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Preventive Health Care - Adult/Pediatric - Ambulatory

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1
Preventive Health Care –
Adult/Pediatric – Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ............................................................................................................ 4
SCOPE ....................................................................................................................................... 4
METHODOLOGY ....................................................................................................................... 5
INTRODUCTION ........................................................................................................................ 5
RECOMMENDATIONS ............................................................................................................... 5
Infants and Children ............................................................................................................................ 6
Adolescents ....................................................................................................................................... 10
Adults ................................................................................................................................................. 11
TOPIC-SPECIFIC RECOMMENDATIONS ............................................................................... 18
Abdominal Aortic Aneurysm .............................................................................................................. 18
Alcohol Use ....................................................................................................................................... 19
Anemia .............................................................................................................................................. 20
Aspirin for Primary Prevention ........................................................................................................... 21
Autism Spectrum Disorder ................................................................................................................ 23
Blood Lead ........................................................................................................................................ 23
Breast Cancer .................................................................................................................................... 24
Breast Feeding .................................................................................................................................. 27
Cervical Cancer ................................................................................................................................. 27
Chlamydia (C. trachomatis) and Gonorrhea (N. gonorrhoeae) ......................................................... 29
Cognitive Screening .......................................................................................................................... 30
Colorectal Cancer .............................................................................................................................. 30
Dental Caries ..................................................................................................................................... 35
Depression ........................................................................................................................................ 36
Developmental Milestones ................................................................................................................ 36
Diabetes ............................................................................................................................................ 37
Falls Risk ........................................................................................................................................... 38
Hearing .............................................................................................................................................. 40
Hepatitis B ......................................................................................................................................... 41
Hepatitis C ......................................................................................................................................... 42
Human Immunodeficiency Virus (HIV) .............................................................................................. 42
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2
Human Papilloma Virus (HPV) .......................................................................................................... 45
Hypertension ..................................................................................................................................... 45
Immunizations ................................................................................................................................... 46
Intimate Partner Violence .................................................................................................................. 47
Lipids ................................................................................................................................................. 48
Lung Cancer ...................................................................................................................................... 50
Newborn Screening ........................................................................................................................... 51
Obesity .............................................................................................................................................. 52
Osteoporosis ..................................................................................................................................... 53
Prostate Cancer ................................................................................................................................. 55
Sexual Activity (Behavioral Counseling)............................................................................................ 57
Skin Cancer (Behavioral Counseling) ............................................................................................... 58
Syphilis .............................................................................................................................................. 60
Tobacco Use ..................................................................................................................................... 60
Tuberculosis ...................................................................................................................................... 62
Vision ................................................................................................................................................. 64
Well Child Visit Frequency ................................................................................................................ 65
UW HEALTH IMPLEMENTATION ............................................................................................ 66
APPENDIX A. TOPIC-SPECIFIC WORKGROUP MEMBERSHIP ............................................ 69
APPENDIX B. HIGH RISK RECOMMENDATIONS .................................................................. 72
Breast Cancer- High Risk .................................................................................................................. 72
Cervical Cancer- High Risk ............................................................................................................... 73
Colorectal Cancer- High Risk ............................................................................................................ 75
APPENDIX C. THE FIVE P’S FOR SEXUALLY TRANSMITTED DISEASE SCREENING....... 76
APPENDIX D. RATING SCHEMES FOR THE STRENGTH OF THE
EVIDENCE/RECOMMENDATIONS .......................................................................................... 77
APPENDIX E. INTERIM REVISIONS ....................................................................................... 81
REFERENCES ......................................................................................................................... 82


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3
Contact for Content:
Name: Jeff Huebner, MD - Family Medicine/Population Health
Email Address: jhuebner@uwhealth.org

Name: Matt Anderson, MD- General Internal Medicine
Email Address: mcanders@medicine.wisc.edu

Contact for Changes:
Name: Lindsey Spencer, MS – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org

Preventive Health Care Guideline Steering Committee Members:
Deborah Boushea, MD – General Internal Medicine
Mark Micek, MD – General Internal Medicine
Kristin Lewicki, MD – General Internal Medicine
Kelly Herold, MD – General Internal Medicine
Prasanna Raman, MD – General Pediatric and Adolescent Medicine
Paula Cody, MD – General Pediatric and Adolescent Medicine
Richard L. Brown, MD – Family Medicine
Jonas Lee, MD – Family Medicine
Kirsten Rindfleisch, MD – Family Medicine
James Bigham, MD – Family Medicine
Thomas Schiller, MD- Family Medicine (SwedishAmerican Health System)
Tim Flynn, MD- Family Medicine (SwedishAmerican Health System)
Elizabeth Chapman, MD – Medicine- Geriatrics
Kara Hoppe, MD – Obstetrics and Gynecology
Laura Kwitek, DNP, WHNP-BC- Obstetrics and Gynecology
Florence Chenoweth- Patient Family Advisor (PFA)
Elaine Rosenblatt, MSN, FNP-BC – Unity Health Insurance
Mary Anne Long, BSN, RN- Unity Health Insurance
Cheryl Lampman, RN- Physicians Plus Insurance Corporation (PPIC)
Julia Wright, MD- Dean Health Plan
Ron Parton, MD- Dean Health Plan
Guirish Agni, MD- Internal Medicine (Dean Health Plan)
Kim Volberg, RN- Dean Clinic
Jason Hampton, MD- Family Medicine (Group Health Cooperative)
Melissa Wuest- UnityPoint Health-Meriter
Karen Briggs, RN, ANP-BC- Gundersen Health Plan
Daniel Ecklund, MD- General Internal Medicine (Gundersen Health Plan)
Aaron Zivney, DO- Family Medicine (Gundersen Health System)

Coordinating Team Members: See Appendix A for Topic-Specific Members

Committee Approvals/Dates:
Preventive Health Care Guideline Steering Committee (10/20/16; 11/10/16; 11/16/16; 11/30/16)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 01/26/2017)
ξ Interim revisions (03/23/2017)

Release Date: May 2017 | Next Review Date: January 2019
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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4
Executive Summary
Guideline Overview
This guideline contains preventive health recommendations for screening, counseling,
education, and interventions in patients ages birth to geriatrics. Specific topics may also include
recommendations for patients considered to be high risk or at an increased risk.

Key Revisions (2017 Periodic Review)
1. Removed recommendations for prenatal and postpartum care.
2. Added new topics including aspirin for primary prevention of cardiovascular disease and
colorectal cancer, dental caries for pediatrics, hepatitis B screening for patients at increased
risk, and tuberculosis screening in adults.
3. Added recommendations related to Illinois state statutes and SwedishAmerican practices.

Companion Documents & Resources
1. UW Health Preventive Health Care and Health Maintenance
2. UW Health Immunization Toolkit


Scope
Disease/Condition(s): Preventable diseases or conditions

Clinical Specialty: Family Medicine, Internal Medicine, Geriatrics, Obstetrics and Gynecology,
Pediatrics, Preventive Medicine

Intended Users: Physicians, Physician Assistants, Advanced Practice Nurses, Registered
Nurses, Medical Assistants, Licensed Practical Nurses, Allied Health Personnel, Health
Plans/Managed Care Organizations, and other health care providers.

Objective(s):
ξ To provide a comprehensive approach to the provision of preventive services; including
counseling, education, therapeutic interventions (e.g., vaccination), and disease
screening for average risk patients from birth through geriatrics.
ξ To assist in the prioritization of screening maneuvers, tests, and counseling
opportunities.
ξ To provide guidelines for decision support tools in Health Link such as Health
Maintenance (HM) and Best Practice Alerts (BPAs).

Target Population: All patients from birth to geriatrics who are average risk or asymptomatic.
This guideline does not include recommendations for prenatal or postpartum care.

NOTE: There are occasional exceptions to the following guidelines for high risk populations where
noted (Appendix B). Some sections also include surveillance guidelines following a procedure or
personal history of disease/condition. This guidance is intended to educate primary care providers and to
direct appropriate referral or expectation from specialty providers. This guideline is not intended to
diagnose or treat any condition. Once a health issue or condition has been identified, other clinical
practice guidelines will take precedence during any further diagnosis and management.

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5
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by CCKM and workgroup
members to collect evidence for review. Expert opinion and clinical experience was also
considered during discussions of evidence.

Methods Used to Formulate the Recommendations:
The topic-specific workgroup members agreed to adopt recommendations developed by
external organizations and/or arrived at a consensus through discussion of the literature
evidence and expert experience. Recommendations developed by each topic-specific group
were reviewed and approved by the Preventive Health Care Guideline Steering Committee as
well as other UW Health committees as appropriate.

Methods Used to Assess the Quality and Strength of the Evidence:
Recommendations developed by external organizations (such as the U.S. Preventive Services
Task Force) maintained the evidence grade assigned within the original source document and
were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the topic-specific workgroup and Steering
Committee members using an algorithm adapted from the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) methodology (see Figure 1 within
Appendix D).

Rating Schemes for the Strength of the Evidence/Recommendations:
See Appendix D for the various rating schemes used within this document.

Recognition of Potential Health Care Disparities:
Data from the National Ambulatory Medical Care Survey (2005-2010) found racial and financial
healthcare disparities related to cancer screening performed in the primary care setting, which
are not significantly impacted by use of an electronic health record or automated electronic
reminders.1,2 The 2010 Affordable Care Act worked to improve access to preventive services by
removing barriers such as cost; however disparities in healthcare delivery and patient
compliance still exist. Evidence suggests that many factors can influence a patient’s acceptance
of and adherence to preventive services, including individual risk factors, race/ethnicity, primary
or preferred language, education level, social support, sexual orientation, and socioeconomic
status.3-7 Additional research is needed to identify interventions which will help to reduce these
disparities in the provision of and adherence to preventive services. One solution which is being
evaluated is whether peer support can improve cancer screening rates and adherence in
African American adults aged 50-74 years.8 If successful, this model could be implemented
across other vulnerable populations and health care topics.
Introduction
This guideline contains recommendations designed to assist clinicians in delivering and
supporting preventive health care services for patients across their lifetime.
Recommendations
The following tables summarize the recommendations based upon patient age. Detailed
recommendations may be found within each topic-specific section.

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6
INFANTS AND CHILDREN
Table 1. Infant/Child Preventive Health Care Summary (Age 0-1 year)
CHILDREN
AGE 0-1 YR. Birth to 1 mo. 2 mo. 4 mo. 6 mo. 9 mo. 12 mo.
Anemia
Consider risk
assessment.
Test if at risk.
(UW Health Low
quality evidence,
weak/conditional
recommendation)

Test using CBC without
differential.
(UW Health Low
quality evidence, weak/conditional
recommendation)
Routine iron supplementation (1 mg/kg/day) based on breastfeeding status.
(UW Health High quality evidence, strong recommendation)
Blood Lead
Perform risk assessment.
Test if at risk.
(UW Health Low
quality evidence, weak/conditional
recommendation)
Breastfeeding
Exclusive breastfeeding for approximately 6 months after delivery is recommended. (UW Health Low quality evidence, strong recommendation)
Thereafter, infants may receive complementary foods with continued breast feeding up to 1 yr. of age or beyond.
(UW Health Low quality evidence, weak/conditional recommendation)
Dental Caries
Apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth
eruption. (USPSTF Grade B) Children should be seen by a dentist within 6 months of first tooth eruption or 12
months of age, whichever comes first. (UW Health Low quality evidence, weak/conditional recommendation)

Oral fluoride supplementation starting at age 6 months through 5 yrs. for children whose water supply is
deficient in fluoride. (USPSTF Grade B)
Development Complete ASQ. (UW Health Moderate quality
evidence, strong recommendation)

Hearing
Perform newborn
screening.
(Mandated by law)

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7
CHILDREN
AGE 0-1 YR. Birth to 1 mo. 2 mo. 4 mo. 6 mo. 9 mo. 12 mo.
Hypertension Patients with specific risk conditions should have their blood pressure obtained every six months.
(UW Health Very low quality evidence, weak/conditional recommendation)
Immunization Follow ACIP/CDC Schedule (UW Health High quality evidence, strong recommendation); Vaccine Refusal Form should be completed annually (UW Health Very low quality evidence, weak/conditional recommendation)
Newborn
Screening
Complete within
24-48 hrs. of birth
(Mandated by law)

Tobacco Assess secondhand smoke exposure at every clinical encounter. (UW Health Moderate quality evidence, strong recommendation)
Tuberculosis
Perform risk assessment. Test if at risk.
(UW Health Very low quality evidence, weak/conditional
recommendation)

Perform risk assessment.
Test if at risk.
(UW Health Very low quality
evidence, weak/conditional
recommendation)
Vision
Examine using
inspection and red
reflex testing. (UW
Health Very low quality
evidence, strong
recommendation)

An ocular history, ocular alignment and motility assessment, and an ocular examination consisting of an
external examination, pupil examination, red reflex testing to assess ocular media, ocular fundus examination
with ophthalmoscope, and assessment of visual function should be done between 6-12 months. (UW Health Very
low quality evidence, strong recommendation)
*Badger Care Plus eligible children **Medicaid patients should be screened annually between age 3-8 yrs.
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
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8
Table 2. Infant/Child Preventive Health Care Summary (Age > 1 year)
CHILDREN
AGE > 1 YR. 15 mo. 18 mo. 24 mo. 30 mo.* 3-6 yrs. 7-10 yrs.
Alcohol
Beginning at age 10 yrs., screening should take
place at least annually (UW Health Very low quality
evidence, weak/conditional recommendation)
Adolescent patients should be screened using
the CRAFFT (version 2.0). (UW Health Low quality
evidence, strong recommendation) Patients with less
than two “yes” answers on the CRAFFT should
receive a brief counseling intervention. (UW
Health Low quality evidence, weak/conditional
recommendation)
Anemia Consider risk assessment. Test if at risk.
(UW Health Low quality evidence, weak/conditional recommendation)
Autism
Complete
M-CHAT-R/F
(UW Health High quality
evidence, strong
recommendation)
Complete
M-CHAT-R/F
(UW Health High
quality evidence,
strong
recommendation)

Blood Lead
Perform risk
assessment.
Test if at risk.
(UW Health Low
quality evidence,
weak/conditional
recommendation)

Perform risk assessment.
Test if at risk.
(UW Health Low
quality evidence, weak/conditional
recommendation)

Breastfeeding Patients may receive complementary foods with continued breast feeding up to 1 yr. of age or beyond.
(UW Health Low quality evidence, weak/conditional recommendation)
Dental Caries
Apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
(USPSTF Grade B) Oral fluoride supplementation starting at age 6 months through 5 yrs. for children whose water supply is
deficient in fluoride. (USPSTF Grade B)

Development
Complete ASQ.
(UW Health Moderate
quality evidence, strong
recommendation)
Complete ASQ between 24-30
months.
(UW Health Moderate quality evidence,
strong recommendation)

Diabetes Test for type 2 diabetes at age 10 yrs. or onset
of puberty if at risk (ADA Grade E)
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9
CHILDREN
AGE > 1 YR. 15 mo. 18 mo. 24 mo. 30 mo.* 3-6 yrs. 7-10 yrs.
Hearing
Test once between
4-6 yrs.**
(UW Health Very low quality evidence,
weak/conditional recommendation)
Test once between
8-10 yrs.**
(UW Health Very low quality evidence, weak/conditional
recommendation)
Hypertension
Patients with specific risk conditions should have their blood pressure obtained
every six months.
(UW Health Very low quality evidence, weak/conditional recommendation)
Measure blood pressure annually.
(ICSI High quality evidence, strong recommendation)
Immunization Follow ACIP/CDC Schedule (UW Health High quality evidence, strong recommendation); Vaccine Refusal Form should be completed annually (UW Health Very low quality evidence, weak/conditional recommendation)
Lipids
Complete universal screen once between 9-11
yrs. using non-fasting total cholesterol and
HDL.
(NHLBI Grade B, strongly recommended)
Obesity Measure BMI annually (ICSI High quality evidence, strong recommendation)
Skin Cancer Provide counseling beginning at age 10 yrs. if
at risk. (USPSTF Grade B)
Tobacco Assess secondhand smoke exposure at every clinical encounter. (UW Health Moderate quality evidence, strong recommendation)
Tuberculosis
Perform risk
assessment.
Test if at risk.
(UW Health Very
low quality
evidence,
weak/conditional
recommendation)

Perform risk assessment annually.
Test if at risk.
(UW Health Very low quality evidence, weak/conditional recommendation)
Vision
An ocular history, ocular alignment and motility assessment, and an ocular examination consisting of an external
examination, pupil examination, red reflex testing to assess ocular media, ocular fundus examination with ophthalmoscope,
and assessment of visual function be done between the following ages: 1-3 yrs., and 4-5 yrs. (UW Health Very low quality
evidence, strong recommendation)
Vision acuity screening tests and additional
ophthalmic assessments should be completed
once during the following age ranges to detect
the presence of myopia: 6-8 yrs. and 10-12 yrs.
(UW Health Very low quality evidence, strong
recommendation)
*Badger Care Plus eligible children **Medicaid patients should be screened annually between age 3-8 yrs.


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ADOLESCENTS
Table 3. Adolescent Preventive Health Care Summary
ADOLESCENTS 11 yr. 12 yr. 13 yr. 14 yr. 15 yr. 16 yr. 17 yr.
Alcohol
Screening should take place at least annually (UW Health Very low quality evidence, weak/conditional recommendation)
Adolescents should be screened using Part A of the CRAFFT (version 2.0). (UW Health Low quality evidence, strong recommendation) If positive screen, all 6 CRAFFT Part B questions
should be asked. The CAR question should be asked regardless of patient response to Part A.
Patients with less than two “yes” answers on the CRAFFT should receive a brief counseling intervention. (UW Health Low quality evidence, weak/conditional recommendation)
Chlamydia,
Gonorrhea
Screen sexually active females annually for chlamydia and gonorrhea (USPSTF Grade B)
Perform annual chlamydia and gonorrhea screening in MSM (UW Health High quality evidence, strong recommendation)
Depression Screen annually using the PHQ-2. (UW Health Very low quality evidence, strong recommendation)
If positive screen, complete further assessment using PHQ-A or PHQ-9. (UW Health Low quality evidence, strong recommendation)
Diabetes Test for type 2 diabetes at onset of puberty if at risk. (ADA Grade E) Repeat testing every 3 yrs. (ADA Grade C)
Hearing No current recommendations for routine screening.*
HIV
Universal opt-out HIV screening should be offered once by 16 to 18 yrs. of age.
(UW Health Very low quality evidence, strong recommendation)
High-risk youth should be tested annually for HIV. (UW Health Very low quality evidence, weak/conditional recommendation)
Hypertension Measure blood pressure annually (ICSI High quality evidence, strong recommendation)
Immunization Follow ACIP/CDC Schedule (UW Health High quality evidence, strong recommendation); Vaccine Refusal Form should be completed annually (UW Health Very low quality evidence, weak/conditional recommendation)
Intimate Partner
Violence
Screen females of childbearing age for intimate partner violence (USPSTF Grade B) using the HITS assessment
tool. (UW Health Moderate quality evidence, weak/conditional recommendation)
Screening may be considered annually. (UW Health Very low quality evidence, weak/conditional recommendation)
Lipids
Complete universal screen once
between 9-11 yrs. using non-fasting
total cholesterol and HDL. (NHLBI
Grade B, strongly recommended)

Complete universal screen once between 17-21 yrs. using non-
fasting total cholesterol and HDL
(NHLBI Grade B, strongly recommended)
Obesity Measure BMI annually. (ICSI High quality evidence, strong recommendation)
Sexual Activity Provide behavioral counseling if sexually active (USPSTF Grade B)
Skin Cancer Provide behavioral counseling about minimizing exposure to ultraviolet radiation if at risk. (USPSTF Grade B)
Tobacco Tobacco use status should be assessed and documented at every clinical encounter. (UW Health High quality evidence, strong recommendation)
In nonusers, assess secondhand smoke exposure at every clinical encounter. (UW Health Moderate quality evidence, strong recommendation)
Tuberculosis Perform annual risk assessment. Test if at risk. (UW Health Very low quality evidence, weak/conditional recommendation)
Vision Vision acuity screening tests and additional ophthalmic assessments should be completed once during the following age ranges to detect the presence of myopia:
10-12 yrs., 13-15 yrs., and 16-18 yrs. (UW Health Very low quality evidence, strong recommendation)
*Medicaid patients should be screened at age 12 yrs. and 16 yrs.
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11
ADULTS
Table 4. Adult Preventive Health Care Summary (Men and Non-pregnant Women)
ALL ADULTS 18-29 yrs. 30-39 yrs. 40-49 yrs. 50-64 yrs. 65-69 yrs. 70 yrs. and older
Alcohol
Screening should take place at least annually. (UW Health Very low quality evidence, weak/conditional recommendation)
Adults should be screened using the AUDIT-C. (UW Health Low quality evidence, strong recommendation)

Adult patients who screen positive for unhealthy alcohol use should receive a brief counseling intervention. (UW Health Moderate quality evidence, weak/conditional
recommendation) Adult patients who are likely to have an alcohol use disorder should receive further assessment and/or a referral to treatment with a specialist in
alcohol and drug related issues. (UW Health Moderate quality evidence, weak/conditional recommendation)
Aspirin
(81 mg daily)
Aspirin can be considered
following shared decision making
in patients younger than 40 yrs.
at very high risk for
cardiovascular disease. (UW
Health Very low quality evidence,
weak/conditional recommendation)
However, aspirin use in patients
younger than 21 yrs. is not
recommended.
(UW Health Low quality evidence,
weak/conditional recommendation)
Aspirin is not recommended
for ASCVD prevention in
adults aged 40-49 yrs. with
diabetes at low ASCVD risk
(< 5%). (ADA Grade C)
Aspirin may be used on an
individual basis in patients
aged 40-49 yrs. with diabetes
at intermediate ASCVD risk
(5-10%), following
consideration of the benefits
and harms of initiation.
(UW Health Very low quality
evidence, weak/conditional
recommendation)
Initiating low-dose aspirin for primary prevention is
recommended in adults aged 50-59 yrs. who have a 10% or
greater 10-yr. cardiovascular disease risk, are not at increased
risk for bleeding, have a life expectancy of at least 10 yrs., and
are willing to take low-dose aspirin daily for at least 10 yrs.
(USPSTF Grade B)
The decision to initiate low-dose aspirin for primary prevention of
CVD and CRC in adults aged 60-69 yrs. who have a 10% or
greater 10-yr. CVD risk should be an individual one.
(USPSTF Grade C)
Due to the increased
risk of bleeding with
age, initiation of aspirin
for primary prevention
may be considered on
an individual basis.
(UW Health Very low quality
evidence, weak/conditional
recommendation)
It is recommended to use the ACC/AHA ASCVD Risk Estimator to evaluate 10-yr. cardiovascular disease risk (http://tools.acc.org/ASCVD-Risk-Estimator/).
(UW Health Low quality evidence, strong recommendation)
Cognitive
Screening
Routine screening is not recommended. (USPSTF I Statement)
However, if performing a CMS Annual Wellness Visit,
screening should be completed annually.
(UW Health Low quality evidence, weak/conditional recommendation)
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12
ALL ADULTS 18-29 yrs. 30-39 yrs. 40-49 yrs. 50-64 yrs. 65-69 yrs. 70 yrs. and older
Colorectal
Cancer
Screen patients aged 50-75 yrs. (USPSTF Grade A) Routine universal screening should not be
performed in patients 76-85 yrs.; however there may be considerations that support
screening in an individual patient. (USPSTF Grade C)
The most important outcome is that eligible patients are screened. Patient choice has been
independently associated with greater participation and adherence to screening, therefore,
appropriate patient-physician discussion of the screening testing options should occur. (UW
Health High quality evidence, strong recommendation) Optical colonoscopy (UW Health Moderate quality
evidence, strong recommendation), CT colonography (UW Health Moderate quality evidence, strong
recommendation), fecal immunohistochemical test (FIT) (UW Health Moderate quality evidence, strong
recommendation), or multi-target stool DNA (Cologuard®/FIT-DNA) (UW Health Low quality evidence,
weak/conditional recommendation) are recommended for colon cancer screening. Flexible
sigmoidoscopy is also acceptable. (UW Health Moderate quality evidence, strong recommendation)
See text below for the pros and cons of each testing option as well as the screening
intervals.
Patients with a life expectancy of less than 10 yrs. should not be screened.
(UW Health Low quality evidence, weak/conditional recommendation)
Depression Screen annually using the PHQ-2. (UW Health Very low quality evidence, strong recommendation)
If positive screen, complete further assessment using PHQ-9. (UW Health Low quality evidence, strong recommendation)
Diabetes
Screening for type 2 diabetes with an informal assessment of risk factors should be considered in asymptomatic adults. (ADA Grade B) It is reasonable to perform a
risk assessment annually. (UW Health Very low quality evidence, weak/conditional recommendation) Testing for type 2 diabetes should be considered in all adult patients who
are overweight or obese (BMI > 25 kg/m2 or > 23 kg/m2 in Asian Americans) and have one or more risk factors (UW Health Moderate quality evidence, weak/conditional
recommendation) Frequency should be based upon individual clinical judgement that is influenced by the patient’s clinical status, any prior test results, and the
presence of or changes in risk factors. (UW Health Very low quality evidence, weak/conditional recommendation) If prior test results are normal and patients do not demonstrate
other significant risk, testing should not be repeated more frequently than every 3 years. (UW Health Low quality evidence, weak/conditional recommendation)
Falls Risk
Screen patients age 65 yrs. or older annually (AGS Grade A)
using the STEADI screening questionnaire.
If positive screen, complete assessment using the TUG.
Hepatitis B Patients should be screened if at high risk. (USPSTF Grade B) Patients with ongoing risk factors may be tested annually. (UW Health Low quality evidence, weak/conditional recommendation)
Hepatitis C
Patients should be screened once if born between the yrs. of 1945-1965. (USPSTF Grade B)
Patients should be screened if at increased risk. (USPSTF Grade B)
Patients with ongoing risk factors may be tested annually. (UW Health Low quality evidence, weak/conditional recommendation)
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13
ALL ADULTS 18-29 yrs. 30-39 yrs. 40-49 yrs. 50-64 yrs. 65-69 yrs. 70 yrs. and older
HIV
Universal opt-out HIV screening is recommended in average risk patients aged 19-64 yrs. who
were not tested in adolescence, regardless of sexual activity or risk.
(UW Health Very low quality evidence, strong recommendation)

