services accounts for contextual issues beyond traditional research evidence used by the USPSTF. The committee looked at women’s preventive service needs more broadly to account for women’s health and well-being.

The committee found that the USPSTF Grade A and B recommendations required close examination. The specificity of several recommendations is not clear in some cases, including such details as the periodicity of screenings or how the service is to be delivered. For example, the Grade B recommendation for screening for depression could be interpreted to be universal screening, under the assumption that the primary care provider offices offering the service have adequate staff in place to support the correct delivery of the service, or the USPSTF’s recommendation could be interpreted narrowly to include screening only in those practices that have a certified depression screening quality assurance program in place. Thus, after a review of the supporting evidence that led to their recommendations, the committee decided that it was important to note its interpretation of the Grade A and B recommendations in those cases in which specific aspects of the recommendation were found to be ambiguous (see Table 5-1). The committee also compared the USPSTF guidelines with the guidelines of other professional organizations to identify potential gaps.

The USPSTF Grade C and I statements (Table 4-1) also required further analysis by the committee because in neither case had the USPSTF intended its conclusions to limit or preclude consideration for coverage. The USPSTF informally refers to Grade C recommendations as close calls in which the balance of potential benefits and harms does not strongly favor the clinician recommending the preventive service to all patients, although it may be appropriate in some cases. The USPSTF makes the point that either choosing or not choosing the service with a Grade C recommendation would be within the standard of care and assumes that the service would be covered if clinically appropriate (USPSTF, 2008). The USPSTF also considers decision making to be a shared activity of the patient and the provider based on the individual circumstances of the patient.

The Grade I statement is a conclusion that the evidence is “insufficient to conclude whether the service is effective or not because evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined” (USPSTF, 2008). The I statement simply means that important outcomes have not yet been adequately evaluated by current research. The committee notes that from a coverage perspective, the evidence supporting many clinical interventions in common use, whether in prevention or in general medical practice, is insufficient or unclear, and that coverage decisions may be made or have been made on the basis of other factors. For example, although knowledge of the evidence for the benefits and harms of services and screenings informs a primary care provider’s

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