Preventive Care Recommendations Research Articles

Correction to "Preventive care recommendations to promote health equity".

Correction to "Preventive care recommendations to promote health equity".

Preventive care recommendations to promote health equity.

Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages. The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders. We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-γ release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages. Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada.

Assessing the effects of pharmacist education on colorectal cancer screening and access to a stool-based DNA test

BackgroundColorectal cancer is the third most common cancer and is anticipated to cause 52,580 deaths in 2022 in the United States. Despite the effectiveness of colorectal cancer screening (CRCS), only 74% of adults eligible for CRCS complete the screening. Community pharmacists are well positioned to provide preventive care education and recommendations to the general population. ObjectivesThis study aimed to evaluate overall participants’ knowledge, perceptions, and barriers on CRCS before and after receiving pharmacist-led education in the outpatient, community pharmacy setting and to assess the impact of pharmacist intervention on screening uptake with the stool-based DNA test. MethodsA 16-item prequestionnaire/postquestionnaire was administered by clinical pharmacists in a grocery store pharmacy chain in the Kansas City area. The questionnaire assessed participants’ knowledge, perceptions, barriers, CRCS intentions, and demographics. After completing the prequestionnaire, participants received verbal and written education. For those participants interested in the stool-based DNA test, a facsimile transmission was sent to the participant’s provider. The postquestionnaire was administered by the pharmacist coach at visit two 6 to 10 weeks later. Participant demographics were assessed using descriptive statistics. Wilcoxon signed rank test was used to assess prechanges/postchanges in perceptions, awareness, and knowledge. We reported the stool-based DNA test completion rate as an overall percentage. ResultsParticipants' knowledge of CRCS reached statistical significance after pharmacist-led education (score 4.5-6, P = 0.003). There was no change in perception pre/post. The 3 most common reported barriers were cost of screening, not being concerned with colon cancer, and lack of follow-up from a physician. Of 42 participants, 23 (54.8%) were indicated for CRCS and 4 (17%) completed screening during the study. ConclusionNot all eligible participants completed CRCS, but pharmacists improved participants’ knowledge of CRCS.

Risk perception about the covid-19 pandemic and its effect on self-medication practices in population of northwestern Mexico

The objective of the present study was to analyze the effect of the risk perception of covid-19 on self-medication practices in Mexican population. A total of 526 participants over 18 years of age were surveyed, 68.4% women and 31.6% men residing in northwestern Mexico. Using a structural model, the relation and prevalence of self-medication were analyzed. Risk perception about covid-19, consisting of preventive practices and the perception of the threat of the pandemic, was negatively correlated with self-medication practices, which indicates that people who follow preventive care recommendations tend to reduce the use of self-medication and to improve emotional selfmedication. Furthermore, the study shows that at least half of the participants have used drugs during the pandemic without medical prescription. Self-medication is a critical health problem; therefore, awareness programs about the adverse effects of medications can help reduce self-medication practices in Mexico.

Connecting Patient and Provider Burnout to Eye Exam Frequency among Latinx Older Adults with Diabetes Mellitus

Both social and medical factors can negatively affect health outcomes, especially in vulnerable populations. To address these two types of factors in a hospital post-discharge population, two non-profit organizations collaborated to combine their novel decision support programs to address the question: could combined programs have greater potential for improved health outcomes? HomeMeds (HM), a social health program in which trained social services staff make home visits to vulnerable clients, was combined with MedSafety Scan (MSS), a medical health, clinical decision support tool. Data captured in the home visits were entered into the HM and MSS programs to detect those patients at greatest risk of adverse health outcomes due to medications. Patients received a post-discharge home visit by trained social services staff. The number of drugs reported as being taken was on average 10.4, which was less than prescribed at discharge in 62% of patients. Both programs detected serious risk of medication-induced harm, mostly from different causes such as drug-drug interactions or for use not recommended in older adult. Combined analysis of data from two novel decision support programs yielded complementary findings that together address both medical and social determinants of health. These have the potential to reduce medication-induced harm, costly re-hospitalization and/or emergency room visits and support the further evaluation of this combined approach in other vulnerable populations such as the seriously mentally ill, frail, those confined to home, opioid-dependent or otherwise impaired.