Annual screening is recommended in patients at an increased or high risk for infection.
(UW Health Low quality evidence, strong recommendation)
Screen after age 65 yrs. if at increased risk. (USPSTF Grade A)
Pre-exposure prophylaxis may be indicated if at increased risk. (UW Health High quality evidence, strong recommendation)
Hypertension Screen adults age 18 yrs. or older. (USPSTF Grade A) Annual screening in adults > 40 yrs. and for all adults at increased risk. (UW Health Moderate quality evidence, strong
recommendation) Patients age 18-30 yrs. with normal blood pressure and no other risk factors should be rescreened every 3-5 yrs. (USPSTF Grade A)
Immunizations Follow ACIP/CDC Schedule. (UW Health High quality evidence, strong recommendation)
Lipids
Complete universal screen once
between 17-21 yrs. using non-
fasting total cholesterol and
HDL. (NHLBI Grade B, strongly
recommended)
Test once every 5 yrs. between
ages of 22-39 yrs. (NHLBI Grade B,
Moderate) using a fasting lipid
panel or non-fasting total
cholesterol and HDL. Patients at
increased risk may be tested
more frequently. If LDL and TG
levels are within normal limits,
subsequent screening may be
delayed until age 35 (men) and
age 45 (women) unless risk
factors develop. (UW Health Low
quality evidence, weak/conditional
recommendation)
Test once every 5 yrs. between ages of 40-75 yrs. (NHLBI Grade B, Moderate) using a fasting lipid panel or non-fasting total
cholesterol and HDL. Patients at increased risk may need to be tested more frequently. If a woman’s 10 yr. cardiovascular risk
is < 2.5% and if LDL and TG levels are within normal limits subsequent screening may be delayed until age 45 unless risk
factors develop.139 It is recommended to use the ACC/AHA ASCVD Risk Estimator to evaluate 10-yr. CVD risk
(http://tools.acc.org/ASCVD-Risk-Estimator/). (UW Health Low quality evidence, weak/conditional recommendation)
Lung Cancer


Complete annual screening using low dose CT in high-risk patients age 55-80 yrs. who have
a 30 pack-yr. smoking history AND are a current smokers or have quit within the last 15 yrs.
(USPSTF Grade B) Discontinue screening once patient has not smoked for 15 yrs. or develops
a health problem which limits life expectancy. (USPSTF Grade B)
Obesity Measure BMI annually. (ICSI High quality evidence, strong recommendation)
Sexual Activity Provide behavioral counseling if sexually active and at increased risk for sexually transmitted infection. (USPSTF Grade B)
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ALL ADULTS 18-29 yrs. 30-39 yrs. 40-49 yrs. 50-64 yrs. 65-69 yrs. 70 yrs. and older
Skin Cancer
Provide behavioral counseling about minimizing exposure to ultraviolet radiation in patients age 18-24 yrs. and at risk. (USPSTF Grade B)
Provide behavioral counseling about minimizing exposure to ultraviolet radiation in all patients aged 25 yrs. or older.
(UW Health Very low quality evidence, weak/conditional recommendation)
Syphilis Screen if at increased risk. (USPSTF Grade A) Screen MSM annually using a complete syphilis serology with confirmatory testing. (UW Health High quality evidence, strong recommendation)
Tobacco Tobacco use status should be assessed and documented at every clinical encounter. (UW Health High quality evidence, strong recommendation)
In non-users, assess secondhand smoke exposure at every clinical encounter. (UW Health Moderate quality evidence, strong recommendation)
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Table 5. Adult Preventive Health Care Summary (Men Only)
ADULT MEN* 18-29 yrs. 30-39 yrs. 40-49 yrs. 50-64 yrs. 65-69 yrs. 70 yrs. and older
Abdominal Aortic
Aneurysm
Screen once between the ages of 65-75 yrs. if patient
ever smoked using abdominal duplex ultrasonography.
(USPSTF Grade B)
Selective screening may be considered in men who have
never smoked with additional risk factors.
(USPSTF Grade C)
Chlamydia or
Gonorrhea
Insufficient evidence in regards to routine screening in heterosexual men (USPSTF I Statement); screening may be considered in settings with high prevalence. (UW Health Low
quality evidence, strong recommendation)
Screen MSM annually, including extragenital sites. (UW Health High quality evidence, strong recommendation)
Osteoporosis
Risk assessment using the NOF guideline criteria
is recommended in men between the ages of 50-69
years. (UW Health Low quality evidence, weak/conditional
recommendation) Central dual-energy X-ray
absorptiometry (DXA) should be completed in
patients who exhibit one or more risk factor. (UW
Health Low quality evidence, weak/conditional recommendation)
Central dual-energy X-ray
absorptiometry (DXA)
should be completed in
men age 70 years or older.
(UW Health Low quality
evidence, weak/conditional
recommendation)
Following completion of the first DXA scan, a FRAX assessment should be
completed using the T-score to determine major osteoporotic fracture risk and
future screening interval.
(UW Health Very low quality evidence, weak/conditional recommendation)
Prostate Cancer
Routine prostate cancer screening
is not recommended.
(UW Health Very low quality evidence,
strong recommendation)

Shared decision making may be
considered in men with increased
risk.
(UW Health Very low quality evidence,
weak/conditional recommendation)
A one-time shared decision making conversation is
recommended. (UW Health Moderate quality evidence,
weak/conditional recommendation)
If the decision made is to screen, PSA testing may
be completed every 1-2 yrs. (UW Health Low quality
evidence, weak recommendation)
Routine prostate cancer
screening is not
recommended.
(UW Health High quality
evidence, strong
recommendation)
Men with a life expectancy of less than 10 yrs. should not be screened.
(UW Health Moderate quality evidence, weak recommendation)
*Sex-based screening should be dependent upon organ inventory and the individual needs of a patient.





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Table 6. Adult Preventive Health Care Summary (Non-pregnant Women Only)
ADULT WOMEN* 18-29 yrs. 30-39 yrs. 40-49 yrs. 50-64 yrs. 65-69 yrs. 70 yrs.
and older
Abdominal Aortic
Aneurysm
Current evidence insufficient to assess
benefits and harms of screening in women
65-75 yrs. who have smoked. (USPSTF I
Statement) It may be appropriate in individual
cases to perform screening. (UW Health Very low
quality evidence, weak/conditional recommendation)
It is not recommended to screen women who
have never smoked. (USPSTF Grade D)
Breast Cancer


Beginning at age 40 yrs., a shared
decision making conversation is
recommended to determine patient
preferences and assess breast
cancer risk. (UW Health Very low quality
evidence, weak/conditional
recommendation)
Recommend discussion of the risk
and benefits to consider additional
screening every 1-2 yrs. in the
context of patient preferences,
breast density, and other risk
factors. (UW Health Moderate quality
evidence, weak/conditional
recommendation)
Screen women age 50-74 yrs. using 2-D mammography. (UW Health Moderate quality
evidence, strong recommendation) Digital breast tomosynthesis (DBT), a 3-D
mammography method which UW Health has available at most imaging sites,
may be considered. (UW Health Low quality evidence , weak/conditional recommendation)
Biennial or annual screening frequency may be influenced by patient’s expressed
preference during shared-decision making or risk factors such as mammographic
breast density. (UW Health Low quality evidence, weak/conditional recommendation)
Consider mammography screening in women age 75 yrs. or older every 1-2 yrs.
based upon a discussion of the risks and benefits, as well as consideration for life
expectancy. (UW Health Low quality evidence, weak/conditional recommendation)
Women with a life expectancy of less than 10 yrs. should not be screened.
(UW Health Low quality evidence, weak/conditional recommendation)
UW Health Prevention and Tailored Health Screening (PATHS) clinic referral for women at high risk. (Appendix B)
Cervical Cancer
Screening is not
recommended in patients
younger than 21 yrs.
(USPSTF Grade D) unless at
high risk (see Appendix B)
Screen patients age 21-29
yrs. using cytology alone
every 3 yrs. (USPSTF Grade A)
Screen women age 30-65 yrs. with a combination cytology and high risk HPV co-test every
5 yrs. OR screen with cytology alone every 3 yrs. (USPSTF Grade A)
Stop screening at age 65
yrs. if three normal
results OR two negative
high risk HPV results in
the last decade AND no
history of CIN 2, 3, or
cervical cancer in last 20
yrs.
(USPSTF Grade D)

Patients at high risk should follow alternative screening intervals (see Appendix B.)
More frequent screening intervals (i.e., annual) is not recommended for average risk women of any age.
(UW Health High quality evidence, strong recommendation)
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ADULT WOMEN* 18-29 yrs. 30-39 yrs. 40-49 yrs. 50-64 yrs. 65-69 yrs. 70 yrs.
and older
Chlamydia or
Gonorrhea
Screen sexually active
patients 24 yrs. or younger.
(USPSTF Grade B)

Screen sexually active
patients age 25-29 yrs. if at
increased risk.
(USPSTF Grade B)

Patients should be
screened annually. (UW
Health Low quality evidence,
strong recommendation)
Screen sexually active patients age 30-69 yrs. if at increased risk. (USPSTF Grade B)
Patients should be screened annually. (UW Health Low quality evidence, strong recommendation)


Osteoporosis
Assessment using the FRAX is
recommended in
postmenopausal women
between the ages of 50-64
years, especially if the patient is
considered at increased risk.
(UW Health Moderate quality evidence,
weak/conditional recommendation)

Central dual-energy X-ray
absorptiometry (DXA) should be
completed in patients whose
fracture risk is equal to or
greater than that of a 65 year old
white woman who has no
additional risk factors (major
osteoporotic fracture score
9.3%). (UW Health Moderate quality
evidence, strong recommendation)

In patients without risk factors or
at low risk, risk should be
reassessed every 5 years. (UW
Health Very low quality evidence,
weak/conditional recommendation)
Perform DXA in women age 65 yrs. or older.
(USPSTF Grade B)
Following completion of the first DXA scan, a
FRAX assessment should be completed
using the T-score to determine major
osteoporotic fracture risk and future screening
interval. (UW Health Very low quality evidence,
weak/conditional recommendation)
Intimate Partner
Violence
Screen women of childbearing age (18-46 yrs.) for intimate partner violence (USPSTF
Grade B) using the HITS assessment tool. (UW Health Moderate quality evidence,
weak/conditional recommendation) Screening may be considered annually. (UW Health Very
low quality evidence, weak/conditional recommendation)


*Sex-based screening should be dependent upon organ inventory and the individual needs of a patient.
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Topic-specific Recommendations
ABDOMINAL AORTIC ANEURYSM
Return to Adult Table (Men Only) | Return to Adult Table (Women Only)
Risk Factors
Important risk factors for abdominal aortic aneurysm (AAA) in men include9,10:
ξ Smoking (at least 100 cigarettes in lifetime)
ξ First degree relative with an AAA
ξ History of other vascular aneurysms
ξ Coronary artery disease
ξ Cerebrovascular disease
ξ Atherosclerosis.
ξ eGFR < 60 mL/min
ξ Hypercholesterolemia
ξ Obesity
ξ Hypertension

Factors associated with a reduced risk for AAA in men include9:
ξ African American race
ξ Hispanic ethnicity
ξ Diabetes mellitus

Men age 65-75 years
It is recommended to perform one-time screening for AAA with abdominal duplex ultrasonography in men
ages of 65-75 years who have ever smoked (i.e., at least 100 cigarettes in his lifetime).9,11 (USPSTF Grade B)

Selective screening using abdominal duplex ultrasonography in men who have never smoked may be
considered in patients with additional risk factors.9,12,13 (USPSTF Grade C) In determining whether this
service is appropriate in individual cases, patients and clinicians should consider the balance of benefits
and harms on the basis of evidence relevant to the patient’s medical history, family history, other risk
factors, and personal values.9,12,13

Women age 65-75 years
The current evidence is insufficient to assess the balance of benefits and harms related to AAA screening in
women age 65-75 years who have ever smoked (i.e., at least 100 cigarettes in her lifetime).9 (USPSTF I
Statement) It may be appropriate in individual cases to perform screening. (UW Health Very low quality
evidence, weak/conditional recommendation) Patients and clinicians should consider the balance of benefits
and harms relevant to the patient’s medical history, family history, other risk factors, and personal values.

It is not recommended to routinely screen women who have never smoked.9 (USPSTF Grade D)).

Contraindications to Screening
There are no established contraindications to AAA screening in the literature. The benefits of screening and
surgical repair have been demonstrated even in patients with a limited life expectancy or comorbidities (e.g.,
obesity). (UW Health Very low quality evidence, strong recommendation) In accordance with Choosing Wisely
principles, patients with prior imaging adequate enough to view the abdominal aorta within the previous 5
years do not need to receive additional imaging. (UW Health Very low quality evidence, weak/conditional
recommendation)

Surveillance
Patients determined to have an abdominal aortic aneurysm upon screening may require modified screening
recommendations as outlined below (Table 7).14
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Table 7. Abdominal Aortic Aneurysm Surveillance Recommendations
Size determined by
initial screening Suggested Follow-up
3 cm - 3.5 cm 5 years (following a complete ultrasound)
3.6 cm – 4 cm 2 years (following a complete ultrasound)
4.1 cm – 4.5 cm 1 year (if clinically warranted further imaging with CT)
4.6 cm – 4.9 cm 6 months (if clinically warranted further imaging with CT)
5 cm – 6.9 cm Consider referral to Vascular Surgery
> 7 cm Critical result- patient kept in the imaging suite until further direction
from a specialty physician.

Patients who have undergone abdominal aortic aneurysm repair are no longer considered average risk and
fall outside the scope of this guideline.

Patient Resources
1. HFFY #4885: Surgery of the Aorta
2. Healthwise: Well Visit: 50 to 65 Year Men
3. Healthwise: Well Visit: Over 65 Years
4. Health Information: Abdominal Aortic Aneurysm
Screening
5. Health Information: Abdominal Aortic Aneurysm:
Should I Get a Screening Test?
ALCOHOL USE
Return to Adolescent Table | Return to Adult Table

Detailed recommendations for providing a brief intervention and treatment can be found within the full
UW Health Alcohol Assessment and Intervention – Adult/Pediatric – Inpatient/Ambulatory Guideline.

Patients age 10-17 years
Screening should take place at least annually in the primary care setting.15 (UW Health Very low quality
evidence, weak/conditional recommendation) The CRAFFT (Car, Relax, Alone, Forget, Family/Friends, Trouble)
is a validated tool to screen adolescents for risky drinking and drug behaviors. Adolescent patients should
be screened for alcohol and drug use using Part A of the CRAFFT (version 2.0).16-19 (UW Health Low quality
evidence, strong recommendation) If the patient responds to any question with a number greater than “0,” all 6
CRAFFT Part B questions should be asked. The CAR question should be asked regardless of patient
response to Part A.

Patients with less than two “yes” answers on the CRAFFT should receive a brief counseling intervention.16,18
(UW Health Low quality evidence, weak/conditional recommendation) A score of two or more “yes” answers
suggest a serious problem and need for further assessment. Patients with two or more “yes” answers on the
CRAFFT should receive a brief intervention and a referral to treatment with a specialist in alcohol and drug
related issues.16,18 (UW Health Low quality evidence, weak/conditional recommendation)

Patients age 18 years or older
The United States Preventive Services Task Force (USPSTF) recommends that clinicians screen adults
aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with
brief behavioral counseling interventions to reduce alcohol misuse.20 (USPSTF B Recommendation) Screening
should take place at least annually in the primary care setting.15,20 (UW Health Very low quality evidence,
weak/conditional recommendation) UW Health recommends using the Alcohol Use Disorders Identification
Test – Consumption (AUDIT-C) to screen for alcohol misuse in non-pregnant adults.21-23 (UW Health Low
quality evidence, strong recommendation) The AUDIT-C includes the first three questions of the full AUDIT
screening tool.

Adult patients who screen positive for unhealthy alcohol use (AUDIT-C score of 3 to 7 for men over 65
years and all adult women; 4 to 7 for men 18 to 65 years) should receive a brief counseling intervention.24
(UW Health Moderate quality evidence, weak/conditional recommendation) It is important to note that even low or
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20
moderate drinking is risky for some patients in certain clinical situations (e.g. pregnancy, taking warfarin),
and these patients should be advised to not drink at all.25-27 (UW Health Moderate quality evidence,
weak/conditional recommendation) Adult patients who are likely to have an alcohol use disorder (AUDIT-C
score of 8 or greater) should receive further assessment and/or a referral to treatment with a specialist in
alcohol and drug related issues.20,28 (UW Health Moderate quality evidence, weak/conditional recommendation)

Clinicians may consider using the entire AUDIT screening tool to evaluate adult patients for potential
negative health or social consequences associated with drinking.22,29 (UW Health Moderate quality evidence,
weak/conditional recommendation) This information may be helpful when conducting the brief intervention or
when discussing referral to treatment with the patient.

Pertinent UW Health Policies & Procedures
1. UWHC Policy 4.38: Release of Alcohol & Other Drug Abuse Information

Patient Resources
1. HFFY #4611: Alcohol and Drug Abuse: A Guide to
Community Services
2. HFFY #7628: Cutting Back On Your Drinking
3. HFFY #7373: Maintaining Your Sobriety
4. HFFY #5717: Older Adults and Alcohol Abuse
5. HFFY #5669: A Health Guide for Men Age 50 or Older
6. HFFY #6419: A Health Guide for Men Age 50 or Older
7. HFFY #5668: A Health Guide for Women 50 or Older
8. Healthwise: Alcohol Abuse: Your Teen: General Info
9. Healthwise: Alcohol Abuse and Addition: Teen:
General Info
10. Healthwise: Alcohol and Drug Problems
11. Healthwise: Alcohol Intoxication : Your Teen
12. Healthwise: Alcohol Intoxication: Acute
13. Healthwise: Alcohol Use: Teen: General Info
14. Healthwise: Well Visit: 18 to 50 Years
15. Healthwise: Well Visit: 50 to 65 Year Men
16. Healthwise: Well Visit: 50 to 65 Year Women
17. Healthwise: Well Visit: Over 65 Years
18. Health Information: Alcohol Abuse and Dependence
19. Health Information: Alcohol Abuse, Do You Have a
Drinking Problem Interactive Tool
20. Health Information: Alcohol Abuse, Teen
21. Health Information: Alcohol Abuse: Dealing with Teen
Substance Abuse
22. Health Information: Alcohol Abuse: Other Health
Problems That May Occur
23. Health Information: Alcohol and Drug Problems
24. Health Information: Alcohol Problems: How to Stop
Drinking
ANEMIA
Return to Infant/Child Table
Risk Factors
Positive risk factors for iron deficiency or iron-deficiency anemia30 include:
ξ History of prematurity or low birth weight
ξ Exposure to lead
ξ Exclusive breastfeeding beyond 4 months of age without supplemental iron
ξ Weaning to whole milk or complementary foods that do not include iron-fortified cereals or foods
naturally rich in iron
ξ Feeding problems
ξ Poor growth
ξ Inadequate nutrition (typically in infants with special needs or low socioeconomic status)

Patients age 1 year
Universal screening for anemia via complete blood count (CBC) without differential lab is recommended by
the American Academy of Pediatrics at approximately 1 year of age.30-32 (UW Health Low quality evidence,
weak/conditional recommendation)

Patients at Increased Risk (age 4 months, > 15 months)
Selective screening can be performed at any age when risk factors have been identified, including risk of
inadequate iron intake according to dietary history.30 An assessment of risk factors associated with iron
deficiency or iron-deficiency anemia may be considered for any patient age 4 months or 15 months and
older (see risk factors above).30,32 (UW Health Low quality evidence, weak/conditional recommendation)
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Patients exhibiting any of the above risk factors or with a hemoglobin (Hb) concentration of less than 11.0
mg/dL may have serum ferritin (SF), C-reactive protein (CRP), and reticulocyte hemoglobin (CHr) levels
measured in addition to Hb concentration to increase the sensitivity and specificity of the diagnosis.30

Iron Supplementation
It is recommended that exclusively breastfed term infants receive an iron supplementation of 1 mg/kg per
day, starting at 4 months of age and continued until appropriate iron-containing complementary foods have
been introduced. For partially breastfed infants, the proportion of human milk versus formula is uncertain;
therefore, beginning at 4 months of age, infants who receive more than one-half of their daily feedings as
human milk and who are not receiving iron-containing complementary foods should also receive 1 mg/kg
per day of supplemental iron.30 (UW Health High quality evidence, strong recommendation)

Patient Resources
1. HFFY #182: Vitamins and Minerals: Iron in Your Diet
2. Healthwise: Iron

ASPIRIN FOR PRIMARY PREVENTION
Return to Adult Table
Risk Factors
It is recommended to use the ACC/AHA Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator to
evaluate 10-year cardiovascular disease (CVD) risk (http://tools.acc.org/ASCVD-Risk-Estimator/).33,34 (UW
Health Low quality evidence, strong recommendation) Clinicians should remain aware of the calculator’s
limitations, including the inability to calculate 10-year risk in patients younger than 40 years, absence of
consideration for family history, potential to overpredict risk, and lack of generalizability to racial/ethnic
minorities. However, despite these limitations, this calculator is the only U.S.-based, externally validated
equation which evaluates risk as a combination of cerebrovascular and coronary heart disease events.33

The independent risk factors for cardiovascular diseases33,35,36 include:
ξ Older age
ξ Male sex
ξ Abnormal lipid levels (total cholesterol > 240 mg/dL)
ξ High blood pressure
ξ Diabetes mellitus (type 1 of type 2)
ξ Smoking
ξ Family history of premature atherosclerotic cardiovascular disease (ASCVD)

Risk factors for gastrointestinal (GI) bleeding with aspirin use33,37 include:
ξ Higher dose and longer duration of use
ξ History of GI ulcers or upper GI tract pain
ξ Bleeding disorders
ξ Renal failure
ξ Severe liver disease
ξ Thrombocytopenia

Risk factors for GI or intracranial bleeding with aspirin use33,37 include:
ξ Concurrent anticoagulation or nonsteroidal anti-inflammatory drug (NSAID) use
ξ Uncontrolled hypertension
ξ Male sex
ξ Older age

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Life Expectancy
Life expectancy is often difficult to ascertain38, however the following resources are available:
ξ ePrognosis
ξ CDC Tables

Patients younger than 50 years
The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for
the primary prevention of cardiovascular disease and colorectal cancer in adults younger than 50 years.33
(USPSTF I Statement) Mixed literature suggests an association between aspirin use and risk of Reye
syndrome, therefore aspirin use in patients younger than 21 years is not recommended.35,36,39-41 (UW Health
Low quality evidence, weak/conditional recommendation) Aspirin could be considered following a shared
decision making process in patients younger than 40 years at very high risk for cardiovascular disease (i.e.,
familial hypercholesterolemia, heavy smoking, type 2 diabetes mellitus with additional risk factors, or strong
family history of premature coronary artery disease). (UW Health Very low quality evidence, weak/conditional
recommendation)

Despite diabetes being an independent risk factor for cardiovascular disease, aspirin should not be
recommended for ASCVD prevention in adults age 40-49 years with diabetes at low 10-year ASCVD risk (<
5%), as the potential adverse effects from bleeding likely offset the potential benefits.36 (ADA Grade C)
Aspirin may be used on an individual basis in patients age 40-49 years with diabetes at intermediate 10-
year ASCVD risk (5-10%), following consideration of the benefits and harms of initiation.36 (UW Health Very
low quality evidence, weak/conditional recommendation)

Patients age 50-59 years
Initiating low-dose aspirin use for the primary prevention of cardiovascular disease and colorectal cancer is
recommended in adults aged 50-59 years who have a 10% or greater 10-year cardiovascular disease risk,
are not at increased risk for bleeding (see USPSTF tables 1 and 2), have a life expectancy of at least 10
years, and are willing to take low-dose aspirin daily for at least 10 years.33 (USPSTF Grade B) This
recommendation applies to adults at increased CVD risk and/or whom are at average risk for colorectal
cancer.33 The evidence to initiate aspirin in patients at intermediate or low ASCVD risk is uncertain; however
patients at lower baseline cardiovascular risk are less likely to have a favorable balance of the benefit and
harms.33

Patients age 60-69 years
The decision to initiate low-dose aspirin use for the primary prevention of CVD and CRC in adults aged 60-
69 years who have a 10% or greater 10-year CVD risk should be an individual one. Persons who are not at
increased risk for bleeding (see USPSTF tables 1 and 2), have a life expectancy of at least 10 years, and
are willing to take low-dose aspirin daily for at least 10 years are more likely to benefit. Persons who place a
higher value on the potential benefits than the potential harms may choose to initiate low-dose aspirin.33
(USPSTF Grade C) This recommendation applies to adults at increased CVD risk and/or whom are at
average risk for colorectal cancer.33 The evidence to initiate aspirin in patients at intermediate or low
ASCVD risk is uncertain; however patients at lower baseline cardiovascular risk are less likely to have a
favorable balance of the benefit and harms.33

Patients age 70 years or older
The current evidence is insufficient to assess the balance of benefits and harms of initiating aspirin use for
the primary prevention of CVD and CRC in adults aged 70 years or older.33 (USPSTF I Statement) Due to the
increased risk of bleeding, concomitant illness or medication use with age, initiation of aspirin for primary
prevention may be considered on an individual basis. (UW Health Very low quality evidence, weak/conditional
recommendation) It is important to consider life expectancy, as the cardiovascular benefit appears to begin
within the first 5 years of administration but the benefit of colorectal cancer prevention is not demonstrated
until 10-20 years after aspirin initiation.33,35


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Dosing and Cessation
While the optimal dose of aspirin to prevent CVD events is not known, a reasonable approach is to
prescribe 81 mg/day. (UW Health Low quality evidence, weak/conditional recommendation) Clinicians should
assess CVD and bleeding risk factors at least annually, or if a patient’s clinical condition changes. (UW
Health Low quality evidence, weak/conditional recommendation) Aspirin use should be stopped once the risk for
bleeding exceeds the long-term benefits. (UW Health Low quality evidence, strong recommendation)

Patient Resources
1. HFFY #7722: Aspirin
2. HFFY #6982: Colorectal Cancer Prevention
3. Health Information: Aspirin
4. Health Information: Aspirin to Prevent Heart Attack
and Stroke
5. Health Information: Aspirin: Should I Take Daily
Aspirin to Prevent Heart Attack or Stroke?

