative
process to develop the final list of indicators. A work group that
included leaders from multiple CDC programs was formed to
develop a proposal; the proposal was then reviewed in more
detail by personnel from a broader set of CDC programs and
by an external expert work group convened by a member of
the Advisory Committee of the Director of CDC.* The work
group included leaders in academia, public health, other
government agencies, and the private sector. A revised proposal
was developed and approved by CDC leadership.
*A list of the members of the two work groups appears on page 78.
76 MMWR / June 15, 2012 / Vol. 61
Several steps might be considered by public health and
other stakeholders to improve delivery of the clinical services
identified in this supplement by better coordinating efforts
and improving coordination of clinical care and public
health. Health officials can share this report with their clinical
community and convene meetings to discuss statewide and
local strategies to support the optimal use of preventive
services. They can work with employers and insurers to
review health plan benefit language to improve coverage for
all of the medical procedures required to implement a single
clinical practice guideline and for appropriate populations
to be covered (30,31). Health officials also can facilitate
collaboration among hospital associations, medical staff
leaders, professional trade associations, and residency program
directors to improve access to preventive services. Medical
practices that use electronic health records can assess individual
practitioner or group practice performance on service delivery
and work to improve office systems that increase rates of use.
At the same time, public health officials can apply strategies to
encourage members of the public to seek these services and help
practitioners to understand the community services available to
their patients to support health-promoting behaviors such as
tobacco cessation. Claims data for state Medicaid and private
insurance can be used locally to target attention to populations
with the greatest service gaps. Public health professionals can
work with leaders in business, voluntary associations, and
faith-based organizations to use their leadership positions to
increase awareness of the gap in services and encourage the use
of clinical preventive services.
Improving Public Health Surveillance
Ideally, public health surveillance systems would have the
capacity to track, in a timely, comprehensive, and accurate
manner, the effects of numerous efforts that might influence use
of clinical preventive services, including implementation of the
Affordable Care Act and electronic health information systems,
as well as actions by public health and other stakeholders. These
systems would have the ability to characterize persons who are
eligible for specific services and those who do or do not receive
them, examine the effects of legislation and other interventions,
and assess resulting health outcomes at both the individual and
population levels. The ability of current resources and public
health surveillance systems to examine such relationships is
limited. However, surveillance reports such as those in this
supplement can be helpful by highlighting underuse of the
services, identifying trends that might be due, in part, to various
interventions currently underway, and illuminating disparities.
The reports in this supplement also highlight several gaps in
the types of health surveillance information needed to guide
efforts to increase use of important clinical preventive services.
For example, as noted in the Rationale for this supplement,
several preventive services of interest could not be addressed
because of a lack of available information (1). Although all
these reports present national data, most cannot provide data
that are necessary to monitor progress at the state and local
levels. This supplement challenges health and public health
professionals to identify resources that can be used to provide
information at the state and local levels.
Additional sources of health surveillance information might
help address some of the gaps identified in these reports.
Increasing use of electronic health information systems and
electronic data exchange systems offers the possibility of
collecting and reporting on use of clinical preventive services
at the national, state, and local levels (1,28). State and local
surveys, such as the Behavioral Risk Factor Surveillance System,
might be able to capture more of the kind of information
included in this supplement. Deidentified information from
Medicare and Medicaid databases also might provide new
opportunities for this type of surveillance (32). Additional
sources of information for surveillance and an increased ability
to link information from a various sources can help provide
a more complete and integrated perspective on steps that
stakeholders need to take to improve use of these services.
Future Reports on Clinical
Surveillance reports on the use of selected clinical preventive
services by U.S. adults will be published periodically. Future
reports might include additional indicators for clinical
preventive services that are known to have important health
benefits but were not included in this supplement for various
reasons, primarily lack of adequate surveillance information
(1). Such reports might include screening and counseling for
alcohol consumption and for mental health, services that can
benefit large segments of the adult population. Because this
supplement does not address the important goal of improving
use of clinical preventive services for adolescents and children,
CDC is planning a surveillance report on use of those services
and methods for improvement. As information becomes more
available in public health surveillance systems, future reports
might be useful for monitoring interventions implemented by
public health and other stakeholders to improve service use.
MMWR / June 15, 2012 / Vol. 61 77
This report is based, in part, on contributions by Kelly
J. Henning, MD, Public Health Programs, Bloomberg
Philanthropies, New York, New York.
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MMWR / June 15, 2012 / Vol. 61 79
Surveillance and Epidemiology Work Group to the Advisory Committee to the Director
Chair: Kelly J. Henning, MD, Public Health Programs, Bloomberg Philanthropies, New York, New York.
Members: Melinda Buntin, PhD, Office of the National Coordinator for Health Information Technology, US Department of Health and Human Services,
Washington, District of Columbia; Jac J. Davies, MS, MPH, Inland Northwest Health Services, Spokane, Washington; Paul Halverson, DrPH, Arkansas
Department of Health, Little Rock; Sara L. Huston, PhD, Maine Center for Disease Control and Prevention, Augusta; Thomas E. Kottke, MD, HealthPartners
Research Foundation, Minneapolis, Minnesota; Jeffrey Levi, PhD, Trust for America’s Health, Washington, District of Columbia; Kimberly Rask, MD, PhD,
Emory Center on Health Outcomes and Quality, Atlanta, Georgia; Steven Teutsch, MD,, Los Angeles County Department of Public Health, California;
Lorna Thorpe, PhD, City University of New York School of Public Health, New York.
Federal Liaison: Ernest Moy, MD, Agency for Healthcare Research and Quality, Rockville, Maryland.
CDC Health Reform Work Group
Chair: Stephen B. Thacker, MD, Office of Surveillance Epidemiology and Laboratory Services.
Members: Peter Briss, MD, Paula Yoon, ScD, National Center for Chronic Disease Prevention and Health Promotion; James W. Buehler, MD, Public Health
Surveillance and Informatics Program Office; Janet L. Collins, PhD, Clay Cooksey, M Ed, Donna Knutson, MSEd, George W. Roberts, PhD, Office of the
Associate Director for Program; Joanne Cono, MD, Office of Infectious Diseases; Richard J. Klein, MPH, National Center for Health Statistics; Denise Koo,
MD, Scientific Education and Professional Development Program Office; Judith A. Monroe, MD, Office for State, Tribal, Local, and Territorial Support;
Chesley M. Richards, MD, Office of the Associate Director for Policy; Richard A. Schieber, MD, Stephanie Zaza, MD, Epidemiology and Analysis Program
U.S. Government Printing Office: 2012-523-218/73521 Region IV ISSN: 1546-0738
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