Connecting Patient and Provider Burnout to Eye Exam Frequency among Latinx Older Adults with Diabetes Mellitus

Among Latinx older adults, our current understanding of barriers to eye exam often fails to consider the impact of patient and provider burnout which can decrease treatment adherence and recommendation receptivity in this group. The purpose of this study was to examine correlates of eye exam frequency among Latinx older adults in South Los Angeles and explore associations reflecting patient and/or provider burnout. Data analysis was informed by the Secret Self-Management Loop and the Burnout Dyad conceptual models. This secondary analysis used data collected from a convenience sample of non-institutionalized Latinx adults 55+ in South LA (n=165) and used multinomial regression analysis. Outcome variable is recency of eye exam, independent variables are self-reported health, including diabetes mellitus diagnosis, and either patient or provider burnout (that are functions of grouped demographic or quality of care variables). Variables associated with Provider Burnout, appear to represent a larger influence on eye examination frequency then variables associated with Patient Burnout, with the most influential factor being provider recommendation. A surprising finding was the number of participants who had never received this recommendation from a provider (21%). One-third (32%) of participants with diabetes mellitus had not had an eye examination within 12 months and almost one-fifth (13%) of participants with diabetes who had received this recommendation had not received the exam. Further exploration is needed to support a better understanding of how both patient and provider burnout impacts adherence to eye examination and other preventive care recommendations for diabetes mellitus among Latinx older adults.

Effect of Individualized Preventive Care Recommendations vs Usual Care on Patient Interest and Use of Recommendations

This randomized clinical trial examines the feasibility and acceptability of a decision-making tool for increasing patient interest in individualized recommendations for preventive care services. To pilot a tool to help patients compare life expectancy gains from evidence-based preventive services. This randomized clinical trial examined patient and physician responses to a pilot decision tool incorporating personalized risk factors at 3 US primary care clinics between 2017 and 2020. Eligible patients were between ages 45 to 70 years with 2 or more high-risk factors. Patients were followed-up after 1 year. The gain in life expectancy associated with guideline adherence to each recommended preventive service was estimated. Personalized estimates incorporating risk factors in electronic health records were displayed in a physician-distributed visual aid. During development, physicians discussed individualized results with patients using shared decision-making (SDM). During the trial, patients were randomized to receive individualized recommendations or usual care (nonmasked, parallel, 1:1 ratio). Primary outcome was patient interest in individualized recommendations, assessed by survey. Secondary outcomes were use of SDM, decisional comfort, readiness to change, and preventive services received within 1 year. The study enrolled 104 patients (31 development, 39 intervention, 34 control), of whom 101 were included in analysis (mean [SD] age, 56.5 [5.3] years; 73 [72.3%] women; 80 [79.2%] Black patients) and 20 physicians. Intervention patients found the tool helpful and wanted to use it again, rating it a median 9 of 10 (IQR, 8-10) and 10 of 10 (8-10), respectively. Compared with the control group, intervention patients more often correctly identified the service least likely (18 [46%] vs 0; P = .03) to improve their life expectancy. A greater number of patients also identified the service most likely to improve their life expectancy (26 [69%] vs 10 [30%]; P = .07), although this result was not statistically significant. Intervention patients reported greater mean [SD] improvement in SDM (4.7 [6.9] points) and near-term readiness to change (13.8 points for top-3-ranked recommendations). Point estimates indicated that patients in the intervention group experienced greater, although non-statistically significant, reductions in percentage of body weight (-2.96%; 95% CI, -8.18% to 2.28%), systolic blood pressure (-6.42 mm Hg; 95% CI, -16.12 to 3.27 mm Hg), hemoglobin A1c (-0.68%; 95% CI, -1.82% to 0.45%), 10-year atherosclerotic cardiovascular disease risk score (-1.20%; 95% CI, -3.65% to 1.26%), and low-density lipoprotein cholesterol (-8.46 mg/dL; 95% CI, -26.63 to 9.70 mg/dL) than the control group. Nineteen of 20 physicians wanted to continue using the decision tool in the future. In this clinical trial, an individualized preventive care decision support tool improved patient understanding of primary prevention and demonstrated promise for improved shared decision-making and preventive care utilization. ClinicalTrials.gov Identifier: NCT03023813.