AUTISM SPECTRUM DISORDER
Return to Infant/Child Table
Patients age 18 and 24 months
Autism screening is recommended in patients age 18 and 24 months.32,42 (UW Health High quality evidence,
strong recommendation) Screening should be completed using the Modified Checklist for Autism in Toddlers,
Revised with Follow-up (M-CHAT-R/F) assessment tool.43

Patient Resources
1. Healthwise: Autism and Autism Spectrum Disorder (ASD): Pediatric
2. Health Information: Autism

BLOOD LEAD
Return to Infant/Child Table
Risk Factors44-46
ξ Child lives in/frequently visits a house or building built before 1950 or has in the past
ξ Child lives in/frequently visits a house or building built before 1978 with recent or ongoing
renovations or has in the past
ξ Child has a sibling or playmate who has/had lead poisoning
ξ Child is enrolled in Medicaid, Head Start, All Kids or WIC
ξ Child is a refugee or adoptee from any foreign country
ξ Child has been to Mexico, Central or South America, Asia or any country where exposure to lead
from certain items could have occurred
ξ Child lives with someone who has a job or hobby that may involve lead
ξ Child has lived near a factory where lead is used
ξ Child resides in a high-risk area (Milwaukee, Racine, Chicago, designated high risk zip code)

Patients age 12 months, 24 months or between 3-6 years
It is recommended to perform a risk assessment using the state-specific tools below for lead exposure
during the 12 and 24 month well child visits, and between 3-6 years of age.32,45,46 (UW Health Low quality
evidence, weak/conditional recommendation)

Lead tests should be completed on patients who screen positively, especially patients eligible for Medicaid
(BadgerCare Plus, IL Public Aid).32,45 (UW Health Low quality evidence, weak/conditional recommendation)
Routine screening for elevated blood lead levels should not be performed in asymptomatic children age 1-5
years who are at average risk.47 (USPSTF Grade D)

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Required testing questionnaires/algorithms vary from state to state; please see the following for more
information:
ξ In Wisconsin- https://www.dhs.wisconsin.gov/lead/links/wibloodleadscreeningrecommendations.pdf
ξ In Illinois- http://idph.prod.acquia-sites.com/sites/default/files/forms/childhood-lead-risk-questionaire-
and-guidelines-042116.pdf

Patient Resources
1. Healthwise: Lead
2. Healthwise: Lead Poisoning: Pediatric
3. Health Information: Lead Poisoning
4. Health Information: Lead Poisoning in Children:
Questions Before Screening
5. Health Information: Lead Poisoning Screening

BREAST CANCER
Return to Adult Table (Women Only) | See High Risk Recommendations in Appendix B

Screening mammography is performed in asymptomatic women who do not currently have any breast
complaints. The following recommendations are made for average risk women, while high risk factors and
recommendations are outlined in Appendix B. Women with clinical signs or symptoms should undergo
diagnostic imaging with mammography and/or ultrasound, based on patient age.

Risk Factors
The risk of breast cancer increases with patient age.48 The risk of breast cancer also increases with
increasing mammographic breast density, as displayed in Table 8 below.49 Note: State differences exist
between Wisconsin and Illinois, as Illinois has breast density notification legislature.

Table 8. Absolute Risk of Breast Cancer Incidence Over 5 Years by BI-RADS Category*
BI-RADS Category
Patient Age
40-44 yrs. 45-49 yrs. 50-54 yrs. 55-59 yrs. 60-64 yrs. 65-69 yrs. 70-74 yrs.
A
(almost entirely fatty) 0.2% 0.4% 0.5% 0.7% 0.8% 1.3% 1.4%
B
(scattered areas of
fibroglandular density)
0.5% 0.8% 1.0% 1.4% 1.7% 2.0% 2.1%
C
(heterogeneously dense)
0.7% 1.2% 1.6% 2.2% 2.6% 2.8% 2.9%
D
(extremely dense) 1.0% 1.6% 2.1% 2.8% 3.3% 2.9% 3.1%
Average Risk
(no density information) 0.7% 1.0% 1.4% 1.7% 2.0% 2.2% 2.4%
*Example: A 57 year old woman has an average risk of 1.7%. If she has a breast density of BI-RADS Category D, her risk is 2.8%;
while with Category A her risk is 0.7%.

Several other factors also increase the risk of developing breast cancer, and may be considered in
decisions regarding the frequency of screening mammography (see Healthwise Breast Cancer Screening-
Health Professional Information ).50 These other minor risk factors may interact in complex and non-additive
ways. It is still not known the degree of clinical significance that these factors play in breast cancer risk
individually or in combination.
1. Obesity (BMI > 30 kg/m2)
2. Alcohol intake on average of two drinks per day
3. Nulliparity
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4. First birth after age 30 years
5. Menstrual cycles that started prior to age 12 years
6. Menopause that ended after age 55 years

Shared Decision-Making
The following resource may be used as physician support for the shared-decision making process:
ξ Health Decision Mammography Screening Tool

Life Expectancy
Patients with a life expectancy of less than 10 years should not be screened.51,52 (UW Health Low quality
evidence, weak/conditional recommendation) Life expectancy is often difficult to ascertain38, however the
following resources are available:
ξ ePrognosis
ξ CDC Tables

Patients age 40-49 years
Beginning at age 40 years, a shared decision making conversation is recommended to determine patient
preferences for screening and assess breast cancer risk (e.g., establishing breast density, discussing family
history, reviewing high risk factors, etc.). (UW Health Very low quality evidence, weak/conditional
recommendation) A baseline 2-D digital screening mammogram can be obtained to assess breast density.53

It is recommended to discuss the risks and benefits of 2-D digital mammography screening every 1-2 years
in this age group, in the context of patient preferences, mammographic breast density, and other risk
factors.50 (UW Health Moderate quality evidence, weak/conditional recommendation) Annual mammography has
some benefit above biennial screening of increased cancer detection with the trade-off of increased false-
positive rates.54 Women who place a higher value on the potential benefit than the potential harms may
choose to be screened more often.

The U.S. Preventive Services Task Force and Canadian Task Force encourage providers to consider
biennial screening in the context of each individual patient’s preferences and the value placed on the
balance of benefits and harms.55,56 In contrast, the National Comprehensive Cancer Network and American
Cancer Society recommend annual screening after age 40 and 45 years, respectively.57,58

Patients age 50-74 years
Routine 2-D digital mammography screening is recommended.48,54-58 (UW Health Moderate quality evidence,
strong recommendation) Biennial or annual screening frequency may be influenced by patient’s expressed
preference during shared decision-making or risk factors such as mammographic breast density. (UW Health
Low quality evidence, weak/conditional recommendation) However, patient values/preferences should be the
primary factor in determining screening frequency as risk-based screening demonstrated only a modest
mortality benefit when compared to universal screening. and risk calculators are often unable to stratify
average risk patients.59 Additionally, evidence supporting either screening frequency is primarily based on
modeling data.60,61 While annual screening has the benefit of increased cancer detection, a possible trade-
off is increase false-positive rates (recalls, biopsy recommendations) and overdiagnosis compared with
biennial screening.55,62 Women who place a higher value on the potential benefit than the potential harms
may choose to be screened more often.

The U.S. Preventive Services Task Force and Canadian Task Force recommend biennial screening for
average risk women; however other organizations such as the National Comprehensive Cancer Network
recommend annual screening.55-57 The American Cancer Society recommends annual screening in patients
age 50-54 years and biennial screening in those aged 55 years and older (with the option to continue
annual screening).58



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Patients age 75 years or older
Consider 2-D digital mammography screening in women age 75 and older every 1- 2 years based upon a
discussion of the risks and benefits with the patient, as well as consideration of a patient’s life
expectancy.52,63-65 (UW Health Low quality evidence, weak/conditional recommendation) Women who place a
higher value on the potential benefit than the potential harms may choose to continue screening.

The U.S. Preventive Services Task Force concludes that the current evidence is insufficient to assess the
balance of benefits and harms of screening mammography in women aged 75 years or older.55 Whereas
the American Cancer Society states that screening should continue as long as a woman is in good health
and is expected to live 10 more years or longer.58

Emerging Primary Screening Method

Digital Breast Tomosynthesis: Digital breast tomosynthesis (DBT), a 3-D mammography method which is
available at most UW Health mammography sites, may be considered as a primary screening method. (UW
Health Low quality evidence, weak/conditional recommendation) It is not yet known which particular groups of
women are most likely to benefit from DBT, however it may be most useful for circumstances when
conventional mammography has been shown to be less accurate, including in women less than 50 years of
age, or in women with heterogeneous or extremely dense breasts on mammography.66 DBT may not be
covered by insurance.

Converging evidence from large randomized studies using 2-D and DBT suggest it is a technique that may
reduce false positive results and increases cancer detection compared to conventional 2-D digital
mammography alone.67-72 DBT software at UW Health now includes FDA-approved virtual reconstruction of
2-D mammography which eliminates the need for a separate digital 2-D mammogram; however insufficient
evidence exists to establish its equivalence to digital 2-D mammography in clinical research.

Adjunctive Screening Methods

Automated Breast Ultrasound: Automated breast ultrasound imaging as an adjunct to mammography, which
is only available at SwedishAmerican, can be considered in patients with mammographically dense
breasts.73,74 (UW Health Low quality evidence, weak/conditional recommendation) There are emerging
observational studies which support the improved sensitivity of adjunctive automated breast ultrasound,
however this technique may increase false positives and lead to additional interventions.73,74 Illinois law
mandates insurance coverage of supplemental screening of comprehensive ultrasound of an entire breast
or breasts, when determined to be medically necessary by a physician [215 ILCS 5/356g (a) (4) and 215
ILCS 125/4-6.1(a) (4)].

Magnetic Resonance Imaging (MRI): The use of breast MRI alone or as an adjunct to mammography for
routine breast cancer screening in average risk women is not recommended. (UW Health Low quality
evidence, strong recommendation) Patients at high risk for breast cancer should follow the recommendations
outlined within Appendix B and/or the UW Health MRI Breast Cancer Screening – Adult – Ambulatory
Guideline.

Clinical and self breast examination: The benefit of clinical breast examination (CBE) alone or in conjunction
with mammography for breast cancer screening among average-risk women at any age is not clearly
demonstrated in the literature.58 Insufficient evidence exists to evaluate whether CBE improves patient
outcomes; moderate quality evidence demonstrates an increased false-positive rate when CBE is added to
mammography screening and other studies show that the addition of CBE can detect some small invasive
breast cancers (i.e., 2-6%) when compared to mammography alone.54,58,75,76

Teaching breast self-examination (BSE) to patients is not recommended.77 (USPSTF Grade D) Instead,
patients should be encouraged to be aware of changes in their bodies and to discuss these changes with
clinicians.55
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Thermography: The use of thermography alone or adjunctive to mammography for breast cancer screening
is not recommended.78,79 (UW Health Low quality evidence, strong recommendation) Despite FDA approval, no
empirical evidence exists which supports the use of this technology for population-based screening
programs.

Patient Resources
1. HFFY #5668: A Health Guide for Women 50 or Older
2. HFFY #7638: Digital Breast Tomosynthesis (DBT)
Mammography
3. HFFY #7444: What You Need to Know about
Mammography
4. Healthwise: Breast Cancer (BRCA) Gene Testing
5. Healthwise: Breast Cancer: Screening
6. Healthwise: Mammogram
7. Healthwise: Well Visit: 18 to 50 Years
8. Healthwise: Well Visit: 50 to 65 Year Women
9. Healthwise: Well Visit: Over 65 Years
10. Health Information: Breast Cancer
11. Health Information: BRCA Gene Test, Should I Have
12. Health Information: Breast Cancer Prevention (PDQ):
Health Professional Information [NCI]
13. Health Information: Breast Cancer Prevention (PDQ):
Patient Information [NCI]
14. Health Information: Breast Cancer Risk: Should I
Have a BRCA Gene Test?
15. Health Information: Breast Cancer Screening
16. Health Information: Breast Cancer Screening (PDQ):
Health Professional Information [NCI]
17. Health Information: Breast Cancer Screening (PDQ):
Patient Information [NCI]
18. Health Information: Breast Cancer Screening and
Dense Breasts: What Are My Options?
19. Health Information: Breast Cancer Screening: When
Should I Start Having Mammograms?

BREAST FEEDING
Return to Infant/Child Table
Pediatric Patients
Exclusive breastfeeding is the ideal nutrition for approximately 6 months after delivery and is sufficient to
support optimal growth and development.80-82 (UW Health Low quality evidence, strong recommendation)
Thereafter, infants may receive complementary foods with continued breast feeding up to 1 year of age or
beyond.80 (UW Health Low quality evidence, weak/conditional recommendation)

The USPSTF recommends providing interventions during pregnancy and after birth to support
breastfeeding.83 (USPSTF Grade B) The promotion and support of breastfeeding may be accomplished
through interventions over the course of pregnancy; around the time of delivery; and after birth, while
breastfeeding is under way. Interventions may include multiple strategies, such as formal breastfeeding
education for mothers and families, direct support of mothers during breastfeeding observations, providing
psychological support, peer support, and the training of health professional staff about breastfeeding and
techniques for breastfeeding support.83 Evidence suggests that interventions that include both prenatal and
postnatal components may be the most effective at increasing breastfeeding duration.83

Patient Resources
1. HFFY #5985: Choosing a Breast Pump

CERVICAL CANCER
Return to Adult Table (Women Only) | See High Risk Recommendations in Appendix B

Note: More frequent screening intervals than those listed in the following recommendations (i.e., annual
cytology) are not recommended for average risk women of any age. (UW Health High quality evidence, strong
recommendation) Increased screening frequency offers little additional benefit, with large increases in harms
such as additional procedures, assessment, and treatment of transient lesions which would otherwise
resolve on their own.84

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Patients younger than 21 years
Cervical cancer screening via cytology (Papanicolaou (pap) smear) is not recommended for patients less
than 21 years, regardless of age of sexual initiation.84-87 (USPSTF Grade D) Any adolescent with a history of
normal cytologic screening should not be rescreened until the age of 21 years.85 Due to the high prevalence
of human papillomavirus (HPV) in adolescents, HPV testing is not recommended.85,87-89 (USPSTF Grade D)

Patients age 21-29 years
It is recommended to screen for cervical cancer using cytology alone every three years.84,86,87 (USPSTF
Grade A) Due to the high prevalence of HPV and low incidence of cervical cancer in this age group, co-
testing is not recommended.84,86,87 (USPSTF Grade D)

Patients age 30-65 years
Women ages 30–65 years should be screened with cytology and HPV testing (“cotesting”) every 5 years
(preferred) or cytology alone every 3 years (acceptable)84,86,87,90 (UW Health High quality evidence, strong
recommendation) Women age 30-65 years with both a negative cytology and HPV test result have been
shown to be at an extremely low risk of developing cervical cancer during the following 4-6 years91,
therefore women 30-65 years with both negative tests may be rescreened every 5 years.87 (UW Health High
quality evidence, strong recommendation)

Stop screening at age 65 if three normal cytology results OR 2 negative high risk HPV results in the last
decade AND no history of CIN 2, 3 or cervical cancer in the last 20 years.84,86,87 (USPSTF Grade D)

Special Considerations
Hysterectomy: No screening should be completed after hysterectomy with removal of the cervix, unless
there is a history of CIN 2 or greater in the last 20 years.84,86 (USPSTF Grade D) Patients who have had
supracervical hysterectomy should continue to have routine screening.84,87

HPV Vaccination: Routine screening guidelines should be followed in patients who have received an HPV
vaccination, as the long-term efficacy of vaccination is not yet known.86,87

HPV Test for Primary Screening: The cobas® HPV test, which is not available at UW Health, is FDA-
approved as a primary screening tool for cervical cancer screening.92,93 While UW Health has HPV testing,
HPV testing alone is not recommended for primary screening in an average risk patient. (UW Health Low
Quality Evidence, strong recommendation)

Surveillance
Screening recommendations and follow-up testing in adolescent patients (under 21 years) with atypical
squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion
(LSIL) should be managed with repeat cytology alone at 12 month intervals, without colposcopy or HPV
testing.89 For patients age 21 and over with abnormal cervical cancer screening test results or cancer
precursors, surveillance recommendations may be found in the 2014 ASCCP guidelines
(http://www.asccp.org/Assets/51b17a58-7af9-4667-879a-3ff48472d6dc/635912165077730000/asccp-
management-guidelines-august-2014-pdf).94

Patient Resources
1. HFFY #5668: A Health Guide for Women 50 or Older
2. Healthwise: Cervical Cancer
3. Healthwise: HPV (Human Papillomavirus)
4. Healthwise: Well Visit: 18 to 50 Years
5. Healthwise: Well Visit: 50 to 65 Year Women
6. Healthwise: Well Visit: Over 65 Years
7. Health Information: Cervical Cancer
8. Health Information: Cervical Cancer Prevention
(PDQ): Prevention- Health Professional Information
9. Health Information: Cervical Cancer Prevention
(PDQ): Prevention- Patient Information
10. Health Information: Cervical Cancer Screening
11. Health Information: Cervical Cancer Screening (PDQ):
Screening- Health Professional Information
12. Health Information: Cervical Cancer Screening (PDQ):
Screening- Patient Information

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CHLAMYDIA (C. trachomatis) AND GONORRHEA (N. gonorrhoeae)
Return to Adolescent Table | Return to Adult Table (Men Only) | Return to Adult Table (Women Only)
Risk Factors
Clinicians should bear in mind that adolescent and adult patients may be reluctant to disclose having risk
factors, even when asked.95 The Five P’s: Partners, Practices, Prevention of Pregnancy, Protection from
STDs, and Past History of STDs, available from the CDC, may be used to guide a dialogue to assess a
patient’s risk of Sexually Transmitted Infections (STI) (see Appendix C).95

Positive risk factors for chlamydial or gonococcal infections include95-97:
ξ History of chlamydia or gonorrhea infection or other sexually transmitted infection
ξ New or multiple sexual partners
ξ Sexual partner with concurrent partners
ξ Sexual partner with a sexually transmitted infection
ξ Inconsistent condom use among persons who are not in mutually monogamous relationships
ξ Exchanging sex for money or drugs
ξ Recent travel history with sexual contacts outside of the United States

Female Patients age 24 years and younger
All sexually active (non-pregnant) female patients 24 years or younger should be screened for chlamydial or
gonococcal infection.95,96 (USPSTF Grade B) The Centers for Disease Control and Prevention (CDC)
recommends annual screening in non-pregnant patients at average risk.95 More frequent screening may be
considered if risk factors are present. (UW Health Low quality evidence, strong recommendation)

Female Patients age 25 years or older
Sexually active non-pregnant female patients age 25 years or older at an increased risk for infection should
be screened (see risk factors above).96 (USPSTF Grade B) The CDC recommends annual screening in
patients 25 years or older at increased risk.95 (UW Health Low quality evidence, strong recommendation)

Heterosexual Male Patients
Insufficient evidence exists in regards to routine chlamydia or gonorrhea screening in sexually active
heterosexual men (USPSTF I Statement), however screening may be considered in clinical settings
associated with high prevalence of chlamydia (i.e., adolescent clinics, correctional facilities, and STD
clinics).95,96 (UW Health Low quality evidence, strong recommendation)

Men Who Have Sex with Men (MSM)
It is recommended by CDC that men who have sex with men (MSM) are screened annually for chlamydia
and gonorrhea using the following tests based upon sexual behavior: urine test using nucleic acid
amplification testing (NAAT) (insertive intercourse) and/or NAAT of a rectal swab (receptive anal
intercourse). NAAT for the detection of chlamydia infection is not recommended in MSM patients who have
performed receptive oral intercourse within the preceding year. NAAT of pharyngeal swab (receptive oral
intercourse) is recommended for the detection of gonococcal infection.95,98 (UW Health High quality evidence,
strong recommendation) More frequent STD screening (i.e., every 3-6 months) may be indicated for MSM with
multiple or anonymous partners or MSM patients who have sex in conjunction with illicit drug use or whose
sex partners participate in similar high-risk behaviors.95,99 (UW Health Low quality evidence, strong
recommendation)

Testing Options
Chlamydial or gonococcal infections are diagnosed by using nucleic acid amplification tests (NAAT), which
are approved by the FDA for use on urogenital sites, including male and female urine; clinician-collected
endocervical, vaginal, and male urethral specimens; and self-collected vaginal specimens in clinical
settings. Rectal and pharyngeal swabs can be collected from persons who engage in receptive anal
intercourse and oral sex.96
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Pertinent UW Health Policies & Procedures
1. UWHC Policy 13.04: Communicable Disease Reporting

Patient Resources
1. HFFY #911: Chlamydia
2. HFFY #917: Gonorrhea
3. HFFY #5669: A Health Guide for Men Age 50 or Older
4. HFFY #6419: A Health Guide for Men Age 50 or Older
5. HFFY #5668: A Health Guide for Women 50 or Older
6. Healthwise: Chlamydia
7. Healthwise: Gonorrhea
8. Healthwise: Chlamydia: Female: Teen
9. Healthwise: Gonorrhea: Female: Teen
10. Healthwise: Gonorrhea and Chlamydia Tests
11. Healthwise: Well Visit: 18 to 50 Years
12. Health Information: Chlamydia
13. Health Information: Chlamydia Trachomatis
14. Health Information: Gonorrhea

COGNITIVE SCREENING
Return to Adult Table
Patients age 65 years or older
The USPSTF concluded that current evidence is insufficient to assess the balance and harms of universal
screening for cognitive impairment100 (USPSTF I Statement); therefore routine cognitive screening is not
recommended.

However, assessment of a patient’s cognitive function by direct observation is required by the Centers for
Medicare and Medicaid Services (CMS) during the Annual Wellness Visit (AWV). If an AWV is performed, it
is recommended that the following questions101 are included in the annual Health Risk Assessment (HRA)
(UW Health Low quality evidence, weak/conditional recommendation):
1. During the past 12 months, have you experienced confusion or memory loss that is happening more
often or is getting worse?
2. During the past 7 days, did you need help with others to perform everyday activities such as eating,
getting dressed, grooming, bathing, walking, or using the toilet?
3. During the past 7 days, did you need help from others to take care of things such as laundry and
housekeeping, banking, shopping, using the telephone, food preparation, transportation, or taking
your own medications?

During the AWV, it is recommended that the clinician have a conversation with the patient and, if present,
an informant, regarding cognition impairment. If no informant is present or concerns are noted from review
of the HRA or during conversation, further evaluation with a structured tool should be performed.101 (UW
Health Low quality evidence, weak/conditional recommendation) The recommended structured tool that providers
should use is the Mini-Cog.101,102 (UW Health Low quality evidence, weak/conditional recommendation)
Patient Resources
1. HFFY #6977: Memory Loss
2. HFFY #5262: Stages of Alzheimer Disease
3. Health Information: Memory Loss

COLORECTAL CANCER
Return to Adult Table | See High Risk Recommendations in Appendix B
Patients age 50-75 years
It is recommended to screen all average-risk patients age 50-75 years for colorectal cancer.103 (USPSTF
Grade A)

Patients age 76-85 years
Routine screening should not be performed in patients who have had a consistently negative screening
history and are not at an increased risk for colorectal cancer. The U.S. Preventive Services Task Force
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recommends that the decision to screen for colorectal cancer screening in adults ages 76-85 years should
be an individual one, taking into account the patient’s overall health and prior screening history.103 (USPSTF
Grade C) Adults in this age group who have never been screened for colorectal cancer are more likely to
benefit.103 Screening would be most appropriate among adults who 1) are healthy enough to undergo
treatment if colorectal cancer is detected and 2) do not have comorbid conditions that would significantly
limit their life expectancy.103

Overscreening for cancer (including colorectal cancer) is common104, despite population-based, randomized
controlled trials which suggest the benefits of screening are not realized until 10 years following the test.
Therefore, patients with a life expectancy of less than 10 years should not be screened.51,52 (UW Health Low
quality evidence, weak/conditional recommendation)

Testing Options
The most important outcome is that eligible patients are screened.103 Patient choice has been
independently associated with greater participation and adherence to screening, therefore, appropriate
patient-physician discussion of the screening testing options should occur.103,105-107 (UW Health High quality
evidence, strong recommendation) Evidence suggests that many factors can influence a patient’s acceptance
of and adherence to colorectal cancer screening, including individual risk factors, race/ethnicity, primary or
preferred language, education level, social support, and socioeconomic status.6,7,107,108 Failure to consider
patient preferences has been negatively associated with satisfaction in the decision-making process,
screening intentions, and test completion rates.109

While no head-to-head comparisons of the testing modalities have been completed103, the tables below
(Table 9 and Table 10) summarize key differences between the screening options to offer physician
support and guidance during the shared-decision making discussion. All options should be presented
together, emphasizing the balance between benefits (e.g., advanced adenoma detection and cancer
detection) against the potential harms or patient burden (e.g., invasive testing, bowel preparation,
adherence, etc.).

Evidence from case control and cohort studies support the ability of colonoscopy to prevent colorectal
cancer (with its associated morbidity) and cancer deaths.110-112 Colonoscopy110,111 and CT colonography
(virtual colonoscopy)113-116 have been shown to be sensitive tests for detection of advanced adenoma and
colorectal cancer thus making them recommended screening modalities.107,117,118 (UW Health Moderate quality
evidence, strong recommendation) Direct evidence from randomized controlled trials has demonstrated that
flexible sigmoidoscopy can reduce mortality and is acceptable for colorectal cancer screening.119-122 (UW
Health Moderate quality evidence, strong recommendation) However, this mortality benefit is limited to
visualization of the distal colon and does not offer protection from advanced proximal neoplasia
demonstrated in several landmark studies.123-125 Optical colonoscopy or CT colonography are better suited
than flexible sigmoidoscopy for detecting advanced adenomas which has seen a shift in polyp presentation
to the right side and significantly worse outcomes in patients with right-sided vs. left-sided colon
cancer.126,127

Screening using fecal immunohistochemical test (FIT)122,128,129 (UW Health Moderate quality evidence, strong
recommendation) or multi-target stool DNA (m-t sDNA or FIT-DNA; Cologuard® from Exact Sciences
Corporation)130 (UW Health Low quality evidence, weak/conditional recommendation) are recommended for colon
cancer screening, with the understanding that a positive result would require follow-up via colonoscopy. The
benefit of screening using FIT or FIT-DNA is dependent upon patient adherence and compliance, and poor
compliance may have a negative impact on the screening outcome.

