Table 2.

Preventive and chronic disease management services included in the cluster-randomized clinical trial

Preventive service		Target
Cancer screenings
1	Breast cancera	Every 2 years
2	Cervical cancer	Co-testing (hrHPV testing plus cytology) every 5 years
3	Colorectal cancer	Decennial colonoscopyb
4	Lung cancer	Every 1 year
Cardiovascular disease reduction
5	Abdominal aortic aneurysm screening	Once
6	Blood pressure controlc	130/80 mmHg
7	Lipids controlc	30% (low-intensity statins) or 50% (moderate-high intensity statins) reduction in LDLd
Diabetes control
8	Diabetes controlc	If baseline 7.0–7.9%, 8.0–8.9%, 9.0–10.9%, ≥11.0%: HbA1c = 1 point reduction, 7%, 2 point reduction, 9%, respectively
Healthy lifestylee
9	Alcohol misusec	≤1 drink/day (female) or ≤2 drinks/day (male)
10	Bariatric surgeryc,f	Mean of roux-en-Y gastric bypass and sleeve gastrectomy
11	Healthy diet	Lowest quintile of risk based on NHANES cycles 2013–2014 through 2017–2018
12	Light exercise	30 min per day
13	Moderate-vigorous exercise	150 min moderate or 75 min vigorous exercise per week, plus muscle strengthening exercise 2 days per week
14	Tobacco cessationc	Quit smoking
Vaccines
15	Influenza vaccineg	Annual
16	Pneumonia vaccineg	PPSV23 (1–2 doses based on ACIP guidelines)
17	Tetanus vaccineg	Decennial
18	Zoster vaccineg	Two doses of Shingrix
Other
19	Hepatitis C virus (HCV) testingg	Once
20	HIV testingg	Once (low-risk individuals) or annual (high-risk individuals)
21	Osteoporosis screening/falls preventiong	Once
22	Testing for sexually transmitted infectionsg	Annual in high-risk individuals

For each preventive service, the model defines eligibility based on the most recent USPSTF recommendation

ACIP Advisory Committee on Immunization Practices, BMI body mass index, hrHPV high-risk human papilloma virus, RCT randomized clinical trial, USPSTF United States Preventive Services Task Force

^aThe RCT excludes BRCA1/BRCA2 genetic testing and breast cancer chemoprevention, which are more relevant in younger women [22, 23] and often require specialist genetic counseling

^bAnnual fecal immunochemical testing is assumed to provide 90% of decennial colonoscopy benefit, based on a decision analysis accompanying the 2016 USPSTF recommendation [24]

^cThe RCT defines a target of risk factor control, rather than a USPSTF recommendation for screening or counseling. Diabetic foot exam is not included because it is expected to be routinely conducted at the baseline primary care visit for eligible patients, without need for shared decision-making. Diabetic eye exam is not included because many eligible Cleveland Clinic Health System patients obtain these exams from providers outside of the health system (e.g., opthamologist in private practice)

^dStatin dosage will be assumed based on American College of Cardiology recommendations

^eDepression screening not included because, typically, it would be faster to screen than to have a discussion about whether the screen a patient. Depression control not included because it is symptomatic; the focus of this RCT is primary prevention and asymptomatic chronic condition (or risk factor) control

^fThe USPSTF recommends weight loss counseling, which this RCT considers achievable through ≥1 of the following: bariatric surgery (assumed eligibility criteria: BMI≥40 kg/m² or ≥35 kg/m² in individuals with diabetes), healthy diet, and/or exercise. As with all services considered by the RCT, the individualized recommendations do not make a recommendation for or against receipt of bariatric surgery. The study assumes that a patient interested in bariatric surgery would have a discussion with his/her primary care provider and then a specialist. Additionally, the study team notes evolving evidence on medication (semaglutide) for weight loss, which may eventually be added to the RCT at the team’s discretion. The study team also may add a service Lose 10 lbs., intended to roughly proxy 5% weight loss, based on expected weight loss across available interventions (e.g., light exercise, partial adherence to healthy diet)

^gBecause the net benefit is likely to be small at the individual level (roughly, the public health benefit divided by the size of the at-risk population), the net benefit is assumed rather than mathematically modeled by the study team. For an average- or low-risk individual, typically assumed as ≤1 month of additional quality-adjusted life expectancy. Model documentation will provide further details, including definitions of high-risk factors and their individualized benefits (often, assumed as 1–2 months of additional quality-adjusted life expectancy)