Knowledge, approach and recommendations of paediatricians for preventing early childhood caries in children

Introduction: Childhood is an important stage in life and Early Childhood Caries (ECC) is the most common disease of this phase. Unlike paediatric dentists, pediatricians see the majority of children periodically during these first years of life and have the opportunity to sensitize parents to the oral health of their children and to prevent ECC. Aim and Objectives: To assess Paediatrician’s knowledge, approach and preventive care recommendations for ECC in children. Materials and Method: A cross-sectional survey was carried out among 36paediatricians selected randomly. A close ended validated questionnaire was solved by all the selected paediatricians. It had questions regarding the knowledge about ECC, child’s first dental visit and anticipatory guidance given to parents. This study also evaluated the recommendation for patients to regular dental visits. Results:Majority of paediatricians (83.3%) were aware of ECC and practiced regular oral screening of their patients. They recommend for the first dental visit at around 1 year of age. Among 36Paediatricians33 (91.7%) considered tooth brushing, regular dental check-up, control over sugary and sticky in between meal snacks as the measures for the prevention of ECC and 83.3% of the paediatricians agreed that syrupy medications containing sucrose as a potential risk factor. However, majority of them didn’t recommend any fluoride supplements in their daily practice. Conclusions:Paediatricians were well aware of ECC. They consider it to be the responsibility of the general practitioner, paediatrician, general dentist and the paediatric dentist together for the spread of awareness and prevention of ECC. Keywords: Child Oral health, Early Childhood Caries, paediatrician, preventive measures

Estimation of the Time Needed to Deliver the 2020 USPSTF Preventive Care Recommendations in Primary Care.

Objectives. To reexamine the time required to provide the US Preventive Services Task Force (USPSTF)-recommended preventive services to a nationally representative adult patient panel of 2500.Methods. We determined the required time for a single physician to deliver the USPSTF preventive services by multiplying the eligible population, annual frequency, and patient-contact time required for each recommendation, all calculated by using data from the recommendations themselves and literature. We modeled a representative panel of 2500 adults based on the 2010 US Census Bureau data.Results. To deliver the USPSTF recommended preventive services across a 2500 adult patient panel would require 8.6 hours per working day, accounting for 131% of available physician time. Compared with 2003, there are fewer recommendations in 2020, but they require 1.2 more physician patient-contact hours per working day.Conclusions. The time required to deliver recommended preventive care places unrealistic expectations on already overwhelmed providers and leaves patients at risk. This is a systems problem, not a time-management problem. The USPSTF provides a set of recommendations with strong evidence of positive impact. It is imperative that our health care system is designed to deliver.

Coding Systems for Clinical Decision Support: Theoretical and Real-World Comparative Analysis.

BackgroundEffective clinical decision support systems require accurate translation of practice recommendations into machine-readable artifacts; developing code sets that represent clinical concepts are an important step in this process. Many clinical coding systems are currently used in electronic health records, and it is unclear whether all of these systems are capable of efficiently representing the clinical concepts required in executing clinical decision support systems.ObjectiveThe aim of this study was to evaluate which clinical coding systems are capable of efficiently representing clinical concepts that are necessary for translating artifacts into executable code for clinical decision support systems.MethodsTwo methods were used to evaluate a set of clinical coding systems. In a theoretical approach, we extracted all the clinical concepts from 3 preventive care recommendations and constructed a series of code sets containing codes from a single clinical coding system. In a practical approach using data from a real-world setting, we studied the content of 1890 code sets used in an internationally available clinical decision support system and compared the usage of various clinical coding systems.ResultsSNOMED CT and ICD-10 (International Classification of Diseases, Tenth Revision) proved to be the most accurate clinical coding systems for most concepts in our theoretical evaluation. In our practical evaluation, we found that International Classification of Diseases (Tenth Revision) was most often used to construct code sets. Some coding systems were very accurate in representing specific types of clinical concepts, for example, LOINC (Logical Observation Identifiers Names and Codes) for investigation results and ATC (Anatomical Therapeutic Chemical Classification) for drugs.ConclusionsNo single coding system seems to fulfill all the needs for representing clinical concepts for clinical decision support systems. Comprehensiveness of the coding systems seems to be offset by complexity and forms a barrier to usability for code set construction. Clinical vocabularies mapped to multiple clinical coding systems could facilitate clinical code set construction.