Although direct evidence from randomized controlled trials has demonstrated that fecal occult blood testing
can reduce mortality from colorectal cancer, fecal occult blood testing is not available at UW Health, as FIT
has replaced this testing modality.112,131-133

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The methylated SEPT9 DNA test (Epi proColon® from Epigenomics) is FDA-approved as a blood test for
annual colorectal cancer screening in average-risk adults134; however, the test is not currently available or
recommended by UW Health due to its low sensitivity. (UW Health Low quality evidence, strong
recommendation)

Screening Intervals
Screening intervals for follow-up to a previously negative result should be based upon the chosen testing
modality. Optical colonoscopy should be completed every 10 years.103,113,135,136 (UW Health Moderate quality
evidence, strong recommendation) CT colonography should be completed every 5 years.103,113,137 (UW Health
Low quality evidence, weak/conditional recommendation) Flexible sigmoidoscopy may be completed every 5
years. (UW Health High quality evidence, strong recommendation)

Fecal immunohistochemical testing (FIT) should be completed annually.103,129 (UW Health Moderate quality
evidence, strong recommendation) The interval for multi-target stool DNA testing (FIT-DNA) is currently
unclear due to a lack of empirical evidence. The U.S. Preventive Services Task Force recommends
rescreening every 1-3 years.103 The recommendation for annual screening is an indirect application of data
supporting FOBT/FIT, whereas the 3 year interval is based on modeling data constructed by the test
manufacturer.130

Table 9. Comparison of Colorectal Cancer Screening Methods
Screening Test
Sensitivity
Specificity
Colorectal Cancer Advanced Adenoma
Colonoscopy 95%116 89-98%
122
( > 10 mm)
75-93%122 ( > 6 mm) 90%
138

CTC 96%116 67-94%
122
( > 10 mm)
73-98%122 ( > 6 mm)
86-98%122 ( > 10 mm)
80-93%122 ( > 6 mm)
FSIG 58-75%124,139 77-86%123,139 92%138
FIT*
79-88%122 (OC-Light)
73-96%122 (OC FIT-CHEK)
22-40%122
(OC-Light and OC FIT-CHEK)
91-93%122 (OC-Light)
87-92%122 (OC FIT-CHEK)
FIT-DNA 92%122 42%122 84%122
mSEPT9 DNA 48%134 11%134 92%134
*OC-Light from Polymedco is available at UW Health; OC FIT-CHEK from Polymedco is available at SwedishAmerican

CTC: CT colonography; FSIG: flexible sigmoidoscopy; FIT: fecal immunohistochemical test;
FIT-DNA: multitarget stool DNA (Cologuard®); mSEPT9 DNA: serology test (epi ProColon®)
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Table 10. Summary of Recommended Colorectal Cancer Screening Tests140-143 Sorted alphabetically by test type
Test Interval* Features Limitations
Tests in the Clinic
Colonoscopy Every 10
years
ξ Procedure takes about 30 minutes
ξ Can usually view entire colon
ξ Full bowel preparation needed
ξ Sedation of some kind usually needed
ξ Can biopsy and remove polyps
ξ Can diagnose other diseases of the colon
ξ Can miss small polyps
ξ Usually requires sedation so a driver is needed and the patient may miss work
ξ Risk of bleeding: National data = 8 of 10,000 patients122
ξ Risk of perforation: National data = 4 of 10,000 patients122 vs.
UW Health data = 0.01% (2 of 18,000 patients)
ξ Risk of colonoscopy-specific mortality: National data = 0.007% (7 of 100,000
patients) vs. UW Health data = 0% (0 of 200,000 patients)
CT
Colonography
(CTC)
Every 5
years
ξ Procedure takes about 10 minutes
ξ Visualizes the entire colon
ξ Full bowel preparation needed
ξ No sedation needed
ξ Can diagnose diseases in other abdominal organs
ξ Alternative for patients who cannot discontinue
anticoagulation therapy
ξ Radiation exposure: typical effective dose < 6
mSv144 (average annual background radiation = 3 mSV)
ξ Can miss polyps under 10mm
ξ Cannot remove polyps during testing
ξ Colonoscopy will be needed if abnormal
ξ Risk of perforation: National data = < 2 of 10,000 patients122 vs.
UW Health data = 0% (0 of 10,000 patients)
ξ Extracolonic findings result in unnecessary testing. UW Health data145,146 =
Potentially important findings are found in < 3% of exams; likely unimportant but
indeterminate findings are found in < 10%; overall work-up rate is 5-6%)***
Flexible
Sigmoidoscopy
Every 5
years
ξ Procedure takes about 20 minutes
ξ Usually doesn’t require full bowel preparation
ξ Sedation usually not used

ξ Views only about a third of the colon and can miss small polyps
ξ Cannot remove all polyps
ξ Typically no sedation so may be uncomfortable
ξ Risk of bleeding: National data = 2 of 10,000 patients122
ξ Risk of perforation: National data = 1 of 10,000 patients122
ξ Risk of death attributable to endoscopic complications: National data = 0.01%
(1 of 10,000 patients)
ξ Colonoscopy will be needed if abnormal
Tests at Home
Fecal
Immunohisto-
chemical Test
(FIT)
Annual
ξ Done at home
ξ No direct risk to the colon
ξ No bowel preparation
ξ No sedation needed
ξ No pretest dietary limitations
ξ May miss polyps and some cancers
ξ May produce false-positive test results
ξ Cannot remove polyps
ξ Colonoscopy will be needed if abnormal
ξ Requires single test
Multitarget stool
DNA (FIT-DNA)
Every 1-3
years**
ξ Done at home
ξ No direct risk to the colon
ξ No bowel preparation
ξ No sedation needed
ξ No pretest dietary limitations
ξ May miss polyps and some cancers
ξ Cannot remove polyps
ξ Higher false positive rate than FIT
ξ Colonoscopy will be needed if abnormal
ξ Based on single cross-sectional study130

*Frequency based upon normal (negative) results. **Interval for rescreening using FIT-DNA is not clear (3 year interval based on modeling data by manufacturer)
***Extracolonic findings: National data122 = 5-37% of exams had likely unimportant but indeterminate or potentially important findings; 2-12% had potentially important findings,
and < 3% require definitive treatment.
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Patients at Increased Risk
Patients who have had polyps removed in the past are no longer considered average risk and fall outside of
the scope of this guideline. These patients may require modified screening recommendations as outlined
below (Table 11).113,147,148 A retrospective cohort study found a low incidence of colorectal cancer and
relatively high rate of postprocedure hospitalization in elderly patients with a history of colorectal cancer or
adenomatous polyps undergoing surveillance colonoscopy.149 Surveillance testing in patients 75 years or
older should be an individual decision which takes into consideration a patient’s overall health and the
impact of comorbid illness and increasing age.149 (UW Health Low quality evidence, weak/conditional
recommendation)

For recommendations related to patients at an increased personal risk of colorectal cancer (e.g., family
history of colorectal cancer) refer to Appendix B. Recommendations for patients with a personal history are
NOT included within this guideline as surveillance schedules for survivors should be determined with
specialty input.

Table 11. Post-polypectomy Surveillance Recommendations
Polypectomy Recommendations113,147,148,150
Hyperplastic polyp
No follow-up necessary, screen using average risk
recommendations. (UW Health Low quality evidence, strong
recommendation)
1-2 adenomas or sessile serrated
adenomas/polyps < 10 mm
Repeat colonoscopy in 5 years.
(UW Health Low quality evidence, weak/conditional recommendation)
3+ adenomas, adenomas > 10 mm,
adenomas with high grade dysplasia,
adenomas with villous features

Sessile serrated adenomas/polyps >
10 mm or sessile serrated adenomas
with high grade dysplasia
Repeat colonoscopy in 3 years. (UW Health Low quality evidence,
weak/conditional recommendation)

If follow-up is normal or shows only 1-2 adenomas with low grade
dysplasia, the subsequent screen should occur in 5 years. (UW
Health Low quality evidence, strong recommendation)
Incomplete or piecemeal resection of
large sessile adenoma or sessile
serrated adenoma/polyp
Repeat colonoscopy in 3-6 months
(UW Health Low quality evidence, weak/conditional recommendation)

Patient Resources
1. HFFY #5668: A Health Guide for Women 50 or Older
2. HFFY #5669: A Health Guide for Men Age 50 or Older
3. HFFY #6982: Colorectal Cancer Prevention
4. HFFY #6258: Getting Ready for Flexible
Sigmoidoscopy (English)
5. HFFY #6518: Getting Ready for Flexible
Sigmoidoscopy (Spanish)
6. HFFY #6257: Getting Ready for Flexible
Sigmoidoscopy with Sedation (English)
7. HFFY #7350: Getting Ready for Flexible
Sigmoidoscopy with Sedation (Spanish)
8. HFFY #7479: Getting Ready for Your Colonoscopy
(MoviPrep)
9. HFFY #7478: Getting Ready for Your Colonoscopy
(PEG)
10. HFFY #7661: Getting Ready for Your Colonoscopy
(Suprep)
11. HFFY #5995: Virtual Colonoscopy
12. HFFY #6293: Getting Ready for Your Virtual
Colonoscopy (VC PEG Prep with Oral Contrast)
13. HFFY #7560: Getting Ready for Your Virtual
Colonoscopy (Omnipaque Routine VC Prep)
14. Healthwise: Colon Cancer
15. Healthwise: Colon Cancer: General Info
16. Healthwise: Colon Cancer Screening
17. Healthwise: Colonoscopy: General Info
18. Healthwise: Colonoscopy: Pre-op
19. Healthwise: Colonoscopy: Post-op
20. Healthwise: Well Visit: 18 to 50 Years
21. Healthwise: Well Visit: 50 to 65 Year Men
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22. Healthwise: Well Visit: 50 to 65 Year Women
23. Healthwise: Well Visit: Over 65 Years
24. Health Information: Colorectal Cancer
25. Health Information: Colorectal Cancer Prevention-
Health Professional Information
26. Health Information: Colorectal Cancer Prevention-
Patient Information
27. Health Information: Colorectal Cancer Screening
28. Health Information: Colorectal Cancer Screening-
Health Professional Information
29. Health Information: Colorectal Cancer Screening-
Patient Information
30. Health Information: Colonoscopy, Virtual
31. Health Information: Colon Cancer Genetic Testing
32. Health Information: Colon Cancer: What Raises Your
Risk
33. Health Information: Colon Cancer: Which Screening
Test Should I Have?
34. Health Information: Diabetes: How to Prepare for a
Colonoscopy

DENTAL CARIES
Return to Infant/Child Table
Risk Factors
Individual risk factors151 that can elevate risk of dental caries:
ξ Primary water supply deficient in fluoride (defined as containing < 0.6 ppm F)
ξ Frequent sugar exposure
ξ Inappropriate bottle feeding
ξ Developmental defects of the tooth enamel
ξ Dry mouth
ξ History of previous caries.
ξ Poor oral hygiene
ξ Low socioeconomic status
ξ Recent maternal caries
ξ Sibling with dental caries
ξ Frequent snacking
ξ Lack of access to dental care
ξ Inadequate preventive measures, such as failure to use fluoride-containing toothpastes
ξ Lack of parental knowledge about oral health.
Patients age 6 months to 5 years
The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at
age 6 months through 5 years for children whose water supply is deficient in fluoride.151 (USPSTF Grade B)

The USPSTF recommends that primary care clinicians apply fluoride varnish to the primary teeth of all
infants and children starting at the age of primary tooth eruption.151 (USPSTF Grade B)

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and
harms of routine screening examinations for dental caries performed by primary care clinicians in children
from birth to age 5 years.151 (USPSTF I Statement)The American Academy of Pediatrics (AAP) and the
American Academy of Pediatric Dentistry (AAPD) recommend that children be seen by a dentist within 6
months of eruption of the first tooth or 12 months of age, whichever comes first.152,153 (UW Health Low quality
evidence, weak/conditional recommendation) The AAP recognizes that this ideal may be impractical in
communities with limited pediatric dental resources, so recommends all children at risk for caries be triaged
for early establishment of a dental home by age 1.152

Patient Resources
None identified

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DEPRESSION
Return to Adolescent Table | Return to Adult Table

Detailed recommendations for the detection and treatment of depression can be found within the UW Health
Depression – Pediatric/Adult – Ambulatory Guideline.

Patients age 12-17 years
All patients age 12 and older should be screened annually using the Patient Health Questionnaire-2 (PHQ-
2).154,155 (UW Health Very low quality evidence, strong recommendation) Patients who screen positive on the
PHQ-2 (score of 3 points or greater) should be administered the PHQ-A or the PHQ-9.155-157 (UW Health Low
quality evidence, strong recommendation) A score of 10 points or greater on the PHQ-A or PHQ-9 indicates
clinically significant depressive symptoms and the need for clinical evaluation and documentation of a
follow-up plan.155-158

Patients age 18 years or older
All patients age 18 year or older should be screened annually using the PHQ-2.155,159 (UW Health Very low
quality evidence, strong recommendation) Patients who screen positive on the PHQ-2 (score 3 points or
greater) should complete the PHQ-9.155,158,160 (UW Health Low quality evidence, strong recommendation) A score
of 10 or greater on the PHQ-9 indicates clinically significant depressive symptoms and the need for clinical
evaluation and documentation of a follow-up plan.155,158,160

Patient Resources
1. HFFY #4525: Depression- A Guide to Recognition
and Treatment
2. HFFY #6327: How to Recognize and Treat Childhood
Depression
3. Healthwise: Depression: Pediatric
4. Health Information: Depression
5. Health Information: Depression Evaluation Calculator
6. Health Information: Depression in Older Adults
7. Health Information: Depression Screening

DEVELOPMENTAL MILESTONES
Return to Infant/Child Table
Patients age 9, 18, and 24-30 months
Universal developmental screening with a standardized validated developmental screening tool (Ages
and Stages Questionnaire-3)161 is recommended for all children at 9, 18, and 24-30 months of age.32,162
(UW Health Moderate quality evidence, strong recommendation)

Targeted screening at any age may be completed when developmental concerns are identified.161-163
(UW Health Moderate quality evidence, weak/conditional recommendation)

Patient Resources
1. Healthwise: Developmental Problems: Pediatric
2. Health Information: Developmental Problems: Testing








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DIABETES
Return to Infant/Child Table | Return to Adolescent Table | Return to Adult Table

Additional recommendations for the detection, diagnosis, and treatment of diabetes mellitus can be found in
the 2017 UW Health Standards of Medical Care in Diabetes Guideline.

Pediatric Risk Factors
Positive risk factors for type 2 diabetes in pediatrics164:
ξ Family history of type 2 diabetes in first- or second-degree relative
ξ Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)
ξ Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans,
hypertension, dyslipidemia, polycystic ovarian syndrome, or small-for-gestational-age birth weight)
ξ Maternal history of diabetes or GDM during the child’s gestation

Adult Risk Factors
Positive risk factors for type 2 diabetes in adults164,165:
ξ A1C > 5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
ξ First-degree relative with diabetes
ξ High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific
Islander)
ξ Women who were diagnosed with gestational diabetes mellitus (GDM)
ξ History of cardiovascular disease
ξ Hypertension (> 140/90 mmHg or on therapy for hypertension)
ξ HDL cholesterol level < 35 mg/dL and/or a triglyceride level > 250 mg/dL
ξ Women with polycystic ovary syndrome
ξ Physical inactivity
ξ Chronic glucocorticoid exposure
ξ Atypical antipsychotic use
ξ Sleep disorders, including obstructive sleep apnea, chronic sleep deprivation, and night-shift
occupation
ξ Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis
nigricans).

Patients age 10-18 years
Testing for type 2 diabetes and prediabetes should be considered in asymptomatic children and
adolescents who are overweight or obese (BMI > 85th percentile for age and sex, weight for height > 85th
percentile, or weight >120% of ideal for height) AND who have two or more additional risk factors for
diabetes (see above).164 (ADA Grade E) Testing should begin at age 10 or at the onset of puberty, if puberty
occurs at a younger age, and repeated every 3 years.164 (ADA Grade C)

Patients age 19 years or older
The 2017 ADA Standards164 recommend universal screening in patients after age 45 years; however, UW
Health recommends targeted screening in all adult patients based on risk. Screening for type 2 diabetes
with an informal assessment of risk factors should be considered in asymptomatic adults.164 (ADA Grade B) It
is reasonable to perform a risk assessment annually. (UW Health Very low quality evidence, weak/conditional
recommendation)

Testing for type 2 diabetes should be considered in all adult patients who are overweight or obese (BMI >
25 kg/m2 or > 23 kg/m2 in Asian Americans) and have one or more risk factors (see above).164-166 (UW Health
Moderate quality evidence, weak/conditional recommendation)


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The appropriate interval between screening tests is not known.164,170 In patients age > 40 years, testing for
type 2 diabetes was not associated with a reduction in all-cause, cardiovascular or diabetes-related
mortality over 10 years.171 Modeling simulation studies have found screening every 3-5 years to be cost-
effective, particularly in patients age 30 or older.170,172,173 A large open cohort study in Japan which stratified
patients age 30-74 years by risk (BMI and 10-yr. cardiovascular risk) demonstrated that screening
frequencies could be extended to 8-10 year intervals in patients at lower risk.174 Therefore, subsequent
screening tests, especially in patients aged 18-44 years, should be based upon individual clinical judgement
that is influenced by the patient’s clinical status, any prior test results, and the presence of or changes in
risk factors. (UW Health Very low quality evidence, weak/conditional recommendation) If prior test results are
normal and patients do not demonstrate other significant risk, testing should not be repeated more
frequently than every 3 years.164 (UW Health Low quality evidence, weak/conditional recommendation)

It is important to recognize that not all of the risk factors are weighted equally. The following alternative
testing frequencies may need to be considered based on the presence of comorbid clinical conditions or
prescription therapies:
ξ Patients with HIV should be screened for diabetes and prediabetes with a fasting glucose every 6-12
months before starting antiretroviral therapy and 3 months after starting or changing antiretroviral
therapy. If initial screening results are normal, checking fasting glucose every year is advised. If
prediabetes is detected, continue to measure fasting glucose levels every 3-6 months to monitor for
progression to diabetes.175 (ADA Grade E)
ξ Annually screen people who are prescribed atypical antipsychotic medications for prediabetes or
diabetes.175 (ADA Grade B)
ξ At least annual monitoring for the development of diabetes in those with prediabetes is suggested.176
(ADA Grade E) Prediabetes is defined as an A1C of 5.7-6.4%, impaired oral glucose tolerance (140-
199 mg/dL), or impaired fasting glucose (100-125 mg/dL) on previous testing.164
ξ It is suggested that patients with polycystic ovary syndrome and normal glucose tolerance be
rescreened every 2 years or sooner if additional risk factors are identified.167 Those with impaired
glucose tolerance should be screened annually.167
ξ Women with a history of gestational diabetes mellitus (GDM) should have lifelong screening for the
development of diabetes or prediabetes at least every 3 years.164 (ADA Grade B)

Testing Options
To test for type 2 diabetes, fasting plasma glucose, 2-hour plasma glucose after 75-g oral glucose tolerance
test, and A1C are equally appropriate.164 (ADA Grade B) In patients with polycystic ovary syndrome, a 2-hour
75-g oral glucose challenge is recommended over the other screening testing options.167-169 (UW Health Low
quality evidence, strong recommendation)

Patient Resources
1. Healthwise: Diabetes: Type 2
2. Healthwise: Diabetes: Type 2: General Info
3. Healthwise: Diabetes: Type 2: Pediatric
4. Healthwise: Diabetes: Type 2: Teen
5. Healthwise: Prediabetes
6. Healthwise: Well Visit: 18 to 50 Years
7. Healthwise: Well Visit: 50 to 65 Year Men
8. Healthwise: Well Visit: 50 to 65 Year Women
9. Healthwise: Well Visit: Over 65 Years
10. Health Information: Diabetes
11. Health Information: Diabetes, Type 2
12. Health Information: Diabetes, Type 2 in Children
FALLS RISK
Return to Adult Table
Risk Factors
Patients who exhibit one or more of the following risk factors are at an increased risk for falling177,178:
ξ Increased age
ξ History of falls or mobility problems
ξ Patient score > 4 on the STEADI Stay Independent screening questionnaire
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39
ξ Poor performance on the Timed-Up-and-Go assessment179 (score > 12 seconds)

Patients age 65 years or older
UW Health endorses the Centers for Disease Control and Prevention (CDC) Stopping Elderly Accidents,
Deaths & Injuries (STEADI) program.178 Annual screening for falls and balance or gait problems is
recommended by the CDC STEADI program178 and American Geriatric Society (AGS) guidelines180 (AGS
Grade A), and is required as an ACO Quality measure.

Testing Options
Providers should screen for patient reports of falling within the previous year, or expression of feeling
unsteady when standing or walking or worry about falling. Patients should complete the STEADI Stay
Independent screening questionnaire.178 (UW Health Low quality evidence, strong recommendation)

Those patients who score > 4 on the screening questionnaire, or report falling in the past year, or express
feeling unsteady when standing/walking or concern for falling should complete the Timed-Up-and-Go
(TUG)179 assessment. (UW Health Low quality evidence, strong recommendation)

Those patients who score > 12 seconds on the TUG should be considered at risk for falling. Providers may
also use their judgment and provide interventions to individual high risk patients with a lower score or refer
those patients to the UW Health Falls Clinic. (UW Health Very low quality evidence, weak/conditional
recommendation)

Preventive Interventions
The STEADI program includes an algorithm for preventive intervention based upon patient risk as
determined by the STEADI screen and other clinical assessments.178

Patients identified at low risk (STEADI screen score < 4) should be rescreened in one year. (UW Health Very
low quality evidence, weak/conditional recommendation)

Patients identified at moderate risk (TUG score > 12 seconds and report 1 fall without injury within the last
year) should receive177,178:
a) Education about fall risk factors (AGS Grade C)
b) Recommendations regarding optimal calcium (UW Health Very low quality evidence, weak/conditional
recommendation)
c) Vitamin D supplementation of 600 IU/day for patients aged 65-70 years. Patients older than 70 years
should receive 800 IU/day. (USPSTF Grade B)
d) Referral to community fall prevention program (i.e., Stepping On)
OR referral to physical therapy (AGS Grade A) (USPSTF Grade B)

Patients at high risk (TUG score > 12 seconds and report 1 fall with injury or report > 2 falls within the last
year) should receive a multifactorial risk assessment.178 The multifactorial fall risk assessment should be
followed by direct interventions in patients considered high risk for falling.180 Interventions should be tailored
to the identified risk factors, coupled with an appropriate exercise program. (AGS Grade A) The components
most commonly included in efficacious interventions include177,180:
a) Adaptation or modification of home environment (AGS Grade A)
b) Withdrawal or minimization of medications which may increase the risk of or adverse events to falls,
including antipsychotics, benzodiazepines, anticonvulsants, antidepressants (e.g., TCAs, SSRIs),
and opioids.181 (UW Health High quality evidence, strong recommendation)
c) In regards to initiation or continuation of anticoagulation therapy, this decision should be based on
patient preferences and estimation of overall bleeding risk. A history of falls and falls risk should not
be considered as absolute or relative contraindications to anticoagulation (UW Health Low quality
evidence, strong recommendation), as the literature suggests that a history of falls is not an important
factor in this decision.182-188
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40
d) Vitamin D supplementation of 600 IU/day for patients age 65-70 years. Patients older than 70 years
should receive 800 IU/day. (USPSTF Grade B)
e) Exercise, particularly balance, strength, and gait training (AGS Grade A) (USPSTF Grade B) The
minimum dose of exercise to protect an older adult against falls is 50 hours.189 The U.S. Department
of Health and Human Services190 recommends balance training 3 or more days per week for older
adults at risk for falling because of a recent fall or difficulty walking. The AGS recommends that
exercise interventions include balance, gait, and strength training.180 (AGS Grade A)

Patient Resources
1. HFFY #6625: Falls and Older Adults
2. HFFY #6626: Home Safety- Preventing Falls
3. HFFY #6752: Home Safety- Preventing Falls
4. HFFY #6627: If You Fall
5. HFFY #7553: Risk of Falls for Older Adults
6. HFFY #5841: What YOU Can Do to Avoid Falls at
Home
7. HFFY #5234: Preventing Falls and Fractures
8. HFFY #3140: Preventing Falls Packet
9. Healthwise: Diabetes: Fall Prevention
10. Healthwise: Fall Prevention
11. Healthwise: Fall Prevention: Outdoors
12. Healthwise: Falls: Get Up Safely Instructions
13. Health Information: Fall Prevention
14. Health Information: Fall-Proofing Your Home

HEARING
Return to Infant/Child Table | Return to Adolescent Table

Please reference the UW Health Standard Primary Care Rooming Criteria – Adult/Pediatric – Ambulatory
Guideline for additional information, including hearing test procedures and interpretation of results.

Newborn Patients (age 0-1 months)
If an initial hearing screening test was not performed before the newborn was discharged from the hospital,
one should be completed within the first month of life.31,82,191,192 (UW Health Moderate quality evidence, strong
recommendation) Newborn hearing screening is supported by state and federal legislation including
Wisconsin Statute (253.115), Illinois Statute (410 ILCS 213),and the Patient Protection and Affordable Care
Act.193

Patients age 4-10 years
Hearing screening tests should be completed once between the ages of 4-6 years and once between the
ages of 8-10 years. (UW Health Very low quality evidence, weak/conditional recommendation)
This recommendation is at variance with previously published guidelines31,32,194,195 which indicate hearing
screening at patient ages 4, 5, 6, 8, and 10 years. However, there is currently no evidence to support an
association with more frequent screening intervals and improved outcomes.

Annual screening between the ages of 3-8 years is required in Medicaid patients, see
https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Print/tabid/154/Default.aspx?ia=1&p=1&sa=24&s=2
&c=61&nt=Description%20of%20Required%20Components%20of%20a%20HealthCheck%20Screening.

Patients age 11-18 years
Current evidence suggests that hearing loss may occur due to secondhand tobacco smoke exposure or
excessive exposure to noise.196 These studies are limited by inconsistent definitions of hearing loss, and
varying frequency and threshold values for accurate testing.196-198 At this time, no recommendation can be
made related to hearing screening in the adolescent patient population.

Screening at age 12 and 16 years is required in Medicaid patients, see
https://www.forwardhealth.wi.gov/WIPortal/Online%20Handbooks/Print/tabid/154/Default.aspx?ia=1&p=1&sa=24&s=2
&c=61&nt=Description%20of%20Required%20Components%20of%20a%20HealthCheck%20Screening.

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41
Patient Resources
1. HFFY #7487: Your Baby’s Hearing Screen
2. Healthwise: Hearing Tests: Pediatrics
3. Healthwise: Hearing Test Abnormal Results:
Pediatric: General Info

HEPATITIS B
Return to Adult Table
Risk Factors
The relative importance of the risk factors for hepatitis B virus (HBV) infection varies substantially, and
depends upon geographical location and patient population. A major risk factor for HBV infection is country
of origin. The risk for HBV infection varies substantially by country of origin in foreign-born persons in the
United States. Another important risk factor for HBV infection is lack of vaccination in infancy in U.S.-born
persons with parents from a country or region with high prevalence. Important risk groups for HBV infection
with a prevalence of greater than or equal to 2% that should be screened199-201:
ξ Persons born in countries and regions with a high prevalence of HBV infection (greater than or
equal to 2%)
ξ U.S.-born persons not vaccinated as infants whose parents were born in regions with a very high
prevalence of HBV infection (greater than or equal to 8%), such as sub-Saharan Africa and central
and Southeast Asia
ξ Human Immunodeficiency Virus (HIV)-positive persons
ξ Injection drug users
ξ Men who have sex with men
ξ Household contacts or sexual partners of persons with HBV infection
ξ Persons receiving hemodialysis
ξ Persons receiving cytotoxic or immunosuppressive therapy (for example, chemotherapy for
malignant diseases, immuno-suppression related to organ transplantation, and for rheumatologic
and gastroenterologic disorders)

For more information on countries and regions with a high prevalence of HBV infection, visit:
http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/hepatitis-b

Adolescent and Adult Patients at High Risk
It is recommended to screen patients at high risk HBV infection (see risk factors above).199 (USPSTF Grade
B) Patients with ongoing risk factors may be tested annually. (UW Health Very low quality evidence,
weak/conditional recommendation)
Patients should be tested using a hepatitis B surface antigen (HBsAg) test followed by a neutralizing
confirmatory test for initially reactive results. Testing for antibodies to HBsAg (anti-HBs) and hepatitis B core
antigen (anti-HBc) should also be performed as part of a screening panel to help distinguish between
infection and immunity.199-201

Pertinent UW Health Policies & Procedures
1. UWHC Policy 13.04: Communicable Disease Reporting

Patient Resources
1. Healthwise: Hepatitis B
2. Healthwise: Hepatitis B- Should I Be Tested?


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HEPATITIS C
Return to Adult Table
Risk Factors
The relative importance of the risk factors for hepatitis C virus (HCV) infection varies substantially, and
depends upon geographical location and patient population. Positive risk factors for HCV infection202-205
include:
ξ Previous or current injection drug use
ξ Recipient of a blood transfusion prior to 1992
ξ Long-term hemodialysis
ξ Being born to a HCV-infected mother
ξ Incarceration
ξ Intranasal drug use
ξ Getting an unregulated tattoo
ξ Other percutaneous exposures (i.e., occupational)

Patients born between the years of 1945-1965
It is recommended to complete a one-time screening in patients born between 1945 and 1965.202-204
(USPSTF Grade B) Patients should be tested using a rapid or laboratory-conducted assay for HCV
antibody test followed by a confirmatory nucleic acid testing (NAT) for HCV RNA.204-207

Patients at Risk
It is recommended to test individuals at an increased risk for hepatitis C virus (HCV) infection (see risk
factors above).202-205 (USPSTF Grade B) Patients with ongoing risk factors may be tested annually. (UW Health
Very low quality evidence, weak recommendation) Tests should be completed using a rapid or laboratory-
conducted assay for HCV antibody test followed by a confirmatory nucleic acid testing (NAT) for HCV
RNA.204-207

Pertinent UW Health Policies & Procedures
1. UWHC Policy 13.04: Communicable Disease Reporting

Patient Resources
1. Healthwise: Hepatitis C
2. Healthwise: Hepatitis C: General Info
3. Healthwise: Hepatitis C Virus Test
4. Health Information: Hepatitis C
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
Return to Adolescent Table | Return to Adult Table
Risk Factors
Clinicians should bear in mind that adolescent and adult patients may be reluctant to disclose having HIV
risk factors, even when asked.208 The Five P’s: Partners, Practices, Prevention of Pregnancy, Protection
from STDs, and Past History of STDs, available from the CDC, may be used to guide a dialogue to assess
a patient’s risk of Sexually Transmitted Infections (STI) (see Appendix C).95

Positive risk factors for HIV infection include95,208:
ξ Sexual partners who are HIV-infected
ξ Exchanging sex for drugs or money
ξ Men who have sex with men (MSM)
ξ Having sex with multiple partners
ξ Active injection drug users
ξ Have acquired or requested testing for another sexually transmitted infections
ξ Sexually active adolescents
ξ Unprotected vaginal or anal intercourse
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Adolescent Patients age 13-18 years
Early testing is beneficial, as patients who are aware of their HIV status are more likely to practice safer sex
or remain abstinent.209 Furthermore, patients who are diagnosed and treated earlier have a slower
progression to acquired immune deficiency syndrome (AIDS), are more likely to restore immunologic
function, and are less likely to transmit HIV to others.209

Universal screening should be offered to all adolescents at least once between 16 to 18 years of age in
health care settings when the prevalence of HIV in the patient population is more than 0.1% (e.g., STI clinic,
correctional facility, clinics serving MSM, homeless shelters, TB clinics, and adolescent health clinics with a
high prevalence of STIs).209 (UW Health Very low quality evidence, strong recommendation) It is important to
inform adolescents that they will receive an HIV test as part of routine screening unless they decline (opt-
out screening).

In areas of lower HIV prevalence, HIV testing is encouraged for all adolescents who are sexually active and
those with other high risk factors for HIV (e.g., IV drug use). Targeted screening based on risk is
recommended beginning at age 13 years, unless an individual is identified at an earlier age with risk factors
for HIV infection.208 (UW Health Very low quality evidence, weak/conditional recommendation) High-risk youth
should be tested annually for HIV. (UW Health Very low quality evidence, weak/conditional recommendation)
Adolescents tested for other STIs should be tested for HIV at the same visit.209 (UW Health Very low quality
evidence, strong recommendation)

Patients age 19-64 years
Universal opt-out HIV screening is recommended in average risk patients age 19-64 years who were not
tested in adolescence, regardless of sexual activity or risk.208 (UW Health Very low quality evidence, strong
recommendation) This one-time screening serves to identify persons who are already HIV-positive, with
repeated screening of those who are known to be at risk for HIV infection, those who are actively engaged
in risky behaviors, and those who live or receive medical care in a high-prevalence setting. While the
evidence is insufficient to determine optimum time intervals for HIV screening, the CDC guideline
recommends annual screening in patients at an increased or high risk for infection.95 (UW Health Low
quality evidence, strong recommendation)

Patients age 65 years and older
Screening after age 65 years is indicated if there is ongoing risk for HIV infection, as indicated by risk
assessment (for example, new sexual partners).208 (USPSTF Grade A) The CDC guideline recommends
annual screening in patients at an increased or high risk for infection.95 (UW Health High quality evidence,
strong recommendation)

Pre-exposure Prophylaxis (PrEP)
Pre-exposure prophylaxis may be considered as additional intervention for uninfected partners in
serodiscordant couples (UW Health High quality evidence, strong recommendation) and MSM, injection drug
users, and heterosexual men and women at high risk of acquiring HIV (i.e., commercial sex workers).210-212
(UW Health High quality evidence, strong recommendation) For details related to therapy initiation and
maintenance, consult Infectious Disease and/or reference the 2014 Centers for Disease Control and
Prevention Preexposure Prophylaxis for the Prevention of HIV Infection in the United States Guideline.212
The following table (Table 12) provides a summary of the CDC recommendations:





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Table 12. Pre-exposure Prophylaxis Recommendations212

Men Who Have Sex
With Men (MSM)
Heterosexual
Women and Men Injection Drug Users
Detecting
substantial risk of
acquiring HIV
infection
HIV-positive sexual partner
Recent bacterial sexually transmitted infection
High number of sex partners
History of inconsistent or no condom use
Commercial sex worker
HIV-positive injecting partner
Sharing injection equipment
Recent drug treatment
(but currently injecting)
Clinically Eligible
Documented negative HIV test result before prescribing PrEP
No signs/symptoms of acute HIV infection
Normal renal function; no contraindicated medications
Documented hepatitis B virus infection and vaccination status
Prescription Daily, continuing, oral doses of Tenofovir disoproxil fumarate/ Emtricitabine < 90-day supply
Other Services
Follow-up visits at least every 3 months to provide the following:
HIV test, medication adherence counseling, behavioral risk reduction support, side effect
assessment, sexually transmitted infection symptom assessment

At 3 months and every 6 months thereafter, assess renal function.
Test for bacterial sexually transmitted infection every 6 months.
Do oral/rectal sexually
transmitted infection
testing
Assess pregnancy
intent; complete
pregnancy test every 3
months
Access to clean needles/syringes
and drug treatment services

Testing Options
Conduct initial testing with an FDA-approved antigen/antibody combination (4th generation) immunoassay
that detects HIV-1 and HIV-2 antibodies and HIV-1 p24 antigen to screen for established (HIV-1 or HIV-2) or
acute (HIV-1) infection.213

Specimens with a reactive antigen/antibody combination immunoassay result (or repeatedly reactive) need
be tested with an FDA-approved antibody immunoassay that differentiates HIV-1 and HIV-2 antibodies.213

Specimens that are reactive on the initial antigen/antibody combination immunoassay and nonreactive or
indeterminate on the HIV-1/HIV-2 antibody differentiation immunoassay need to be tested with an FDA-
approved HIV-1 NAT.213

Pertinent UW Health Policies & Procedures
1. UWHC Policy 13.04: Communicable Disease Reporting
2. UWHC Policy 4.30: Consent for HIV Testing & Release of Protected Health Information
3. UWHC Policy 4.17: Informed Consent

Patient Resources
1. HFFY #4421: HIV/AIDS General Information
2. HFFY #6097: HIV/AIDS General Information
3. HFFY #5669: A Health Guide for Men Age 50 or Older
4. HFFY #6419: A Health Guide for Men Age 50 or Older
5. HFFY #5668: A Health Guide for Women 50 or Older
6. HFFY #6432: A Health Guide for Women 50 or Older
7. Healthwise: HIV
8. Healthwise: HIV: Testing
9. Healthwise: Well Visit: 18 to 50 Years
10. Health Information: HIV Screening

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45
HUMAN PAPILLOMA VIRUS (HPV)
Refer to Cervical Cancer and Immunization recommendations.

HYPERTENSION
Return to Infant/Child Table | Return to Adolescent Table | Return to Adult Table

Risk Factors
Positive risk factors for blood pressure screening in patients younger than 3 years include31,214,215:
ξ History of prematurity, low birth weight, or neonatal complications requiring ICU care
ξ Congenital heart disease (repaired, unrepaired, or family history)
ξ Elevated body mass index (BMI)/obesity (BMI > 95th percentile)
ξ Recurrent UTI, hematuria, or proteinuria
ξ Known renal disease or urologic malformations
ξ Solid organ transplant
ξ Malignancy or bone marrow transplant
ξ Treatment with drugs known to raise blood pressure
ξ Other systemic illnesses associated with hypertension (i.e., neurofibromatosis, evidence of elevated
intracranial pressure, tuberous sclerosis, etc.).

Factors which increase risk for high blood pressure in adults include:36,216-219
ξ High-normal blood pressure/pre-hypertension (130-139/85-89 mmHg)
ξ Overweight or obesity (BMI ≥ 25 kg/m2 or > 23 kg/m2 in Asian Americans)
ξ Diabetes mellitus or impaired fasting glucose
ξ Tobacco use
ξ African American ancestry
ξ Family history of hypertension
ξ Secondary causes of hypertension (obstructive sleep apnea; CKD; thyroid or parathyroid disease;
Cushing syndrome; primary aldosteronism; pheochromocytoma; coarctation of the aorta;
renovascular disease/renal artery stenosis; alcohol abuse; illicit stimulants such as amphetamines,
methamphetamines, and cocaine; or other medications such as stimulants, estrogen,
corticosteroids, erythropoietin alfa, mineralocorticosteroids, cyclosporine, tacrolimus, NSAIDS,
herbals, OTC cold medication, bupropion, triptans, SNRIs)

Patients under age 3 years
Risk factors should be assessed by the provider in patients under the age of 3 years. Patients with specific
risk conditions (see above) or changes in risk should have their blood pressure obtained every six months
during health supervision visits or other illness visits.32 (UW Health Very low quality evidence, weak/conditional
recommendation)

Blood pressure measurements should be obtained using proper technique with manual and/or validated
automated devices.218,220 Measurement should be taken using the right arm in children. Factors such as
food intake, strenuous exercise, smoking, caffeine, or a cold exam room may influence blood pressure
results and should be avoided 30-60 minutes prior to taking the patient’s blood pressure.221

Patients age 3-18 years
Patients over the age of 3 years should have their blood pressure measured annually, preferably during
their health supervision visits.222 (ICSI High quality evidence, strong recommendation) Blood pressure
measurements should not be obtained during every clinic visit, despite recommendations from the National
High Blood Pressure Education Program (NHBPEP) Working Group on Children and Adolescents.215,223 No
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46
direct evidence exists that routine blood pressure measurement accurately identifies children and
adolescents who are at increased risk for cardiovascular disease in adulthood.214

Blood pressure measurements should be obtained using proper technique with manual and/or validated
automated devices.218,220 Measurement should be taken using the right arm in children. Factors such as
food intake, strenuous exercise, smoking, caffeine, or a cold exam room may influence blood pressure
results and should be avoided 30-60 minutes prior to taking the patient’s blood pressure.221

Patients age 18 years or older
The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in
adults aged 18 years or older.218 (USPSTF Grade A) Annual blood pressure screening is recommended for
adults aged ≥ 40 years old and for all adults with an increased risk for high blood pressure (see risk factors
above).218 (UW Health Moderate quality evidence, strong recommendation) Patients aged 18-39 years with
normal blood pressure (< 130/85 mmHg), and no other cardiovascular disease risk factors, should be
rescreened every 3-5 years.218 (USPSTF Grade A)
Blood pressure measurements should be obtained using proper technique with manual and/or validated
automated devices.218,220 For additional details, reference the UW Health Standard Primary Care Rooming
Criteria – Pediatric/Adult – Ambulatory Guideline and UW Health Hypertension – Adult –
Inpatient/Ambulatory Guideline.

Patient Resources
1. HFFY #5669: A Health Guide for Men Age 50 or Older
2. HFFY #6419: A Health Guide for Men Age 50 or Older
3. HFFY #5668: A Health Guide for Women 50 or Older
4. HFFY #4462: High Blood Pressure
5. Healthwise: Hypertension
6. Healthwise: Hypertension: General Info
7. Healthwise: Well Visit: 18 to 50 Years
8. Healthwise: Well Visit: 50 to 65 Year Men
9. Healthwise: Well Visit: 50 to 65 Year Women
10. Healthwise: Well Visit: Over 65 Years
11. Health Information: Blood Pressure Screening
12. Health Information: Prehypertension


IMMUNIZATIONS
Return to Infant/Child Table | Return to Adolescent Table | Return to Adult Table

It is recommended that immunization history for each individual patient is properly documented (including
dates) within the medical record.224 With the exception of influenza vaccine and pneumococcal vaccines
providers should only accept dated records, history of disease, or Immunization Registry (WIR or I-CARE)
documentation as evidence of vaccination; self-reported doses of influenza and pneumococcal vaccines are
acceptable, but efforts should be made to obtain original records. All patients who do not have a
recommended vaccine properly documented should complete serologic testing to prove immunity or be re-
immunized. (UW Health Low quality evidence, strong recommendation)

Pediatric Patients (Birth-18 years)
It is recommended to administer the Hepatitis B vaccine to all infants at birth, in particular, within 12 hours of
birth to infants born to HBsAg positive mothers or to whom mother’s status is unknown.225,226 (UW Health
High level of evidence, strong recommendation)

The Recommended Childhood and Adolescent Immunization Schedule approved by the Advisory
Committee on Immunization Practices (ACIP) and confirmed by the CDC through publication in the MMWR
should be followed.225,226 (UW Health High quality evidence, strong recommendation) The Schedule is provided in
its entirety on the Centers for Disease Control website at http://www.cdc.gov/vaccines/schedules/hcp/child-
adolescent.html and includes additional recommendations for patients with medical and other indications
that put them at high risk for vaccine preventable disease.

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47
Families choosing not to immunize or who do not follow the recommended immunization schedule need to
sign a Vaccine Refusal Form. The forms are located on the UW Health Immunization Toolkit webpage.
Pediatric vaccine refusal forms should be completed per UW Health Clinical Policy 3.1.1.224,227,228 (UW Health
Very low quality evidence, weak recommendation)

Adult Patients (age 19 years+)
The Recommended Adult Immunization Schedule approved by the Advisory Committee on Immunization
Practices (ACIP) and confirmed by the CDC through publication in the MMWR should be followed.226,229 (UW
Health High quality evidence, strong recommendation) The Schedule is provided in its entirety on the Centers for
Disease Control website at http://www.cdc.gov/vaccines/schedules/hcp/adult.html and includes a schedule
with additional recommendations for adults with medical and other indications that put them at high risk for
vaccine preventable disease.

Pertinent UW Health Policies & Procedures
1. UWHC Policy 3.1.1: UW Health Ambulatory Childhood Vaccine Refusal

Patient Resources
1. HFFY #5240: Immunizations for Children & Adults
2. HFFY: Category Medication Instruct. (Immunization)
3. Health Information: Immunization Schedules
4. Health Information: Immunizations
5. Health Information: Immunizations: Questions Parents
Ask
INTIMATE PARTNER VIOLENCE
Return to Adolescent Table | Return to Adult Table (Women Only)
Patients age 14-46 years
It is recommended to screen females of childbearing age for intimate partner violence, such as domestic
violence.230 (USPSTF Grade B) Screening should be completed using the Hurt, Insult, Threaten, and Scream
(HITS) assessment tool.230-233 (UW Health Moderate quality evidence, weak/conditional recommendation) Patients
who score greater than 10 points should be considered a positive screen.232

Screening may be considered annually. (UW Health Very low quality evidence, weak/conditional recommendation)
While evidence supports an increase in identification of intimate partner violence when routine screening is
performed; the literature has not consistently demonstrated improved patient awareness, changes in health
outcomes or quality of life, even when interventions were provided to patients who screened positive.234-237
National guidelines and UW Health support universal screening in female patients age 14-46 because it is
believed that the benefits of screening outweigh potential harm. In the research reviewed, documented
harms were not determined to be significant.230

Clinical documentation and reporting should be completed per UW Health policy. It is recommended to
provide or refer patients who screen positive to intervention services.230 (USPSTF Grade B) Patients may be
referred to Social Work (as available by clinic), UW Health Patient Resources, or may be provided with
community resources. It is important to consider that the patient may not be ready at the present time to
receive interventions (e.g., establishing a safety plan, information cards, referrals to community services,
counseling, mentor support, or home visits) or take actions such as leaving the perpetrator.230 The patient
may wait to participate in or accept interventions until they feel it may be possible without endangering their
life.

Pertinent UW Health Policies & Procedures
1. UW Health Clinical Policy 1.2.7- Suspected Domestic Violence and Abuse

Patient Resources
1. Healthwise: Domestic Abuse
2. Healthwise: Domestic Violence: Safety Instructions
3. Health Information: Domestic Abuse
4. Health Information: Domestic Violence
5. Health Information: Domestic Violence: Checklist of
Things to Take When You Leave
6. Health Information: Domestic Violence: Getting a
Protective Order
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LIPIDS
Return to Infant/Child Table | Return to Adolescent Table | Return to Adult Table
Risk Factors
Pediatric patients who exhibit any of the following risk factors are at an increased risk for coronary heart
disease238:
Positive family history: myocardial infarction, angina, coronary artery bypass graft/stent/angioplasty,
sudden cardiac death in parent, grandparent, aunt, or uncle, male < 55 years, female < 65 years.238
High Risk:
ξ Hypertension requiring drug therapy (BP ≥ 99th percentile + 5 mmHg)
ξ Current cigarette smoker
ξ BMI ≥97th percentile
ξ Diabetes Mellitus, type 1 and type 2
ξ Chronic renal disease/end-stage renal disease/postrenal transplant
ξ Postorthotopic heart transplant
ξ Kawasaki disease with current aneurysms
Moderate Risk:
ξ Hypertension not requiring drug therapy
ξ BMI ≥ 95th percentile, < 97th percentile
ξ HDL-C <40 mg/dL
ξ Kawasaki disease with regressed coronary aneurysms
ξ Chronic inflammatory disease (e.g. systemic lupus, erythematosus, juvenile rheumatoid
arthritis)
ξ HIV
ξ Nephrotic syndrome
ξ BMI percentile >95th percentile
Adult patients who exhibit any of the following risk factors are at an increased risk for coronary heart
disease:219,239-241
ξ Diabetes or glucose intolerance
ξ Personal history of coronary heart disease or non-coronary atherosclerosis (e.g., abdominal aortic
aneurysm, peripheral artery disease, carotid artery stenosis)
ξ Family history of cardiovascular disease before age 65
ξ Tobacco use
ξ Hypertension
ξ Overweight (BMI > 25 kg/m2) or obese (BMI > 30 kg/m2)
ξ Elevated hs-CRP (≥ 3.0 mg/mL)

Patients age 9-11 years
Universal screening is recommended in patients aged 9-11 years (NHLBI Grade B, strongly recommended)
using non-fasting total cholesterol and HDL measurements.238,242 Evidenced-based, early screening has
been shown to identify patients with familial hypercholesterolemia because selective, risk-based screening
has been shown to be ineffective in this population.34

Patients with an LDL between 160 and 190 mg/dL and a family history of premature vascular disease may
also have familial hypercholesterolemia. Further evaluation may be considered.34 (UW Health Very low quality
evidence, weak/conditional recommendation)

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49
Patients age 17-21 years
Universal screening is recommended in all patients age 17-21 years (NHLBI Grade B, strongly recommended)
using non-fasting total cholesterol and HDL measurements.238,242

Patients age 22-39 years
It is recommended to test average risk patients age 22-39 years once every 5 years.243 (NHLBI Grade B,
moderate) However, if LDL and TG levels are within acceptable limits(Table 13) and the patient does not
exhibit any risk factors, subsequent screening may be delayed until age 35 for men and age 45 for women,
unless risk factors develop. (UW Health Very low quality evidence, weak/conditional recommendation)

Patients considered at increased risk (see risk factors above) may need to be screened more frequently.
(UW Health Very low quality evidence, weak/conditional recommendation)

Patients age 40-75 years
It is recommended to test average risk men and women age 40-75 years once every 5 years.243 (NHLBI
Grade B, moderate) However, if a woman’s 10-year CVD risk is less than 2.5% and if LDL and TG levels are
within acceptable limits (Table 13) subsequent screening may be delayed until age 45, unless risk factors
develop. (UW Health Very low quality evidence, weak/conditional recommendation) It is recommended to use the
ACC/AHA ASCVD Risk Estimator to evaluate 10-year CVD risk (http://tools.acc.org/ASCVD-Risk-
Estimator/). (UW Health Low Quality Evidence, weak/conditional recommendation)

Patients considered at increased risk (see risk factors above) may need to be screened more frequently.
(UW Health Very low quality evidence, weak/conditional recommendation)

Testing Options
Initial testing in pediatric patients can be done with non-fasting total cholesterol and an HDL with either a
venous puncture or fingerstick, if available.244 If non-fasting labs are performed and non-HDL is > 145
mg/dL or HDL is < 40 mg/dL, it is recommended to follow up with a fasting lipid panel.245 (UW Health High
quality evidence, strong recommendation)

Testing in adults should be performed with a fasting lipid panel (total cholesterol, LDL, HDL and
Triglycerides) or non-fasting total cholesterol and HDL measurements. If non-fasting labs are performed and
total cholesterol is > 200mg/dL or HDL is < 40 mg/dL, it is recommended to follow up with a fasting lipid
panel for LDL management.241 (UW Health High quality evidence, strong recommendation)

Table 13. Acceptable Lipid Results238,243,246
Age Total Cholesterol HDL Triglycerides LDL Non-HDL Cholesterol
0-19 yrs. < 170 mg/dL > 45 mg/dL 0-9 yrs.: < 75 mg/dL
10-19 yrs.: < 90 mg/dL < 110 mg/dL < 125 mg/dL
20 yrs.
and older
< 200 mg/dL > 40 mg/dL < 150 mg/dL < 100 mg/dL < 160 mg/dL
Patient Resources
1. HFFY #7466: Familial Hypercholesterolemia (FH) in
Children
2. HFFY #7617: My Child’s Lipoprotein (a) Level
3. HFFY #5668: A Health Guide for Women 50 or Older
4. HFFY #5669: A Health Guide for Men 50 or Older
5. HFFY #6419: A Health Guide for Men 50 or Older
6. Healthwise: Cholesterol and Triglycerides Tests
7. Healthwise: Cholesterol and Triglycerides Tests:
Pediatric
8. Healthwise: Cholesterol and Triglycerides Tests: Teen
9. Healthwise: Well Visit: 18 to 50 Years
10. Healthwise: Well Visit: 50 to 65 Year Men
11. Healthwise: Well Visit: 50 to 65 Year Women
12. Healthwise: Well Visit: Over 65 Years
13. Health Information: Cholesterol in Children and Teens
14. Health Information: Lipid Panel


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LUNG CANCER
Return to Adult Table
Risk Factors
High Risk Factors for lung cancer include247,248:
ξ Age 55-80 years AND
ξ > 30 pack-year smoking history AND
ξ Current smoker or smoking cessation < 15 years ago

Patients age 55-80 years
A shared decision making conversation is required prior to the initial LDCT lung cancer screening. (UW
Health Low quality evidence, strong recommendation) It is recommended to complete annual low-dose
computed tomography (LDCT) screening in asymptomatic patients who exhibit all of the high risk factors.247
(USPSTF Grade B) Chest radiography has never been shown to decrease lung cancer mortality; therefore a
chest x-ray should never be used for lung cancer screening.247,249 (UW Health High quality evidence, strong
recommendation)

Screening should be discontinued once the patient has ceased smoking for 15 years or more, if the patient
has or develops a health problem which substantially limits life expectancy or the ability or willingness to
have a curative lung surgery, or when the patient reaches 81 years of age.247 (USPSTF Grade B)

Current evidence is lacking on the net benefit of expanding low-dose computed tomography (LDCT)
screening to include lower or moderate-risk patients. At this time, lung cancer screening should not be
performed in patients who are not high risk.250

Smoking Cessation
Smoking cessation is the most important intervention to prevent lung cancer in current smokers.251 All
patients should be advised on the importance of maintaining abstinence or on smoking cessation, and
should be offered smoking cessation interventions prior to the initial LDCT screening and at every screening
thereafter.247,252 (UW Health Low quality evidence, strong recommendation) The UW Health Tobacco Cessation -
Adult/Pediatric - Inpatient/Ambulatory Guideline contains recommendations related to smoking cessation
interventions based upon patient age and healthcare delivery setting.