Use of a Paper Checklist to Increase Clinician Adherence to Mammography Screening Guidelines

ObjectiveTo increase clinician adherence to mammography screening guidelines. DesignQuality improvement initiative. Setting/Local ProblemAt a nurse practitioner–led primary care practice, a chart audit of adherence to American Cancer Society mammography screening guidelines indicated a 12% adherence rate for clinicians writing mammography orders. ParticipantsNurse practitioners providing care to women ages 40 years and older. Intervention/MeasurementsThe intervention was a screening checklist that was completed by the woman at registration and given to the clinician during the examination. The pre- and postintervention measurement was the percentage of mammogram orders. A Fisher exact test was used to examine changes from pre- to postintervention rates of adherence. ResultsAfter the intervention, the percentage of women for whom a mammogram was recommended and ordered was 69.6%, compared to 12% from the original chart audit. This change was statistically significant (p = .01). ConclusionClinicians must find efficient approaches to improve processes within their practice settings to ensure that preventive care recommendations are made during visits. Although the screening checklist was deemed useful, improvement in adherence rates is still needed, and a paperless system should be initiated.

Assessing Patient Interest in Individualized Preventive Care Recommendations.

Background. Few Americans obtain all 41 guideline-recommended preventive services for nonpregnant adults. We assessed patient interest in prioritizing their preventive care needs. Methods. We conducted a mixed-methods study, with 4 focus groups (N = 28) at a single institution and a nationwide survey (N = 2,103). Participants were middle-aged and older adults with preventive care needs. We obtained reactions to written materials describing the magnitude of benefit from major preventive services, including both absolute and relative benefits. Recommendations were individualized for patient risk factors (“individualized preventive care recommendations”). Focus groups assessed patient interest, how patients would want to discuss individualized recommendations with their providers, and potential for individualized recommendations to influence patient decision making. Survey content was based on focus groups and analyzed with logistic regression. Results. Patients expressed strong interest in individualized recommendations. Among survey respondents, an adjusted 88.2% (95% confidence interval [CI] = 86.7% to 89.7%) found individualized recommendations very easy to understand, 77.2% (95% CI = 75.3% to 79.1%) considered them very useful, and 64.9% (95% CI = 62.8% to 67.0%) highly trustworthy (each ≥6/7 on Likert scale). Three quarters of participants wanted to receive their own individualized recommendations in upcoming primary care visits (adjusted proportion = 77.5%, 95% CI = 75.6% to 79.4%). Both focus group and survey participants supported shared decision making and reported that individualized recommendations would improve motivation to obtain preventive care. Half of survey respondents reported that they would be much more likely to visit their doctor if they knew individualized recommendations would be discussed, compared with 4.2% who would not be more likely to visit their doctor. Survey respondents already prioritized preventive services, stating they were most likely to choose quick/easy preventive services and least likely to choose expensive preventive services (adjusted proportions, 63.8% and 8.5%, respectively). Results were consistent in sensitivity analyses. Conclusions. Individualized preventive care recommendations are likely to be well received in primary care and might motivate patients to improve adherence to evidence-based care.

Tailoring a Survivorship Care Plan: Patient and Provider Preferences for Recipients of Hematopoietic Cell Transplantation

This study aimed to develop a survivorship care plan (SCP) that can be individualized to facilitate long-term follow-up care of hematopoietic cell transplantation (HCT) survivors. A sample SCP was developed that included 2 documents: a treatment summary and preventive care recommendations that combined data on treatment exposures routinely submitted by HCT centers to the Center for International Blood and Marrow Transplant Research (CIBMTR) with long-term follow-up guidelines. Focus groups were conducted by phone to characterize the critical patient-centered elements of the SCP. Focus group eligibility criteria included (1) adult patients >1 year post-HCT and their caregivers (3 groups; n = 22), (2) HCT physicians and advanced practice providers (APPs) (2 groups; n = 14), (3) HCT nurses and social workers (4 groups; n = 17), and (4) community health care professionals (3 groups; n = 24). Transcripts were analyzed for saturation of key themes using NVivo 10 software. Patients and caregivers suggested combining the treatment summary and care guidelines into a single document. They also requested sections on sexual and emotional health and the immune system. Providers wanted the treatment summary to focus only on what they absolutely must know. Themes were similar across healthcare professionals, although screening for psychosocial issues was emphasized more by the nurses and social workers. All preferred to receive the SCP electronically; however, hardcopy was considered necessary for some patients. All felt that the SCP would facilitate appropriate post-HCT care. This study highlights the need for an SCP instrument to facilitate HCT survivorship care. Furthermore, it demonstrates the feasibility and value of engaging HCT recipients, caregivers, and providers in developing an SCP. Their feedback was incorporated into a final SCP that was subsequently tested in a randomized trial.