Shared Decision Making
Elements of the shared decision making discussion should include the harms and benefits of screening,
potential for follow-up diagnostic testing, over-diagnosis, false positive results, false negative results, and
consideration of total radiation exposure.247,253,254 Counseling related to the importance of adherence to
annual lung cancer LDCT screening, impact of comorbidities, and establishment of the patient’s ability or
willingness to undergo diagnosis and treatment should also be completed.247,254 (UW Health Low quality
evidence, strong recommendation)

Patient Decision Aides:
ξ www.shouldiscreen.com
ξ Healthwise
ξ www.HealthDecision.org
ξ National Cancer Institute (English)
ξ National Cancer Institute (Spanish)
ξ Shared Decision Making for Lung Cancer Screening Document

Patient Resources
1. Healthwise: Lung Cancer
2. Health Information: Lung Cancer Screening
3. Health Information: Lung Cancer Screening (PDQ):
Health Professional Information [NCI]
4. Health Information: Lung Cancer Screening (PDQ):
Patient Information [NCI]
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NEWBORN SCREENING
Return to Infant/Child Table
CONGENITAL HEART DISEASE
Screen for critical congenital heart disease (CCHD) using pulse oximetry within 24-48 hours of birth, as
required by Wisconsin Statute (253.13) and Illinois Statute (410 ILCS 240/1.10).82,255

BLINDNESS PREVENTION
Ophthalmic antibiotic should be applied topically to the eyes within 1 hour of birth, in accordance with
Wisconsin Statute (253.11)82,256 and Illinois Statute (410 ILCS 215/3).

BLOOD SCREENING PANEL
Complete a newborn blood screening panel82,257 as required by Wisconsin Statute (253.13)255 and
Illinois Statute (Act 410 ILCS 240) to assess for the following congenital diseases:
ξ Argininosuccinic Acidemia (ASA)
ξ Biotinidase Deficiency
ξ Congenital Adrenal Hyperplasia
ξ Congenital Hypothyroidism
ξ Citrullinemia (Types I & II)
ξ Cystic Fibrosis
ξ Fatty Acid Oxidation Disorders (11)
ξ Galactosemia
ξ Homocystinuria
ξ Hypermethioninemia
ξ Maple Syrup Urine Disease
ξ Organic Acidemias (12)
ξ Phenylketonuria (PKU) and Hyperphenylalaninemia
ξ Severe Combined Immune Deficiency (SCID)
ξ Tyrosinemia (Types I, II & III)
ξ Hemoglobinopathies (Sickle Cell Disease, Hemoglobin S-Beta Thalassemia, Hemoglobin SC Disease,
Hemoglobin Variants)
ξ Urea Cycle Disorders (Argininosuccinic Acidemia (ASA), Citrullinemia (Types I & II))

Additional details regarding the state statutes can be found online:
ξ Wisconsin: http://www.slh.wisc.edu/clinical/newborn/health-care-professionals-guide/.
ξ Illinois:http://www.dph.illinois.gov/sites/default/files/publications/2015%20Newborn%20Metabolic%20Scr
eening%20Disorder%20List.pdf

Illinois only: Liposomal Storage Disease The blood specimen should be collected between 24-48 hours of
life in full term infants, and must be collected prior to discharge from the birth hospital.257 Infants born
outside of a hospital (i.e., home births) must have a specimen collected within one week of life. Additional
state requirements for populations such as premature infants can be found at the applicable department of
public health.

HEARING TEST
See Hearing Section.

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52
VITAMIN D SUPPLEMENTATION
It is recommended that all exclusively breast-fed or formula-fed infants (who receive less than 1,000 mL of
formula per day) begin to receive vitamin D supplement (400 IU) within the first few days of life.82,258 (UW
Health Low quality evidence, weak/conditional recommendation) Vitamin supplementation is also recommended
for breastfed infants who are receiving formula supplementation.82 Supplementation should be continued
unless the infant is weaned to at least 1 L/day of vitamin-D-fortified formula or whole milk.258

VITAMIN K ADMINISTRATION
Intramuscular injection of vitamin K (0.5-1 mg) should be administered within 1 hour of birth to prevent
hemolytic disease of the newborn.82,259 (UW Health Low quality evidence, strong recommendation)

Patient Resources
1. Healthwise: Newborn Screening: Pediatric
OBESITY
Return to Infant/Child Table | Return to Adolescent Table | Return to Adult Table
Pediatric Patients
Body mass index (BMI) should be calculated and documented in the medical record on all children ages 2-
18 at least annually, ideally at a well child visit.222 (ICSI Strong recommendation, High quality evidence)
An assessment of diet, physical activity and sedentary behaviors should be done annually, preferably at a
well child visit. This assessment should be used to target appropriate messages to each family.222 (ICSI
Strong Recommendation, High Quality Evidence) Obesity prevention messages should be targeted at all
families, starting at the time of the child’s birth.222 (ICSI Strong recommendation, High quality evidence)

For a full set of recommendations including additional preventive interventions and anticipatory guidance, or
treatment and counseling methods for patients identified as overweight or obese, reference the UW Health
Obesity– Pediatric – Ambulatory Guideline.

Adult Patients
Clinicians should calculate body mass index (BMI) for their patients on an annual basis for screening and as
needed for management. Classify BMI based on the body mass categories. Educate patients about their
body mass index and associated risks for them.217 (ICSI Strong recommendation, High quality evidence)
Clinicians need to carefully consider BMI and its associated mortality risk across different ethnicity, sex, and
age groups.217 (ICSI Strong recommendation, Moderate quality evidence)
Clinicians should consider waist circumference measurement to estimate disease risk for patients who have
normal or overweight BMI scores. Refer to Table 2 for disease risk relative to weight and waist
circumference.217 (ICSI Strong Recommendation, Moderate Quality Evidence)

For additional recommendations including interventions, treatment and counseling methods, reference the
UW Health Obesity– Adult – Ambulatory Guideline.


Patient Resources
1. HFFY #528: Weight Management: Resources
2. HFFY #168: Healthy Eating Plan (English)
3. HFFY #383: Healthy Eating Plan (Spanish)
4. HFFY Nutrition Category
5. Healthwise: Obesity: Pediatric
6. Healthwise: Weight: Overweight
7. Healthwise: Weight: Overweight: Pediatric
8. Health Information: Obesity


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OSTEOPOROSIS
Return to Adult Table (Women Only) | Return to Adult Table (Men Only)
Risk Factors
An estimated 10-year probability for major osteoporotic fracture may be calculated using the Fracture Risk
Assessment Tool (FRAX) developed by the World Health Organization.260 (UW Health Moderate quality
evidence, weak/conditional recommendation) Risk factors260-264 included within the FRAX calculation include:
ξ Advancing age
ξ Gender
ξ Body mass index
ξ Personal history of fracture(s) without major trauma
ξ Family history (first-degree relative) of hip fracture
ξ Tobacco use (smoking)
ξ Steroid use (glucocorticoid therapy in daily dose of > 5 mg prednisone or equivalent for > 3 months)
ξ Rheumatoid arthritis
ξ Secondary osteoporosis (e.g., insulin dependent type 1 diabetes mellitus; osteogenesis imperfecta;
untreated long-standing hypothyroidism; hypogonadism or premature menopause at < 45 years;
chronic malnutrition or malabsorption; and chronic liver disease)
ξ Excessive alcohol use (> 3 drinks daily)
ξ Bone mineral density (femoral neck BMD calculated on prior DXA scan)

The National Osteoporosis Foundation (NOF) identifies the following risk factors in men265:
ξ Age 70 years and older
ξ Prior fracture after age 50 years
ξ Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticosteroid
use in a daily dose > 5 mg prednisone or equivalent for > 3 months) associated with low bone mass
or bone loss

Postmenopausal Women age 50-64 years
Assessment of risk using the FRAX is recommended in postmenopausal women between the ages of 50-64
years, especially if the patient is considered at increased risk (i.e., exhibiting one or more of the risk factors
above).261-264 (UW Health Moderate quality evidence, weak/conditional recommendation)

Bone mineral density screening should be completed using central dual-energy X-ray absorptiometry (DXA)
in patients whose fracture risk (FRAX) is equal to or greater than that of a 65 year old white woman who has
no additional risk factors (major osteoporotic fracture score 9.3%).261 (UW Health Moderate quality evidence,
strong recommendation) However, the confidence intervals surrounding estimation of fracture risk (FRAX
score) are unknown, therefore clinicians should also consider a patient’s individual values and preferences
and use clinical judgement when discussing screening within this younger age group.

A risk assessment should be completed using the T-score obtained to determine major osteoporotic fracture
risk and future screening interval (Table 14). (UW Health Very low quality evidence, weak/conditional
recommendation)
In patients who are at low 10-year major osteoporotic fracture risk where DXA is not indicated, risk should
be reassessed every 5 years. (UW Health Very low quality evidence, weak/conditional recommendation)

Women age 65 years or older
It is recommended to screen for osteoporosis in women aged 65 years or older using central dual-energy X-
ray absorptiometry (DXA) to measure bone mineral density.261-263 (USPSTF Grade B- for women) This
screening should occur regardless of calculated major osteoporotic fracture risk or prior screening. A risk
assessment should be completed using the T-score to determine major osteoporotic fracture risk and future
screening interval (Table 14). (UW Health Very low quality evidence, weak/conditional recommendation)
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Men age 50 years or older
Strong data to guide screening decisions in men is
extremely limited, however many consensus guidelines
endorse screening in patients at increased risk.265,267,268 In
a retrospective observational study which compared
guideline-recommended clinical criteria to select men for
osteoporosis screening, the National Osteoporosis
Foundation (NOF) criteria provided the highest sensitivity
(82%) in identifying men who will develop a hip
fracture.265,269

Assessment of risk is recommended in men age 50 years
or older. (UW Health Low quality evidence, weak/conditional
recommendation) Bone mineral density should be
completed using dual-energy X-ray absorptiometry (DXA)
in men age 70 and older and in men age 50-69 years who
exhibit one or more of the following: prior fracture,
glucocorticosteroid use, or rheumatoid arthritis.265,269 (UW
Health Low quality evidence, weak/conditional
recommendation)

Following completion of the first DXA scan, a FRAX
assessment should be completed using the T-score to
determine major osteoporotic fracture risk and future
screening interval (Table 14). (UW Health Very low quality
evidence, weak/conditional recommendation)

Screening Interval for All Adults
In patients at low major osteoporotic fracture risk (FRAX <
10%), perform risk assessment every 5 years.268,270 (UW Health Very low quality evidence, weak/conditional
recommendation) Depending on the clinical situation (e.g., comorbid conditions or health issues, recent
hospitalizations, etc.), a DXA scan may be obtained every 5 years to optimize calculation of fracture risk.
(UW Health Very low quality evidence, weak/conditional recommendation)

A risk assessment should be completed every 2-3 years in patients with moderate fracture risk (FRAX 10-
20%) to decide whether to perform additional DXA scans based on patient preferences (e.g., adherence to
treatment and ongoing monitoring) and other clinical risk factors.267,268,270 (UW Health Very low quality evidence,
weak/conditional recommendation)

Patients with high fracture risk (FRAX > 20%) or prior fragility fracture of hip or spine or > 1 fragility fracture
should be considered for therapeutic intervention.263,270 (UW Health Moderate quality evidence, strong
recommendation)

Table 14. BMD Risk Assessment and Screening Intervals
10- yr. estimated risk of major
osteoporotic fracture
FRAX
Calculation DXA Scan
< 10% Every 5 yrs. Not recommended.*
10 - 20% Every 2-3 yrs. Consider every 2-3 years based on patient
preferences and other clinical risk factors.
> 20% n/a Confirm diagnosis and follow treatment
guidelines.
*All women should receive a DXA at age 65, regardless of calculated risk or prior screening. Depending on the clinical
situation, a DXA scan may be obtained in any patient every five years to optimize fracture risk calculation.
Will DXA scans be covered?
Insurance coverage for DXA scans is variable,
especially in men. Providers are encouraged
to discuss the potential burden of out-of-
pocket costs if screening is performed.

Medicare Part B (Medical Insurance) covers
the test once every 24 months (or more often if
medically necessary) for people who meet one
or more of the criteria below266:
ξ Women determined by their physician
or qualified non-physician practitioner
(NPP) to be estrogen deficient and at
clinical risk for osteoporosis, based on
her medical history and other findings
ξ Individuals with a x-ray showing
possible osteoporosis, osteopenia, or
veterbral fractures
ξ Individuals getting (or expecting to get)
glucocorticosteroid therapy for more
than 3 months
ξ Individuals diagnosed with primary
hyperparathyroidism
ξ Individuals being monitored to assess
response to U.S. FDA-approved
osteoporosis drug therapy
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Primary Prevention of Fractures
Falls are the precipitating factor in nearly all fractures, therefore falls risk assessment and prevention is
recommended in patients 65 years or older (see Falls Risk section).263

Opportunistic Screening
Computed tomography (CT) scans are not recommended for routine assessment and are not approved for
monitoring of bone mineral density. (UW Health Low quality evidence, strong recommendation) However, recent
evidence suggests a good correlation between T-scores obtained via DXA and those obtained by CT.271-277
Therefore, opportunistic screening may be considered in the event that a patient is scheduled for a CT scan
that includes imaging of the hip and is eligible for DXA scanning. (UW Health Low quality evidence,
weak/conditional recommendation)

Patients at High Risk
Patients over age 50 years who have experienced a spine or hip fragility fracture can be clinically diagnosed
with osteoporosis.265 For those patients and others with fragility fractures, it is important that they are
assessed using DXA.265 (UW Health Moderate quality evidence, strong recommendation)

Patient Resources
1. HFFY #5646: Bone Mineral Density (BMD) Test
2. HFFY #5668: A Health Guide for Women 50 or Older
3. HFFY #5669: A Health Guide for Men 50 or Older
4. HFFY #6419: A Health Guide for Men 50 or Older
5. Healthwise: Osteoporosis
6. Healthwise: Osteoporosis: Prevention
7. Healthwise: Well Visit: 50 to 65 Years Women
8. Healthwise: Well Visit: Over 65 Years
9. Health Information: Osteoporosis
10. Health Information: Osteoporosis in Men
11. Health Information: Osteoporosis Risk Factors
12. Health Information: Osteoporosis Risk in Younger Women
13. Health Information: Osteoporosis Screening
14. Health Information: Should I Have a Dual-Energy X-Ray Absorptiometry (DXA) Test?
PROSTATE CANCER
Return to Adult Table (Men Only)

Recommendations on prostate cancer screening continue to evolve as new data is published. The Prostate,
Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial was the primary source for the 2012
USPSTF statement, which recommended against PSA-based screening for prostate cancer.278,279 (USPSTF
Grade D) A recent analysis of the PLCO, however, uncovered pervasive contamination of the control group
in this trial, making the trial results difficult or impossible to interpret.280,281 The ERSPC trial, a study
involving about 182,000 men from 7 European countries, has demonstrated an increasing mortality benefit
of prostate cancer screening as longitudinal results continue to be published. The 2013 ERSPC data
showed a 27% reduction in prostate cancer mortality after adjusting for non-participation.282

Risk Factors
Risk factors283-287 for increased prostate cancer mortality include:
ξ Having one or more first-degree relatives (parent, sibling, or child) diagnosed with prostate cancer
before age 65
ξ African American ancestry
ξ Genetic cancer syndromes (e.g., BRCA2 mutation)



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Life Expectancy
Patients with a life expectancy of less than 10 years should not be screened.286 (UW Health Moderate quality
evidence, weak/conditional recommendation) Life expectancy is often difficult to ascertain38, however the
following resources are available:
ξ ePrognosis
ξ CDC Tables

Men age 40-49 years
Routine prostate cancer screening is not recommended in men aged 40-49 years.286 (UW Health Very low
quality evidence, strong recommendation) The prevalence of prostate cancer is low in this age group, so the
harms of screening outweigh the benefit for men at average risk.286

In men at increased risk (see risk factors above), consider a shared decision making discussion of the
harms and benefits of prostate cancer screening.285,286 (UW Health Very low quality evidence, weak/conditional
recommendation) The decision to initiate screening should be based on the man’s values, preferences, and
risk factors.

Men age 50-69 years
A one-time shared decision making conversation regarding the harms and benefits of prostate cancer
screening is recommended.283-286 (UW Health Moderate quality evidence, weak/conditional recommendation) The
decision to initiate screening should be based on the man’s values, preferences, and risk factors.

Men age 70 years or older
Patients 70 years or older should not be routinely screened for prostate cancer, as data suggests little
mortality benefit to treatment in this population.279,288,289 (UW Health High quality evidence, strong
recommendation)

Testing Options and Frequency
PSA testing should not be initiated without first having a shared decision making conversation.278,283-286 (UW
Health Moderate quality evidence, strong recommendation) If the decision is made to perform screening, PSA
testing may be completed every 1-2 years. (UW Health Moderate quality evidence, weak/conditional
recommendation) Longer screening intervals may be considered for PSA levels less than 1.0 ng/mL, as these
values are associated with a low lifetime risk of lethal prostate cancer.290-294 (UW Health Low quality evidence,
weak/conditional recommendation)

There is no demonstrated benefit for digital rectal exam (DRE) as an adjunct to PSA testing.279,282,283,286,295
The sensitivity and specificity of DRE are lower than for PSA testing and no randomized trials have
supported a mortality or morbidity benefit of DRE screening for prostate cancer in average risk men.283,286,295

Shared Decision Making
Shared decision making remains the key component for prostate cancer screening (Table 15). The
following resources may be used as physician support for the shared-decision making process.

Patient Decision Aids:
ξ Annals of Internal Medicine
ξ Healthwise
ξ Georgetown University
ξ Mayo Clinic




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Table 15. Physician Discussion Points for PSA Testing
Benefits of Prostate
Cancer Screening Risks/Harms of Screening
Early stages of prostate
cancer are easier to treat
and more likely to be cured.
Not all prostate cancers need treatment, especially in individuals that are
older or with other health problems. Prostate cancer treatment has some
risks and side effects, including urinary incontinence, problems with
erections, or bowel problems. For patients with low risk cancers, active
surveillance is an available option to mitigate the risks of treatment.
PSA testing can be done
with a widely available blood
test.
PSA testing is not perfect. PSA levels can be elevated when cancer is not
present and not elevated when cancer is present.

Patients with a high PSA level will likely need to be referred to Urology to
undergo a biopsy to determine further treatment (active surveillance,
radiation, or surgery).
PSA screening may help to
detect prostate cancer early.
Many prostate cancers never spread beyond the prostate gland during an
individual’s lifetime.
For some men, having the
test can provide them with
reassurance that they likely
don’t have prostate cancer.
PSA testing can provoke anxiety and confusion especially if an elevated
level is obtained. Inflammation, benign enlargement, and infection of the
prostate can cause false elevations. For abnormal initial PSA results, more
specific free to total PSA testing may be considered to reduce this error.296
The number of deaths from
prostate cancer has gone
down since PSA testing
became available.
Although significant, it’s not yet clear how much of the decrease in deaths
from prostate cancer is due to early detection and treatment based on PSA
testing. Data is still being collected.


Patient Resources
1. Healthwise: Well Visit: 18 to 50 Years
2. Healthwise: Well Visit: 50 to 65 Year Men
3. Healthwise: Well Visit: Over 65 Years
4. Healthwise: Prostate Cancer
5. Healthwise: Prostate Cancer Screening
6. Health Information: Prostate Cancer
7. Health Information: Prostate Cancer Screening
8. Health Information: Prostate Cancer (PDQ):
Screening- Health Professional Information
9. Health Information: Prostate Cancer (PDQ):
Screening- Patient Information
10. Health Information: Prostate Cancer Screening:
Should I Have a PSA Test?

SEXUAL ACTIVITY (BEHAVIORAL COUNSELING)
Return to Adolescent Table | Return to Adult Table
Risk Factors
As part of the clinical encounter, health-care providers should routinely obtain sexual histories from their
patients and address risk reduction. The “Five P’s” approach to obtaining a sexual history is one strategy for
eliciting information concerning five key areas of interest (see Box 1 in Appendix C).95

Effective interviewing and counseling skills characterized by respect, compassion, and a nonjudgmental
attitude toward all patients are essential to obtaining a thorough sexual history and delivering effective
prevention messages.

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Patients with the following risk factors are at increased risk for developing a sexually transmitted infection
(STI)297:
ξ Current STI or other infections within the past year
ξ Multiple sex partners
ξ Inconsistent condom use
ξ Persons who exchange sex for money or drugs

Special Populations
Clinicians should be aware of populations with a particularly high prevalence of STIs including297,298:
ξ African Americans (highest of all ethnic groups)
ξ American Indians, Alaska Natives, and Latinos (higher prevalence)
ξ Men who have sex with men (MSM)
ξ Persons with low income in urban settings
ξ Current or former inmates
ξ Military recruits
ξ Persons with mental illness or a disability
ξ Current or former intravenous drug users
ξ Persons with a history of sexual abuse
ξ Patients at public STI clinics

Patients age 11-17 years
The USPSTF recommends high-intensity behavioral counseling (30 minutes- 2 hours) for all sexually active
adolescents.297,298 (USPSTF Grade B) The most successful counseling approaches provide basic information
about STIs and STI transmission; assess the patient’s risk for transmission; and provide training in pertinent
skills, such as condom use, communication about safe sex, problem solving, and goal setting. Counseling
interventions may include face-to-face counseling, videos, written material, or telephone support.297

Patients age 18 years or older
The USPSTF recommends high-intensity behavioral counseling (30 minutes- 2 hours) for all sexually active
adults at an increased risk for sexually transmitted infection (see risk factors above).297,298 (USPSTF Grade B)
The most successful counseling approaches provide basic information about STIs and STI transmission;
assess the patient’s risk for transmission; and provide training in pertinent skills, such as condom use,
communication about safe sex, problem solving, and goal setting. Counseling interventions may include
face-to-face counseling, videos, written material, or telephone support.297

In the event of time constraints, providers may consider providing brief education to patients on how to
reduce their risk for sexually transmitted infection transmission, including abstinence, correct and consistent
condom use, and limiting the number of sex partners.

Patient Resources
1. Healthwise: Safer Sex
2. Healthwise: Safer Sex: Teen
3. Healthwise: Condom: Male
4. Healthwise: Condom: Female
5. Healthwise: Condoms: General Info
6. Healthwise: Well Care: Teen
7. Healthwise: Well Visit: Young Teen
8. Health Information: Sex Education, Talking with
Children/Teenagers

SKIN CANCER (BEHAVIORAL COUNSELING)
Return to Infant/Child Table | Return to Adolescent Table | Return to Adult Table

High risk factors299-307 associated with developing melanoma:
ξ Strong family history of malignant melanoma (greater than 3 first-degree affected relatives)
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ξ Strong family history of malignant melanoma combined with pancreatic cancer (one melanoma and
2 or more other melanoma and/or pancreatic cancer among first- or second-degree relatives)
ξ Personal history of melanoma
ξ Multiple benign nevi (more than 50) or atypical nevi
ξ Excessive sun exposure
ξ Use of indoor tanning equipment. UW Health concurs with the American Academy of
Dermatology (2014) that the use of indoor tanning beds and devices represents a significant and
avoidable risk factor for the development of both melanoma and non-melanoma skin
cancers.305,307 In addition, the World Health Organization has categorized tanning devices as a
known human carcinogen.

Additional risk factors include fair or freckled skin, light hair (red or blonde) or light eye color (blue, green,
gray), or skin that sunburns easily or a history of blistering sun burns (especially during childhood or
adolescence).301,303,308 It is still not known the degree of clinical significance that these factors play in skin
cancer risk individually or in combination with one another.

Patients age 10-24 years
It is recommended to counsel all patients 10-24 years of age with fair skin or any of the previously stated
risk factors about minimizing their exposure to ultraviolet radiation.308 (USPSTF Grade B) Sun protective
behavior should be encouraged; such as avoiding exposure during certain times of day (peak hours:
between 10 am to 4 pm), applying and reapplying sunscreen of SPF 30 or greater, minimizing overall sun
exposure, and wearing appropriate types of clothing (long-sleeved shirts, pants, wide-brimmed hats and
sunglasses). Clothing can be chosen with ultraviolet protection factor (UPF) labels or with fabric
characteristics that block more UV light (Table 16).309

Patients age 25 years or older
While the benefits are uncertain in adults age 25 years or older, given the low risks associated with
counseling, behavioral counseling and education related to sun protective behavior for all patients may be
considered regardless of age or risk status. (UW Health Very low quality evidence, weak/conditional
recommendation) The specific recommended ultraviolet-avoidance behaviors are the same as specified
above.

Table 16. Influence of Fabric Characteristics on UPF309
Factor Comment
Porosity Tight weave has higher UPF
Color Darker colored fabrics have higher UPF
Weight Heavy fabric have higher UPF
Thickness Thick fabrics have higher UPF
Stretch Stretched fabric have lower UPF
Wetness Dry fabrics have higher UPF
Type of Fabric Cotton and rayon have the least UPF. Wool, silk and nylon have
moderate UPF. Polyester has highest UPF.
Laundry UPF increases after washing
Fabric to skin distance Loose fit has higher UPF
UV absorbing agent Increase UPF

Patient Resources
1. Healthwise: Well Visit: 18 to 50 Years
2. Healthwise: Well Visit: 50 to 65 Year Men
3. Healthwise: Well Visit: 50 to 65 Year Women
4. Healthwise: Well Visit: Over 65 Years
5. Healthwise: Skin Cancer: Prevention
6. Health Information: Skin Cancer Prevention (PDQ):
Prevention- Health Professional Information
7. Health Information: Skin Cancer Prevention (PDQ):
Prevention- Patient Information
8. Health Information: Skin Cancer: Protecting Your Skin
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9. Health Information: Sunblocks to Prevent Sunburn
10. Health Information: Sunburn and Skin Cancer
11. Health Information: Sunburn: Skin Types


SYPHILIS
Return to Adult Table
Risk Factors
Clinicians should bear in mind that adolescent and adult patients may be reluctant to disclose having HIV
risk factors, even when asked.95 The Five P’s: Partners, Practices, Prevention of Pregnancy, Protection
from STDs, and Past History of STDs, available from the CDC, may be used to guide a dialogue to assess
a patient’s risk of Sexually Transmitted Infections (STI) (see Appendix C).95

Patients at an increased risk for syphilis infection include310:
ξ Commercial sex workers
ξ Persons who exchange sex for drugs
ξ History of incarceration
ξ Persons living with HIV
ξ Males younger than 29 years

Heterosexual Male and Nonpregnant Female Patients
Routine screening should not be completed on asymptomatic patients not an increased risk for infection.310
(USPSTF Grade D) Syphilis screening is strongly recommended in patients at an increased risk (see above
risk factors).310 (USPSTF Grade A)

Men Who Have Sex with Men (MSM)
It is recommended that men who have sex with men (MSM) complete syphilis serology, with confirmatory
testing, annually.95 (UW Health High quality evidence, strong recommendation) More frequent STD screening
(i.e., every 3-6 months) may be indicated for MSM with multiple or anonymous partners or MSM patients
who have sex in conjunction with illicit drug use or whose sex partners participate in similar high-risk
behaviors.95 (UW Health High quality evidence, strong recommendation)

Testing Options
Nontreponemal tests commonly used for initial screening are the Venereal Disease Research Laboratory
(VDRL) or Rapid Plasma Reagin (RPR), followed by a confirmatory fluorescent treponemal antibody
absorbed (FTA-ABS) or T.pallidum particle agglutination (TP-PA).311

Pertinent UW Health Policies & Procedures
2. UWHC Policy 13.04: Communicable Disease Reporting

Patient Resources
1. Health Facts For You #977: Syphilis
2. Healthwise: Syphilis
3. Healthwise: Well Visit: 18 to 50 Years
4. Health Information: Syphilis

TOBACCO USE
Return to Infant/Child Table | Return to Adolescent Table | Return to Adult Table
All Patients
Secondhand smoke exposure is harmful to all patients. Therefore, clinicians should ask about tobacco
smoke exposure (Table 17) from parents, caregivers, spouses, or environmental conditions (e.g., multi-unit
housing, public buildings where smoking is allowed).312-316 (UW Health Moderate quality evidence, strong
recommendation)

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Patients age 11 years or older
Tobacco use status should be assessed and documented in adolescent and adult patients at every clinical
encounter (Table 17), preferably when vital signs are obtained or during inpatient admission.312-314,317 (UW
Health High quality evidence, strong recommendation) Parental smoking and tobacco use are two of the
strongest risk factors for smoking initiation in children.315,318 Therefore, it is important to assess parental or
caregiver use of tobacco during pediatric visits, and address dependence as necessary.319,320 (UW Health
Low quality evidence, strong recommendation)

A national survey of adolescent and young adults demonstrated the recent transition from electronic
cigarette use to traditional cigarette smoking, suggesting e-cigarette use as a “gateway drug”. Smokeless
tobacco users (e.g., chewing tobacco, snuff) or users of nicotine products (e.g., electronic cigarettes) should
be identified, strongly urged to quit and provided counseling cessation interventions.312,321-326 (HHS Strength
of Evidence A) Users of cigars, pipes, and other non-cigarette forms of smoking tobacco should be identified,
strongly urged to quit, and offered the same counseling interventions recommended for cigarette
smokers.312 (HHS Strength of Evidence C) Provider should be aware that cigar smokers are at an increased
risk for coronary heart disease, COPD, periodontitis and oral, esophageal, lung, and other cancers.327-330

Table 17. Screening Based Upon Patient Age
Suggested Question (Age 0-10 years)
Is this patient regularly exposed to tobacco smoke (e.g., at home, in a car, at work)?
Suggested Questions (Age 11-17 years)
Have you ever tried tobacco or nicotine products (including e-cigarettes, e-hookah, hookah, vape or chew)?
Are you regularly exposed to tobacco smoke (e.g., at home, in a car, at work)?
Suggested Questions (Age 18 years or older)
Do you currently use or have you used tobacco or nicotine products within the last month?
Are you regularly exposed to tobacco smoke (e.g., at home, in a car, at work)?

Prevention and Anticipatory Guidance
Non-use should be reinforced by providers and other health care professionals in patients of any age. (UW
Health Low quality evidence, strong recommendation)

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians provide interventions,
including education and brief counseling, to prevent initiation of tobacco use in school-aged children and
adolescents.313,315 (USPSTF Grade B) While screening for personal tobacco use should begin at age 11,
anticipatory guidance and education may be appropriate at a much earlier age. The American Academy of
Pediatrics (AAP) supports beginning anticipatory guidance at the age of 5 years.313,319 Children and
adolescents should be warned about the harmful effects of tobacco and the ease with which
experimentation progresses to addiction and regular use.313,314 Messages for adolescents which have been
shown to resonate include those related to the effects of tobacco use on appearance, breath, sports
performance, financial burdens, and lack of benefit for weight loss.319

Brief Advice for Patients age 11 years or older
When using the 5A’s model, patients who screen positive for tobacco use should receive brief advice and
be assessed for their willingness to quit.312 Minimal interventions lasting less than 3 minutes increase overall
tobacco abstinence rates. Every tobacco user should be offered at least minimal intervention, whether or
not the patient is referred to an intensive intervention.312,331 (HHS Strength of Evidence A)

In a clear, strong, and personalized manner, urge every tobacco user to quit.312 All physicians should
strongly advise every patient who smokes to quit because evidence shows that physician advice to quit
smoking increases abstinence rates.312 (HHS Strength of Evidence A)
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Advice should be312:
ξ Clear—“It is important that you quit smoking (or using chewing tobacco) now, and I can help you.”
“Cutting down while you are ill is not enough.” “Occasional or light smoking is still dangerous.”
ξ Strong—“As your clinician, I need you to know that quitting smoking is the most important thing you
can do to protect your health now and in the future. The clinic staff and I will help you.”
ξ Personalized—Tie tobacco use to current symptoms and health concerns, and/or its social and
economic costs, and/or the impact of tobacco use on children and others in the household.
“Continuing to smoke makes your asthma worse, and quitting may dramatically improve your
health.” “Quitting smoking may reduce the number of ear infections your child has”.312

For additional detailed recommendations, refer to the UW Health Assessment of Tobacco Use or
Secondhand Smoke Exposure and Interventions for Tobacco Cessation – Adult/Pediatric –
Inpatient/Ambulatory Guideline.

Patient Resources
1. HFFY #5669: A Health Guide for Men Age 50 or Older
2. HFFY #6419: A Health Guide for Men Age 50 or Older
3. HFFY #5668: A Health Guide for Women 50 or Older
4. HFFY #6432: A Health Guide for Women 50 or Older
5. HFFY #3096: Quit Smoking (English)
6. HFFY #6763: Quit Smoking (Spanish)
7. HFFY #2022: Quit Smoking Fact Sheet
8. HFFY #7515: Why You Should Quit Smoking
9. HFFY # 2028: You Can Quit Smoking (Spanish)
10. HFFY #5623: Quit Tobacco Program Workbook for
Teens
11. HFFY #7008: Tobacco Use- How to Avoid Once
You’ve Quit
12. HFFY #6141: Using a Nicotine Patch
13. HFFY #6150: Smoking and Wound Healing (Burn
Patients)
14. HFFY #5328: Bupropion ER (ZYBAN®) for Smoking
Cessation
15. Healthwise: Smokeless Tobacco: Quitting
16. Healthwise: Anti-Smoking Medication: Deciding About
17. Healthwise: Smoking: Stopping
18. Healthwise: Stopping Smoking- Teen
19. Healthwise: Teens Thinking About Quitting Smoking:
After Your Visit
20. Healthwise: Well Visit: 18 to 50 Years
21. Healthwise: Well Visit: 50 to 65 Year Men
22. Healthwise: Well Visit: 50 to 65 Year Women
23. Healthwise: Well Visit: Over 65 Years
24. Health Information: Tobacco Use in Teens
TUBERCULOSIS
Return to Infant/Child Table | Return to Adolescent Table
Risk Factors for All Patients
Positive risk factors for immediate tuberculosis (TB) testing include332:
ξ Contact with people with confirmed or suspected contagious TB (contact investigation)
ξ Radiographic or clinical findings suggesting TB
ξ Recipients of immunosuppressive therapy or with immunosuppressive conditions, including HIV
ξ Immigration from countries with endemic infections (e.g., Asia, Middle East, Africa, Latin America,
countries of the former Soviet Union), including international adoptees
ξ Travel histories greater than 1 week to countries with endemic infection and substantial contact with
indigenous people from such countries. (Note: If the child is well and has no history of exposure, the
test may be delayed up to 10 weeks after return)
ξ Health care workers, and workers in high-risk congregate settings may also be at increased risk of
exposure

Pediatric Risk Factors for Latent Tuberculosis Infection (LTBI)
Patients at increased risk of progression of latent tuberculosis infection (LTBI) to tuberculosis disease
include those with recent exposure AND one or more of the following risk factors332:
ξ Other medical conditions, including diabetes mellitus, organ transplant or chronic renal failure,
Hodgkin disease or lymphoma
ξ Malnutrition
ξ Congenital or acquired immunodeficiencies
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ξ Receiving tumor necrosis factor (TNF) antagonists

Pediatric Risk Assessment Tool for Latent Tuberculosis Infection
Validated screening questions to determine the risk of latent tuberculosis infection (exposure) in children are
included below.332 Patients who respond positively to the screening questions are considered at risk for
latent TB infection.
1. Has a family member or contact had tuberculosis disease?
2. Has a family member had a positive tuberculin skin test result?
3. Was your child born in a high-risk country (i.e., countries other than the United States, Canada,
Australia, New Zealand, or Western and North European countries)?
4. Has your child traveled (had contact with resident populations) to a high-risk country for more than 1
week?

Adult Risk Factors for Latent Tuberculosis Infection (LTBI)
Adult patients at increased risk for LTBI include333:
ξ Persons who were born in, or are former residents of, countries with increased tuberculosis
prevalence
ξ Persons who live in, or have lived in, high-risk congregate settings (e.g., homeless shelters and
correctional facilities)
ξ Persons who are immunosuppressed (e.g., persons living with HIV, patients receiving
immunosuppressive medications such as tumor necrosis factor-alpha inhibitors, and patients who
have received an organ transplant)
ξ Patients with silicosis

Pediatric Patients (age 6 months, 12 months, 24 months, 3-10 years)
It is recommended to complete a risk assessment for LTBI (see above) in pediatric patients by 1 month of
age, and at ages 6 months, 12 months, 24 months, and then annually between 3-10 years.32,332 (UW Health
Very low quality evidence, weak/conditional recommendation) Those patients found to be at risk for TB infection
should be tested using a tuberculin skin test (TST) or interferon gamma release assay (IGRA) as indicated
by age (see Table 18). (UW Health Very low quality evidence, weak/conditional recommendation) Pediatric
patients living with HIV should be tested with TST annually.332 (UW Health High quality evidence, strong
recommendation)

Adolescent Patients (age 11-17 years)
It is recommended to complete an annual risk assessment for LTBI (see above) in adolescent patients and
to test those found to be at risk for tuberculosis infection.32,332 (UW Health Very low quality evidence,
weak/conditional recommendation) using a tuberculin skin test (TST) or interferon gamma release assay
(IGRA) as indicated by age (see Table 18). (UW Health Very low quality evidence, weak/conditional
recommendation) Pediatric patients living with HIV should be tested with TST annually.332 (UW Health High
quality evidence, strong recommendation)

Asymptomatic Adult Patients (age 18 years or older)
The USPSTF concludes with moderate certainty that the net benefit of screening for LTBI in persons who
are at increased risk for tuberculosis is moderate.333 (USPSTF Grade B). It is recommended to test adults
with immediate risk factors once as needed. (UW Health Very low quality evidence, strong recommendation)

The USPSTF found no evidence on the optimal frequency of screening for LTBI. Depending on specific risk
factors, screening frequency could range from 1-time only screening among persons who are at low risk for
future tuberculosis exposure to annual screening among those who are at continued risk of exposure.333
(UW Health Very low quality evidence, weak/conditional recommendation)

Testing Options
In addition to testing based upon risk, an initial TST or IGRA should be performed before initiation of
immunosuppressive therapy, including prolonged steroid administration, organ transplantation, use of TNF-
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alpha antagonists or blockers, or other immunosuppressive therapy in any patient requiring these
treatments.332 (UW Health Very low quality evidence, weak/conditional recommendation) Children infected with
HIV should have an annual TST performed.332 (UW Health Very low quality evidence, strong recommendation)

Table 18. Tuberculosis Testing Options332
TST preferred,
IGRA acceptable
Pediatric or adult patients who are likely to return for TST reading

Limited data exists regarding the usefulness of IGRAs in children 2-4 years; therefore IGRA
should not be used in children < 2 years of age unless TB is suspected.
IGRA preferred,
TST acceptable
> 5 years of age who have received Bacillus Calmette-Guérin (BCG) vaccine

> 5 years of age or adults who are unlikely to return for TST reading
TST only 3 months – 18 years of age with HIV infection
Patient Resources
1. Healthwise: TB (Tuberculosis)
2. Healthwise: TB (Tuberculosis): Pediatric
3. Healthwise: Tuberculin Skin Test
4. Health Information: Tuberculosis (TB)
5. Health Information: Tuberculosis Screening
6. Health Information: Tuberculin Skin Test

VISION
Return to Infant/Child Table | Return to Adolescent Table
Newborns to 6 months
Newborn infants should be examined using inspection and red reflex testing to detect structural ocular
abnormalities, such as cataract, corneal opacity, and ptosis.334 (UW Health Very low quality evidence, strong
recommendation)

Visual acuity in young children should be completed by assessing the patient’s ability to fixate on and follow
a target. Development of fixating on and following a target should occur by 6 months of age children who do
not meet this milestone should be referred.334,335 (UW Health High quality evidence, strong recommendation)

Patients age 6 months – 5 years
An ocular history, ocular alignment and motility assessment, and an ocular examination consisting of an
external examination, pupil examination, red reflex testing to assess ocular media, ocular fundus
examination with ophthalmoscope, and assessment of visual function should be done between the following
ages: 6-12 months, 1-3 years, and 4-5 years.334,335 (UW Health Very low quality evidence, strong
recommendation)

Wisconsin statute 118.135 recommends that all students entering kindergarten request an eye examination
by a licensed optometrist or physician.336 Illinois statute SB0641 requires an eye exam as part of a health
examination within one year prior to entering kindergarten or the first grade, or irrespective of grade,
immediately prior to or upon entrance into any public, private, or parochial nursery school. It is
recommended that vision screening occur at least once between the ages of 3 to 5 years to detect the
presence of amblyopia or its risk factors.31,337 (USPSTF Grade B) Therefore, a visual acuity screen (LEA
symbol or letter optotype) performed by rooming staff is recommended at age 5 years, or in cooperative 3 or
4 year olds.335 The Allen figures, Lighthouse characters, and the Sail Boat chart are not standardized and
no longer recommended by the American Academy of Pediatrics.335 If the patient is uncooperative and the
test cannot be completed, vision screening may be rescheduled for the next Well Child exam.

Alternatively, instrument based screening devices for vision screening are available commercially and have
had extensive validation, both in field studies and, more recently, in the pediatrician’s offices. Screening
instruments detect amblyopia, high refractive error, and strabismus, which are the most common conditions
producing visual impairment in children. If available, they can be used at any age but have better success
after 18 months of age. Instrument- based screening can be repeated at each annual preventive medicine
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encounter through 5 years of age or until visual acuity can be assessed reliably using optotypes.334 (UW
Health Moderate quality evidence, weak/conditional recommendation)

Patients age 6-18 years
Vision acuity screening tests and additional ophthalmic assessments should be completed once during the
following age ranges to detect the presence of myopia: 6-8 years, 10-12 years, 13-15 years, and 16-18
years. (UW Health Very low quality evidence, strong recommendation) The visual acuity screen should be
completed using the Snellen chart. Additional ophthalmic assessments include ocular history, ocular
alignment and motility assessment, and an ocular examination consisting of an external examination, pupil
examination, red reflex testing, and ocular fundus examination with ophthalmoscope.334,335

These recommendation are consistent with the 2013 American Academy of Family Physicians (AAFP)
report338 for pediatric vision screening every 1-2 years after the age of 5 years; however they are slightly
discrepant from previously published guidelines which indicate screening at ages 3, 4, 5, 6, 8, 10, 12, and
15 years.31,32 Illinois statute SB0641 requires an eye exam as part of a health examination upon entering
fifth and ninth grades, or irrespective of grade, immediately prior to or upon entrance into any public, private,
or parochial nursery school.

Patient Resources
1. Healthwise: Vision Tests: General Info

WELL CHILD VISIT FREQUENCY
Return to Infant/Child Table | Return to Adolescent Table
Well Child Checks
All infants discharged on the first or second postpartum day need to be seen within 48 hours of discharge.
This is a state requirement for children who are Medicaid or HealthCheck eligible.

Well Child visits should occur at 2, 4, 6, 9, 12, 15, 18, 24 months, annually between ages 3-6 years and
every 1-2 years between the ages of 7-17 years.31,32 (UW Health Low quality evidence, strong recommendation)
It is recommended to consider patient privacy (absence of parent or guardian in the room) beginning at age
12 (or as developmentally appropriate) when discussing sensitive topics such as sexual activity, drug or
alcohol use, mental health symptoms, etc.339,340 (UW Health Very low quality evidence, strong recommendation)

Patient Resources
1. Healthwise: Well Visit: Pediatric: Birth to 4 Weeks
2. Healthwise: Well Visit: 1 Week: Pediatric
3. Healthwise: Well Visit: Pediatric: 2 Months
4. Healthwise: Well Visit: Pediatric: 4 Months
5. Healthwise: Well Visit: Pediatric: 6 Months
6. Healthwise: Well Visit: Pediatric: 9 to 10 Months
7. Healthwise: Well Visit: Pediatric: 12 Months
8. Healthwise: Well Visit: Pediatric: 14 to 15 Months
9. Healthwise: Well Visit: Pediatric: 18 Months
10. Healthwise: Well Visit: Pediatric: 24 Months
11. Healthwise: Well Visit: Pediatric: 30 Months
12. Healthwise: Well Visit: Pediatric: 3 Years
13. Healthwise: Well Visit: Pediatric: 4 Years
14. Healthwise: Well Visit: Pediatric: 5 Years
15. Healthwise: Well Visit: Pediatric: 6 Years
16. Healthwise: Well Visit: Pediatric: 7 to 8 Years
17. Healthwise: Well Visit: Pediatric: 9 to 11 Years
18. Healthwise: Well Visit: Pediatric: Young Teen

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UW Health Implementation
Potential Benefits:
ξ Systematic approach to screening for and identifying preventive diseases.
ξ Appropriate use of a comprehensive approach of preventive services (counseling,
education, and disease screening) for average risk, asymptomatic patients will result in an
increase in patients who are up to date with preventive services.
ξ Decreased mortality rates from preventive diseases.

Potential Harms:
ξ Screening tests may lead to potential harms including false-positives, over diagnosis,
unnecessary biopsies or surgery, and patient anxiety.

Qualifying Statements: This guideline is NOT intended to diagnose or treat any condition.
Once a health issue or condition has been uncovered, other guidelines and clinical policies and
practice will take precedence during any further diagnosis and management.

Note: Any referenced materials outside this guideline are for supplemental informational
purposes only. Their mention in this guideline does not imply full agreement of all
positions represented in those documents. To the extent that referenced materials
appear to conflict with this guidelines’ recommendations, the positions described in this
document are the ones believed to be most appropriate for UW Health.

Pertinent UW Health Policies & Procedures
See Topic-specific sections within the Recommendations

Patient Resources*
1. Health Information Interactive Tool: Which Health Screenings Do You Need?

*See additional topic-specific resources within the Recommendations section above.

Guideline Metrics

ACO Metrics:
1. Breast Cancer Screening
2. Colorectal Cancer Screening
3. Falls: Screening for Future Fall Risk
4. Pneumococcal Vaccination Status for Older Adults
5. Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
6. Preventive Care and Screening: Influenza Immunization
7. Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan
8. Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented
9. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
10. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

WCHQ Metrics:
1. Chronic Care- Diabetes: Most Recent Tobacco Status is Tobacco-Free
2. Chronic Care- Ischemic Vascular Disease: Most Recent Tobacco Status is Tobacco-Free
3. Preventive Care- Adolescent Immunization Status
4. Preventive Care- Adult Body Mass Index (BMI) Screening Annually
5. Preventive Care- Breast Cancer Screening
6. Preventive Care- Cervical Cancer Screening
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7. Preventive Care- Childhood Immunization Status
8. Preventive Care- Colorectal Cancer Screening
9. Preventive Care- Screening for Clinical Depression
10. Preventive Care- Screening for Osteoporosis
11. Preventive Care- Adults with Pneumococcal Vaccinations
12. Preventive Care- Tobacco User Receiving Tobacco Cessation Advice
Implementation Plan/Clinical Tools
1. Guideline will be housed on uConnect and uwhealth.org in a dedicated location for guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter and presented at
division/department meetings (e.g., DFM, GIM, GPAM).
3. Content of the UW Health Screening, Prevention & Wellness website (uwhealth.org) will be reviewed and
updated as necessary, including any other publicly-facing websites.
4. Links to the guideline will be updated and/or added in appropriate Health Link or equivalent tools and
content will be reviewed for consistency, including:

Smart Sets
ξ Preventive Screening- Adult HM [4351]
ξ Preventive Screening- Pediatric HM [5128]
ξ Welcome to Medicare [139]
ξ Annual Wellness Visit-Medicare [4148]
ξ Lead Screening [2984]
ξ Chlamydia Screening [167]
ξ Depression [77]
ξ Depression-ACHC [154]
ξ Adult Fall Risk [5097]
ξ Passive Smoking Exposure [5326]
ξ Well Child 0-1 Month [148]
ξ Well Child 2 Month [104]
ξ Well Child 4 Month [224]
ξ Well Child 6 Month [225]
ξ Well Child 9 Month [192]
ξ Well Child 12 Month [103]
ξ Well Child 15 Month [105]
ξ Well Child 18 Month [226]
ξ Well Child 24 Month [121]
ξ Well Child 30 Month [4780]
ξ Well Child 3 Year [223]
ξ Well Child 4 Year [106]
ξ Well Child 5 Year [222]
ξ Well Child 6 Year [4857]
ξ Well Child 7-8 Years [107]
ξ Well Child 9-10 Years [4783]
ξ Well Child 11-14 Years [221]
ξ Well Child 15-17 Year [204]
ξ Well Young Adult 18-21 Year [4788]
ξ Pediatric Well Child and Development Followup [5065]

Health Maintenance (HM) Topics
ξ Anemia Lab Screening [56]
ξ Bone Mineral Density [18]
ξ Breast Cancer Screening Mammogram [30]
ξ Cervical Cancer Screening Pap Smear [10]
ξ Colon Cancer Screening Colonoscopy [9]
ξ Colon Cancer Screening FOBT [11]
ξ Dtap Vaccination [44]
ξ Hepatitis A Vaccination [52]
ξ Hepatitis B Vaccination [50]
ξ HIB Vaccination [42]
ξ HPV Vaccination [46]
ξ Influenza Vaccination [22, 65]
ξ IPV Vaccination [51]
ξ Lead Screening [57]
ξ Lipid Screening [25]
ξ Lipid Screening- Peds [60]
ξ Meningococcal Vaccination [53]
ξ MMR Vaccination [49]
ξ Pneumococcal Vaccination [26]
ξ Pneumococcal Vaccination- Peds [43]
ξ Rotavirus Vaccination [45]
ξ TD/TDAP Vaccination [23]
ξ TD/TDAP Vaccination- Peds [47]
ξ Varicella Vaccination [48]

Best Practice Alerts (BPA)
ξ Chlamydia [20]
ξ Pediatric Blood Pressure >/= 95th Percentile [1001089]
ξ Elevated Blood Pressure or Goal Not Met [10123456]
ξ ASQ [1001420]
ξ MCHAT [1001431]
ξ Well Child Visit [1001314, 1001312]
ξ Pregravid Weight Gain [1001940, 1001941, 1001942,
1001943, 2245, 2247, 2246, 2391]
ξ Screening Mammography Assessment [1001170]

Delegation Protocols
ξ Immunization Ordering – Adult/Pediatric – Ambulatory [56]
ξ Influenza Screening and Treatment – Adult/Pediatric – Ambulatory [133]
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ξ Fluoride Varnish – Pediatric – Ambulatory [91]
ξ Laboratory Screening and Chronic Disease Monitoring Laboratory Test Ordering – Adult/Pediatric – Ambulatory- Primary Care [93]
ξ Referral to Wisconsin Tobacco Quit Line – Adult – Ambulatory [130]
ξ Tuberculin (TB) Skin Test Ordering – Adult/Pediatric – Ambulatory [92]

Related UW Health Clinical Practice Guidelines
ξ UW Health Alcohol Assessment and Intervention – Adult/Pediatric – Inpatient/Ambulatory
ξ UW Health Assessment of Tobacco Use or Secondhand Exposure and Cessation – Pediatric/Adult – Inpatient/Ambulatory
ξ UW Health Diagnosing and Treating Depression – Adult/Pediatric – Ambulatory
ξ UW Health Diagnosis and Management of Hypertension – Adult – Ambulatory
ξ UW Health MRI Screening in Patients at Increased Risk of Breast Cancer – Adult – Ambulatory
ξ UW Health Prevention and Management of Obesity – Adult – Ambulatory
ξ UW Health Prevention and Management of Obesity – Pediatric – Ambulatory
ξ UW Health Standard Primary Care Rooming Criteria – Pediatric/Adult – Ambulatory
ξ UW Health Standards of Medical Care in Diabetes – Adult/Pediatric – Inpatient/Ambulatory


Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and treatment of
patients. This guideline outlines the preferred approach for most patients. It is not intended to replace a
clinician’s judgment or to establish a protocol for all patients. It is understood that some patients will not fit the
clinical condition contemplated by a guideline and that a guideline will rarely establish the only appropriate
approach to a problem.