Knowledge, practices and expectations of preventive care: a qualitative study of patients attending government general outpatient clinics in Hong Kong

BackgroundEvidence-based preventive care recommendations have been well established, but studies have persistently reported gaps between these recommendations and general practitioners’ practices in providing preventive care. Many studies have explored factors that affect the delivery of preventive care from the perspectives of the practitioners, but relatively few have evaluated the patients’ point of view. The purpose of this study was to explore patients’ understanding of preventive care, the actions they were taking in terms of preventive health and their expectations from family doctors in providing preventive care.MethodsA qualitative study was conducted based on one-on-one in-depth interviews. Twenty-eight patients without chronic illnesses were purposively recruited from government general outpatient clinics in Hong Kong. The interviews took place between November 2013 and February 2014.ResultsThe participants’ knowledge of preventive care was limited, and their preventive practices were mostly restricted to healthy lifestyle practices. They rarely obtained individualised preventive care advice from doctors. Screening investigations were initiated after symptoms had already occurred, and the decision of what to check was arbitrary. Few of the participants knew what they wanted from their doctors in terms of preventive care.ConclusionsThese findings show significant gaps between evidence-based preventive recommendations and patients’ current knowledge and practice, and show the need for a wider spectrum of preventive care education and reliable sources to provide individualised and affordable preventive assessment and screening services. Most importantly, primary care providers must take a more proactive role to provide preventive services.

Perspectives on Providing And Receiving Preventive Health Care From Primary Care Providers and Their Patients With Mental Illnesses

Individuals with mental illnesses have higher morbidity rates and reduced life expectancy compared to the general population. Understanding how patients and providers perceive the need for prevention, as well as the barriers and beliefs that may contribute to insufficient care, are important for improving service delivery tailored to this population. Cross-sectional; mixed methods. An integrated health system and a network of federally qualified health centers and safety net clinics. Interviews (n = 30) and surveys (n = 249) with primary care providers. Interviews (n = 158) and surveys (n = 160) with patients diagnosed with schizophrenia, bipolar, anxiety, or major depressive disorders. Semi-structured interviews and surveys. Thematic analysis for qualitative data; frequencies for quantitative data. More than half (n = 131, 53%) of clinicians believed patients with mental illnesses care less about preventive care than the general population, yet 88% (n = 139) of patients reported interest in improving health. Most providers (n = 216, 88%) lacked confidence that patients with mental illnesses would follow preventive recommendations; 82% (n = 129) of patients reported they would try to change lifestyles if their doctor recommended. Clinicians explained that their perception of patients' chaotic lives and lack of interest in preventive care contributed to their fatalistic attitudes on care delivery to this population. Clinicians and patients agreed on substantial need for additional support for behavior changes. Clinicians reported providing informational support by keeping messages simple; patients reported a desire for more detailed information on reasons to complete preventive care. Patients also detailed the need for assistive and tangible support to manage behavioral health changes. Our results suggest a few clinical changes could help patients complete preventive care recommendations and improve health behaviors: improving clinician-patient collaboration on realistic goal setting, increasing visit time or utilizing behavioral health consultants that bridge primary and specialty mental health care, and increasing educational and tangible patient support services.

How do general practitioners put preventive care recommendations into practice? A cross-sectional study in Switzerland and France

ObjectivesWe previously identified that general practitioners (GPs) in French-speaking regions of Europe had a variable uptake of common preventive recommendations. In this study, we describe GPs’ reports of how they...

CE: Tuberculosis: A New Screening Recommendation and an Expanded Approach to Elimination in the United States.

: Nurses play a critical role in the diagnosis and treatment of tuberculosis and in the prevention of tuberculosis transmission through infection control practices. To eliminate tuberculosis in the United States, however, an expanded approach to testing and treating people with latent tuberculosis infection must be implemented. Recently, the U.S. Preventive Services Task Force (USPSTF) issued a new recommendation statement on latent tuberculosis infection testing that expands nurses' opportunities to identify at-risk populations for tuberculosis prevention. In combination with newer testing methodologies and shorter treatment regimens, implementation of the USPSTF recommendation has the potential to remove previously existing barriers to screening and treatment of both patients and health care providers. This article provides a general overview of tuberculosis transmission, pathogenesis, and epidemiology; presents preventive care recommendations for targeted testing among high-risk groups; and discusses the USPSTF recommendation's applicability to public health and primary care practice in the United States.

Disparities in recommended preventive care usage among persons living with diabetes in the Appalachian region

ObjectiveTo examine disparities in the receipt of preventive care recommended by the American Diabetes Association (ADA) between Appalachian and non-Appalachian counties and within Appalachian counties.Research design and methodsBehavioral Risk Factor...

Recommendations for Treating Males: An Ethical Rationale for the Inclusion of Testicular Self-Examination (TSE) in a Standard of Care

The phrase "standard of care" is primarily a legal term representing what procedure a reasonable person (i.e., health practitioner) would administer to patients across similar circumstances. One major concern for health practitioners is delivering and advocating for treatments not defined as a standard of care. While providing such treatments may meet certain ethical imperatives, doing so may unwittingly trigger medical malpractice litigation fears from practitioners. Apprehension to deviate, even slightly, from the standard of care may (seem to) put the practitioner at significant risk for litigation, which, in turn, may limit options for treatment and preventive measures recommended by the practitioner. Specific to testicular treatment, certain guidelines exist for cancer, torsion, vasectomy, and scrotal masses, among others. As it relates to screening, practitioner examination is expected for patients presenting with testicular abnormalities. Testicular self-examination (TSE) advocacy, however, is discouraged by the U.S. Preventive Services Task Force, which may prompt a general unwillingness among health practitioners to promote the behavior. Considering the benefits TSE has beyond cancer detection, and the historical support it has received among health practitioners, it is paramount to consider the ethical implications of its official "exclusion" from preventive health and clinical care recommendations (i.e., standard of care). Since good ethics should lead practitioner patient care guidelines, not fear of increased malpractice risks, we recommend the development of a standard of care for counseling males to perform TSE.

35: Examining the Evidence and Strength of Recommendations Behind the 2014 Rourke Baby Record Preventive Care Guide

Recommendations for preventive care in children, including screening maneuvers, anticipatory guidance and specific interventions, should be based on sound evidence. The health maintenance recommendations should be effective if applied, should not cause unintended consequences (harm), and should optimize the time spent in clinic between the primary care provider and family. The Rourke Baby Record (RBR) is a tool for primary care providers, which includes preventive care recommendations based on available evidence. We sought to rank recommendations for preventive care in the most recent iteration of the RBR by order of priority based on level of evidence and strength of recommendation. We also highlighted advantages and drawbacks to assigning a priority value to preventive services in children based on the current classification system. We assigned a level of evidence (low, moderate, or high) using the GRADE system and a strength of recommendation (weak or strong) for each of the recommendations in the 2014 RBR. We gave the highest values to strong recommendations supported by high quality evidence, and the lowest values to weak recommendations supported by low quality evidence. We re-examined the evidence base for strong recommendations and ranked them according to 1) importance of outcomes, 2) uncertainty and magnitude of estimates of benefits or harms, and 3) feasibility for implementation during well-baby and well-child visits. The number of preventive care recommendations in children supported by high quality studies is limited. A large majority of recommendations are based on expert consensus. Recommendations that ranked high in priority had a large potential for health improvement, including immunizations, growth monitoring, breastfeeding counseling, vehicle safety and counseling to prevent sudden infant death syndrome. We highlight some of the difficulties encountered in developing an evidence base for pediatric preventive care, including the lack of evidence for long-term health benefits and the poor methodological quality of studies. Evidence of benefits and harms from randomized controlled trials is often lacking for ethical or feasibility reasons. Except for maneuvers with a clear potential for health improvement such as immunizations, the evidence is limited for preventive care recommendations, leaving clinicians with little empirical guidance on how to implement them. While evidence of causality between preventive care and better health outcomes should be established, estimates of benefits from randomized trials should not always be sought. Observational study designs or quasi-experimental designs of high quality can make a large contribution to the evidence base in this field and should be considered in future research.