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Appendix A. Topic-Specific Workgroup Membership

Abdominal Aortic Aneurysm
Jon Matsumura, MD – Surgery- Vascular Surgery
Kyla Bennett, MD- Surgery- Vascular Surgery
Matt Anderson, MD- General Internal Medicine
Briana Jelenc, MD- General Internal Medicine
Elizabeth Chapman, MD - Medicine- Geriatrics
Nancy Bell – Echo/Vascular Lab Manager
Dana Walker – Radiology Manager

Alcohol Use
See UW Health Alcohol Assessment and Intervention – Adult/Pediatric – Ambulatory Guideline

Aspirin for Primary Prevention
Jim Stein, MD – Cardiology
Mark Micek, MD – General Internal Medicine
Briana Jelenc, MD – General Internal Medicine
Danalyn Rayner, MD- Family Medicine
Tammy Homman, MD- Family Medicine (Swedish
American Health System)
Anne Rose, PharmD - Pharmacy
Carin Endres, PharmD – Drug Policy Program
Vanessa Grapsas, PharmD- Pharmacy
Luiza Kerstenetzky, PharmD- Pharmacy

Breast Cancer
Lee Wilke, MD – General Surgery
Elizabeth Burnside, MD – Radiology
Amy Fowler, MD – Radiology
Frederick Kelcz, MD - Radiology
Marc Bernstein, MD- Radiology (SwedishAmerican
Health System)
Joanna Ruchala, MD – General Internal Medicine
Deb Boushea, MD – General Internal Medicine
Sarina Schrager, MD – Family Medicine
Elizabeth Chapman, MD – Medicine- Geriatrics
Aaron Zivney, MD – Family Medicine (Gundersen
Health System)
Gillian Schroeder – Oncology Administration
Carol Hassemer – Clinical Operations
Katie Jungers- Radiology Manager
Adrea Bennett- Manager (SwedishAmerican Health
System)
Lori Bue - Family Medicine Clinic Operations

Cervical Cancer
Sarina Schrager, MD – Family Medicine
Katherine Porter, MD- Family Medicine
Kelly Herold, MD – General Internal Medicine
Kristin Lewicki, MD – General Internal Medicine
Eliza Bennett, MD – OB/GYN- General
Angelean Wotruba – Clinical Labs- Cytology

Cognitive Screening
Deb Boushea, MD – General Internal Medicine
Elizabeth Chapman, MD – Medicine - Geriatrics
Alexis Eastman, MD – Medicine- Geriatrics
Robert Przybelski, MD – Medicine- Geriatrics
Sanjay Asthana, MD - Medicine- Geriatrics
Nathanial Chin, MD – Medicine- Geriatrics
Art Walaszek, MD - Psychiatry

Colorectal Cancer
Perry Pickhardt, MD – Radiology
Pat Pfau, MD – Gastroenterology
Jennifer Weiss, MD – Gastroenterology
Sam Lubner, MD – Hematology/Oncology
Kirsten Rindfleisch, MD – Family Medicine
Derek Hubbard, MD – Family Medicine
Snigdha Volety, MD – Family Medicine (Swedish
American Health System)
David Feldstein, MD – Internal Medicine
Matt Anderson, MD – Internal Medicine
Teresa Darcy, MD – Pathology- General
Leanne Preston- Clinical Labs
Lori Bue – Clinic Operations
Aimee Arnoldussen, PhD – CCKM
Lisa Brunette – Marketing and Public Affairs
Nicole Barreau – Marketing and Public Affairs
Elaine Rosenblatt – Unity Health Insurance
Mark Micek, MD – Internal Medicine
Jeff Huebner, MD – Family Medicine


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Depression
See UW Health Diagnosing and Treating Depression – Adult/Pediatric – Ambulatory Guideline

Diabetes
See UW Health Standards of Medical Care in Diabetes – Adult/Pediatric – Inpatient/Ambulatory Guideline

Falls Risk
Jane Mahoney, MD – Medicine- Geriatrics
Gerald Pankratz, MD – Medicine- Geriatrics
Irene Hamrick, MD – Family Medicine
David Erickson, MD – Internal Medicine
Jodi Janczewski, PT – Neurorehabilitation
Elizabeth Chapman, MD – Medicine- Geriatrics
Sara Shull, PharmD- Drug Policy Program
Janis Lindsey, NP – Medicine- Geriatrics
Anne Rose, PharmD- Anticoagulation

Hepatitis B and C
Kristin Lewicki, MD – General Internal Medicine
John Rice, MD – Gastroenterology
Jonas Lee, MD – Family Medicine

Hypertension
Pediatric: See UW Health Standard Primary Care Rooming Criteria – Adult/Pediatric – Ambulatory Guideline
Adult: See UW Health Diagnosis and Management of Hypertension – Adult – Ambulatory Guideline

Immunizations
James Conway, MD – Pediatrics - Infectious Disease
Jon Temte, MD – Family Medicine
Prasanna Raman, MD – Pediatrics
Kim Zielke- Pediatrics Clinic Operations
Elaine Rosenblatt – Unity Health Insurance
Josh Vanderloo, PharmD – Drug Policy Program
Sandy Jacobson - Director Pediatric Clinical
Operations

Intimate Partner Violence
Sarina Schrager, MD- Family Medicine
Jeff Huebner, MD- Family Medicine
Paula Cody, MD- Pediatrics (Adolescent Medicine)
Lorna Belsky, MD- Internal Medicine
Kathy Chambers, MA LPC- Patient Resources
Elizabeth Boyle- Social Work
Linda Stevens- Nursing
Allison Olenski- CCKM

Lipids
Patrick McBride, MD – Cardiology
Matthew Tattersall, MD - Cardiology
Michael Thom, MD – Internal Medicine
Matthew Anderson, MD –Internal Medicine
Michelle Bryan, MD – Family Medicine
Sarah Hackenmueller, PhD – Pathology- General
Prasana Raman, MD – Pediatrics
Troy Kleist, MD – Pediatrics
Erin Marriott, APNP – Pediatric Cardiology

Lung Cancer
Mark Schiebler, MD – Radiology
J. Scott Ferguson, MD – Pulmonary Medicine
Ticana Leal, MD – Hematology/Oncology
Jeff Kanne, MD - Radiology
Kirsten Rindfleisch, MD – Family Medicine
Kelly Herold, MD – Internal Medicine
Ann Schmidt, MD – Internal Medicine
Kari Pulfer – Radiology Manager

Obesity/BMI
Pediatric: See UW Health Prevention and Management of Obesity – Pediatric – Ambulatory Guideline
Adult: See UW Health Prevention and Management of Obesity – Adult – Ambulatory Guideline

Osteoporosis
Neil Binkley, MD – Medicine-Geriatrics
Elizabeth Chapman, MD – Medicine-Geriatrics
Sarina Schrager, MD – Family Medicine
Jeff Huebner, MD – Family Medicine
Matt Anderson, MD – Internal Medicine
Kristyn Hare, PA – Ortho/Rehab- Ortho General
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Mark Micek, MD- Internal Medicine
Lori Bue- Clinic Operations
Jennifer Kuroda- SwedishAmerican


Pediatrics
Prasanna Raman, MD – Pediatrics
Troy Kleist, MD – Pediatrics
Paula Cody, MD – Pediatrics (Adolescent Medicine)
Maria Stanley, MD – Pediatrics (Child Development)
Gregg Heatley, MD – Ophthalmology
Michael Struck, MD – Ophthalmology
Tom Schiller, MD – Family Medicine
(SwedishAmerican Health System)
James Bigham, MD- Family Medicine

Prostate Cancer
David Jarrard, MD – Urology
Mark Micek, MD – Internal Medicine
Jonas Lee, MD – Family Medicine

Skin Cancer
Apple Bodemer, MD – Dermatology
Mark Albertini, MD – Oncology
Heather Neuman, MD – Surgery
Kirsten Rindfleisch, MD – Family Medicine
Mark Micek, MD – Internal Medicine
Linda Razbadouski, MD – Internal Medicine
(SwedishAmerican Health System)
Prasanna Raman, MD - Pediatrics

Sexually Transmitted Disease
Kara Hoppe, MD – OB/GYN
Kristin Lewicki, MD – Internal Medicine
Paula Cody, MD – Pediatrics (Adolescent Medicine)
KDerrick Chen, MD – Pathology- General
Rose Staden, NP – Medicine- Infectious Disease
Elaine Rosenblatt – Unity Health Insurance
Josh Vanderloo, PharmD – Drug Policy Program
Luke Schulz, PharmD – Pharmacy

Tobacco Use
See UW Health Assessment of Tobacco Use or Secondhand Exposure and Interventions for Tobacco
Cessation – Adult/Pediatric – Inpatient/Ambulatory Guideline

Additional Steering Committee Members (Operational Support)
Jennifer Kuroda- Quality Improvement Manager (SwedishAmerican Health System)
Lisa Brunette- Marketing and Public Affairs
Lori Bue- Ambulatory Operations
Kara Kropelin- UW IS- Clinical Systems
Melissa Perkins, MSN, RN- Nurse Manager, Patient and Family Education
Deb Dunham, RPh- Center for Clinical Knowledge Management (CCKM)
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Janna Lind, RN- Center for Clinical Knowledge Management (CCKM)
Chris Nemergut, PharmD- Center for Clinical Knowledge Management (CCKM)
Kris Hahn, PharmD- Center for Clinical Knowledge Management (CCKM)
Chad Warner- Center for Clinical Knowledge Management (CCKM)

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Appendix B. High Risk Recommendations
Patients who exhibit one or more of the following high risk factors are no longer considered average risk, and
fall outside the scope of this guideline. These patients may require more frequent preventive screening,
therefore suggested actions are provided to guide primary care physicians in the proper referral and treatment
of identified patients.
BREAST CANCER- HIGH RISK
The UW Health Prevention and Tailored Health Screening (PATHS) clinic exists to screen, counsel, treat, and
follow patients at a high risk for the development of breast malignancies.

High Risk Factors341
(For the purpose of these guidelines, DCIS is considered breast cancer)
Breast Cancer Screening
Recommendations
Women with a family history of any of the following:
ξ A known breast cancer gene mutation in the family
ξ First or second-degree relative with breast cancer diagnosed < age 45
ξ First or second-degree relative with ovarian/fallopian tube/primary
peritoneal cancer
ξ First or second-degree relative with male breast cancer
ξ Two or more breast cancers diagnosed at any age among first, second, or
third-degree relatives on the same side of the family (maternal or
paternal). This can include two primary breast cancers in one relative.
ξ A family history of breast cancer at any age AND any one of the following
in a first, second, or third-degree relative on the same side of the family
(maternal or paternal): pancreatic cancer, prostate cancer (Gleason > 7),
sarcoma, adrenocortical carcinoma, brain tumor, endometrial cancer,
leukemia, lymphoma, diffuse gastric cancer, thyroid cancer,
macrocephaly, hamartomatous GI polyps, trichilemmomas, palmoplantar
keratosis, oral mucosal papillomatosis, or other unusual dermatologic
findings
ξ Ashkenazi Jewish ancestry and any family history of breast or ovarian
cancer in first, second, or third-degree relatives
Further genetic risk
evaluation is recommended.
Patient should be referred
to PATHS clinic.
Personal history of breast cancer
(including invasive ductal, lobular, and DCIS)
Annual screening unless
otherwise recommended by
oncology physicians.
Breast biopsy with atypia or LCIS
Complete annual screening
unless indicated by
oncology physicians; should
be referred to PATHS clinic.
Prior chest wall radiation between the ages of 10-30 for treatment of cancer
(Hodgkin’s)
Complete annual screening
at 8 years post therapy or
age 40; patient should be
referred to PATHS clinic.
First-degree: parents, siblings, children
Second-degree: grandparents, aunts, uncles, nieces, nephews, grandchildren, half-siblings
Third-degree: great-grandparents, great-aunts, great-uncles, great-grandchildren, first cousins

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CERVICAL CANCER- HIGH RISK

High Risk Factor Cervical Cancer Screening Recommendations84,86
Immunosuppression
(HIV positive, transplant,
etc.)
Cervical cancer screening in immunosuppressed populations has been
debated and insufficiently investigated except in the HIV-infected
population, but some evidence suggests that risks of cervical cancer in
immunocompromised patients are equal to that of HIV infected
patients.342,343 (UW Health Low Quality Evidence, strong recommendation)

Women Aged 29 years and younger343:
ξ If younger than age 21, known to be immunocompromised or
newly diagnosed, and sexually active, screen within 1 year.
ξ Immunocompromised women aged 21-29 should have cytology
testing following initial diagnosis
ξ Cytology should be done at baseline and every 12 months
ξ Some experts recommend cytology 6 months after baseline test
ξ If results of 3 consecutive Pap tests are normal, follow-up tests
can be performed every 3 years.
ξ Co-testing (cytology and HPV test) is not recommended for
women younger than 30.

Women Aged 30 years and older343:
Cytology only:
ξ Cytology should be done at baseline and every 12 months
ξ Some experts recommend cytology 6 months after baseline test.
ξ If results of 3 consecutive Pap tests are normal, follow-up tests
can be performed every 3 years.
Or:
Cytology and HPV Co-Testing:
ξ Cytology and HPV co-testing should be done at baseline
ξ If result of the cytology is normal and HPV co-testing is negative,
follow-up cytology and HPV co-testing can be performed every 3
years.
ξ If the result of the cytology is normal but HPV co-testing is
positive, follow up test with cytology and HPV co-testing should
be performed in one year.
ξ If the one year follow-up cytology is abnormal or HPV co-testing
is positive, referral to colposcopy is recommended.

Cervical cancer screening in immunosuppressed women should
continue throughout a woman’s lifetime (and not, as in the general
population, end at 65 years of age).342-344
History of diethylstilbestrol
(DES) exposure
Colposcopy may be considered during an initial exam. If the
colposcopic exam is abnormal, repeat annually with four-quadrant Pap
test. If the colposcopic exam is normal, perform annual examinations
including cytology sampling of endocervical, ectocervical and vaginal
fornices cells (four-quadrant Pap test).345,346 (UW Health Very low quality
evidence, strong recommendation)
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High Risk Factor Cervical Cancer Screening Recommendations84,86
History of CIN 2, 3
Patients up to age 21 years
Observation over intervention is recommended for CIN 2. Patients with
CIN 3 should be treated.89 (UW Health Very low quality evidence, strong
recommendation)

Patients 21-24 years
Either treatment or observation is acceptable, provided colposcopy is
adequate. (UW Health Very low quality evidence, strong recommendation) When
CIN 2 is specified, observation is preferred (see additional ASCCP
recommendations based upon results during observation).94 (UW Health
Very low quality evidence, strong recommendation)

When CIN 3 is specified, or colposcopy is inadequate, treatment using
excision or ablation of T-zone is preferred.94(UW Health Very low quality
evidence, strong recommendation)

Patients 25 years or older
After appropriate treatment of CIN 2,3 and complete co-testing at 12 and
24 months with gynecology. Co-testing should be performed at 3 years
later then resume age appropriate routine screening for at least 20
years.94 (UW Health Very low quality evidence, strong recommendation)
Positive HPV result or
infection with negative
cytology
Patients up to age 29 years
Due to the high prevalence of human papillomavirus (HPV) in
adolescents, HPV testing is not recommended.85,87-89 (USPSTF Grade
D)

In the absence of abnormal cytology, observation over intervention is
recommended88, as more than 90% of HPV infections regress within 3
years.89 (UW Health Very low quality evidence, strong recommendation)

Patients 30 years or older
Either repeat co-testing in 12 months or complete an immediate HPV
genotype-specific testing for HPV16 alone or HPV16/18 (see additional
ASCCP recommendations based upon test result).87,94(UW Health Low
quality evidence, strong recommendation)


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75
COLORECTAL CANCER- HIGH RISK

High Risk Factors Colorectal Cancer Screening Recommendations112,113,135,140,147,148
One first-degree relative* with colorectal
cancer diagnosed before age 60 years
Colonoscopy** every five years beginning at age 40 or
10 years before the age of the youngest case in the
immediate family. (UW Health Moderate quality evidence,
weak/conditional recommendation)
Two or more first-degree relatives* diagnosed
at any age with colorectal cancer
Colonoscopy** every five years beginning at age 40 or
10 years before the age of the youngest case in the
immediate family. (UW Health Moderate quality evidence,
weak/conditional recommendation)
First-degree relative* with colorectal cancer at
greater than or equal to 60 years, or two
second-degree relatives with colorectal cancer
The workgroup recognizes this imposes an increased
risk; however, due to lack of evidence supporting more
frequent screening recommendations, routine
screening is recommended. (UW Health Low quality
evidence, weak/conditional recommendation)
Inflammatory bowel disease, chronic ulcerative
colitis and Crohn’s disease
Colonoscopy every one to two years starting eight
years after the onset of pancolitis or 12 to 15 years
after the onset of left-sided colitis. (UW Health Moderate
quality evidence, weak/conditional recommendation)
Genetic diagnosis of familial adenomatous
polyposis (FAP) or suspected FAP without
genetic testing evidence
Annual flexible sigmoidoscopy beginning at age 10 to
12 years, along with genetic counseling. (UW Health
Moderate quality evidence, weak/conditional
recommendation)
Genetic or clinical diagnosis of hereditary
nonpolyposis (Lynch Syndrome) colorectal
cancer
Colonoscopy every one to two years beginning at age
20 to 25 years or 10 years before the age of the
youngest case in the immediate family. (UW Health
Moderate quality evidence, weak/conditional
recommendation)
* First-degree relatives include only parents, siblings, and children.

** CT colonography may be considered as an alternative in high risk patients with family history who are
unable to undergo or refuse colonoscopy (P. Pickhardt et al., unpublished data, 2016) (UW Health Very
low quality evidence, weak/conditional recommendation)



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76
Appendix C. The Five P’s for Sexually Transmitted Disease Screening

The Five P’s: Partners, Practices, Prevention of Pregnancy, Protection from STDs, and Past History of STDs95

Partners
“Do you have sex with men, women, or both?”
“In the past 2 months, how many partners have you had sex with?”
“In the past 12 months, how many partners have you had sex with?”
“Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were
still in a sexual relationship with you?”
Practices
“To understand your risks for STDs, I need to understand the kind of sex you have had recently.”
“Have you had vaginal sex, meaning ‘penis in vagina sex’?”
If yes, “Do you use condoms: never, sometimes, or always?”
“Have you had anal sex, meaning ‘penis in rectum/anus sex’?”
If yes, “Do you use condoms: never, sometimes, or always?”
“Have you had oral sex, meaning ‘mouth on penis/vagina’?”
If yes, “Do you use condoms: never, sometimes, or always?”

For condom answers:
If “never”: “Why don’t you use condoms?”
If “sometimes”: “In what situations (or with whom) do you use condoms?”
Prevention of Pregnancy
“What are you doing to prevent pregnancy?”
Protection from STDs
“What do you do to protect yourself from STDs and HIV?”
Past History of STDs
“Have you ever had an STD?”
“Have any of your partners had an STD?”
Additional Questions to Identify HIV and Viral Hepatitis Risk
“Have you or any of your partners ever injected drugs?”
“Have you or any of your partners exchanged money or drugs for sex?”
“Is there anything else about your sexual practices that I need to know about?”


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77
Appendix D. Rating Schemes for the Strength of the Evidence/Recommendations

U.S. Preventive Services Task Force (USPSTF)

USPSTF Ranking of Evidence
Level of
Certainty*
High
The available evidence usually includes consistent results from well-designed, well-conducted studies in
representative primary care populations. These studies assess the effects of the preventive service on
health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future
studies.
Moderate
The available evidence is sufficient to determine the effects of the preventive service on health outcomes,
but confidence in the estimate is constrained by such factors as:
ξ The number, size, or quality of individual studies.
ξ Inconsistency of findings across individual studies.
ξ Limited generalizability of findings to routine primary care practice.
ξ Lack of coherence in the chain of evidence.
As more information becomes available, the magnitude or direction of the observed effect could change,
and this change may be large enough to alter the conclusion.
Low
The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient
because of:
ξ The limited number or size of studies.
ξ Important flaws in study design or methods.
ξ Inconsistency of findings across individual studies.
ξ Gaps in the chain of evidence.
ξ Findings not generalizable to routine primary care practice.
ξ Lack of information on important health outcomes.
More information may allow estimation of effects on health outcomes.
* The USPSTF defines certainty as "likelihood that the USPSTF assessment of the net benefit of a preventive service is correct." The net benefit is
defined as benefit minus harm of the preventive service as implemented in a general, primary care population. The USPSTF assigns a certainty level
based on the nature of the overall evidence available to assess the net benefit of a preventive service.

USPSTF Grades for Recommendations
Grade Definition
A The USPSTF recommends the service. There is high certainty that the net benefit is
substantial.
B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
C
The USPSTF recommends selectively offering or providing this service to individual
patients based on professional judgment and patient preferences. There is at least
moderate certainty that the net benefit is small.
D The USPSTF recommends against the service. There is moderate or high certainty that
the service has no net benefit or that the harms outweigh the benefits.
I Statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and
the balance of benefits and harms cannot be determined.



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78
Grading of Recommendations Assessment, Development and Evaluation (GRADE)

Figure 1: GRADE Methodology adapted by UW Health

GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances are unlikely to
affect the decision.
Weak/conditional Recommendation may be conditional upon patient values and preferences, the resources
available, or the setting in which the intervention will be implemented.

U.S. Department of Health and Human Services (HHS)

HHS Grading Scheme
A Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a consistent
pattern of findings.
B Some evidence from randomized clinical trials supported the recommendation, but the scientific support was not
optimal.
C Reserved for important clinical situations in which the Panel achieved consensus on the recommendation in the
absence of relevant randomized clinical trials.





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79
American Geriatrics Society (AGS)

AGS Grading Scheme
A
A strong recommendation that the clinicians provide the intervention to eligible patients.
Good evidence was found that the intervention improves health outcomes and the conclusion is that
benefits substantially outweigh harm.
B
A recommendation that clinicians provide this intervention to eligible patients.
At least fair evidence was found that the intervention improves health outcomes and the conclusion is
that benefits outweigh harm.
C
No recommendation for or against the routine provision of the intervention is made.
At least fair evidence was found that the intervention can improve health outcomes, but the balance of
benefits and harms is too close to justify a general recommendation.
D Recommendation is made against routinely providing the intervention to asymptomatic patients. At
least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.
I
Evidence is insufficient to recommend for or against routinely providing the intervention. Evidence that
the intervention is lacking, or of poor quality, or conflicting, and the balance of benefits and harms
cannot be determined.

American Diabetes Association (ADA)

ADA Grading Scheme
Level of
Evidence Description
A
Clear evidence from well-conducted, generalizable RCTs that are adequately powered, including:
ξ Evidence from a well-conducted multicenter trial
ξ Evidence from a meta-analysis that incorporated quality ratings in the analysis

Compelling non-experimental evidence, i.e., “all or none” rule developed by the Center for Evidence-Based
Medicine at the University of Oxford

Supportive evidence from well-conducted RCTs that are adequately powered, including:
ξ Evidence from a well-conducted trial at one or more institutions
ξ Evidence from a meta-analysis that incorporated quality ratings in the analysis
B
Supportive evidence from well-conducted cohort studies
ξ Evidence from a well-conducted prospective cohort study or registry
ξ Evidence from a well-conducted meta-analysis of cohort studies

Supportive evidence from a well-conducted case-control study
C
Supportive evidence from poorly controlled or uncontrolled studies
ξ Evidence from randomized clinical trials with one or more major of three or more minor
methodological flaws that could invalidate the results
ξ Evidence from observational studies with high potential for bias (such as case series with comparison
with historical controls)
ξ Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E Expert consensus or clinical experience




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80
National Heart, Lung, and Blood Institute (NHLBI)

NHLBI Grading Scheme
Grade Strength of Recommendation*
A Strong recommendation There is high certainty based on evidence that the net benefit† is substantial.
B
Moderate recommendation
There is moderate certainty based on evidence that the net benefit is moderate to substantial, or there is high
certainty that the net benefit is moderate.
C Weak recommendation There is at least moderate certainty based on evidence that there is a small net benefit.
D
Recommendation against
There is at least moderate certainty based on evidence that it has no net benefit or that risks/harms outweigh
benefits.
E
Expert opinion (“There is insufficient evidence or evidence is unclear or conflicting, but this
is what the Work Group recommends.”)
Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient
evidence, unclear evidence, or conflicting evidence, but the Work Group thought it was important to provide
clinical guidance and make a recommendation. Further research is recommended in this area.
N
No recommendation for or against (“There is insufficient evidence or evidence is unclear or
conflicting.”)
Net benefit is unclear. Balance of benefits and harms cannot be determined because of no evidence, insufficient
evidence, unclear evidence, or conflicting evidence, and the Work Group thought no recommendation should be
made. Further research is recommended in this area.
*In most cases, the strength of the recommendation should be closely aligned with the quality of the evidence; however, under some circumstances,
there may be valid reasons for making recommendations that are not closely aligned with the quality of the evidence (e.g., strong recommendation when
the evidence quality is moderate, like smoking cessation to reduce CVD risk or ordering an ECG as part of the initial diagnostic work-up for a patient
presenting with possible MI). Those situations should be limited and the rationale explained clearly by the Work Group.

†Net benefit is defined as benefits minus risks/harms of the service/intervention.


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81
Appendix E. Interim Revisions
Date Summary of Change(s) Page(s)
05/2017 Addition of osteoporosis screening recommendations
05/2017 Reconciliation of diabetes screening recommendations with Diabetes Guideline








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82
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