Seasonal dynamics and environmental drivers of tissue and mucus microbiomes in the staghorn coral Acropora pulchra.

Background: Rainfall-induced coastal runoff represents an important environmental impact in near-shore coral reefs that may affect coral-associated bacterial microbiomes. Shifts in microbiome community composition and function can stress corals and ultimately cause mortality and reef declines. Impacts of environmental stress may be site specific and differ between coral microbiome compartments (e.g., tissue versus mucus). Coastal runoff and associated water pollution represent a major stressor for near-shore reef-ecosystems in Guam, Micronesia. Methods: Acropora pulchra colonies growing on the West Hagåtña reef flat in Guam were sampled over a period of 8 months spanning the 2021 wet and dry seasons. To examine bacterial microbiome diversity and composition, samples of A. pulchra tissue and mucus were collected during late April, early July, late September, and at the end of December. Samples were collected from populations in two different habitat zones, near the reef crest (farshore) and close to shore (nearshore). Seawater samples were collected during the same time period to evaluate microbiome dynamics of the waters surrounding coral colonies. Tissue, mucus, and seawater microbiomes were characterized using 16S DNA metabarcoding in conjunction with Illumina sequencing. In addition, water samples were collected to determine fecal indicator bacteria (FIB) concentrations as an indicator of water pollution. Water temperatures were recorded using data loggers and precipitation data obtained from a nearby rain gauge. The correlation structure of environmental parameters (temperature and rainfall), FIB concentrations, and A. pulchra microbiome diversity was evaluated using a structural equation model. Beta diversity analyses were used to investigate spatio-temporal trends of microbiome composition. Results: Acropora pulchra microbiome diversity differed between tissues and mucus, with mucus microbiome diversity being similar to the surrounding seawater. Rainfall and associated fluctuations of FIB concentrations were correlated with changes in tissue and mucus microbiomes, indicating their role as drivers of A. pulchra microbiome diversity. A. pulchra tissue microbiome composition remained relatively stable throughout dry and wet seasons; tissues were dominated by Endozoicomonadaceae, coral endosymbionts and putative indicators of coral health. In nearshore A. pulchra tissue microbiomes, Simkaniaceae, putative obligate coral endosymbionts, were more abundant than in A. pulchra colonies growing near the reef crest (farshore). A. pulchra mucus microbiomes were more diverse during the wet season than the dry season, a distinction that was also associated with drastic shifts in microbiome composition. This study highlights the seasonal dynamics of coral microbiomes and demonstrates that microbiome diversity and composition may differ between coral tissues and the surface mucus layer.

What AHRQ Learned While Working to Transform Primary Care.

Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.

A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

BACKGROUND: There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. METHODS: We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. RESULTS: Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. CONCLUSIONS: Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

Prioritizing Evidence-based Interventions for Dissemination and Implementation Investments: AHRQ's Model and Experience.

BACKGROUND: The Agency for Healthcare Research and Quality (AHRQ) is mandated to implement patient-centered outcomes research (PCOR) to promote safer, higher quality care. With this goal, we developed a process to identify which evidence-based PCOR interventions merit investment in implementation. We present our process and experience to date. MATERIALS AND METHODS: AHRQ developed and applied a systematic, transparent, and stakeholder-driven process to identify, evaluate, and prioritize PCOR interventions for broad dissemination and implementation. AHRQ encouraged public nominations, and assessed them against criteria for quality of evidence, potential impact, and feasibility of successful implementation. Nominations with sufficient evidence, impact, and feasibility were considered for funding. RESULTS: Between June 2016 and June 2018, AHRQ received 35 nominations from researchers, nonprofit corporations, and federal agencies. Topics covered diverse settings, populations, and clinical areas. Twenty-eight unique PCOR interventions met minimum criteria; 16 of those had moderate to high evidence/impact and were assessed for feasibility. Fourteen topics either duplicated other efforts or lacked evidence on implementation feasibility. Two topics were prioritized for funding (cardiac rehabilitation after myocardial infarction and screening/treatment for unhealthy alcohol use). CONCLUSIONS: AHRQ developed replicable criteria, and a transparent and stakeholder-driven framework that attracted a diverse array of nominations. We identified 2 evidence-based practice interventions to improve care with sufficient evidence, impact, and feasibility to justify an AHRQ investment to scale up practice. Other funders, health systems or institutions could use or modify this process to guide prioritization for implementation.

The Practice Gap: National Estimates of Screening and Counseling for Alcohol, Tobacco, and Obesity.

Tobacco use, lack of physical activity and poor diet, and alcohol consumption are leading causes of death in the United States. We estimated screening and counseling rates by using a nationally representative sample of adults aged 35 years and older with a preventive care supplement to the 2014 Medical Expenditure Panel Survey. Receipt of the recommended level of services ranged from nearly two-thirds (64.2% for obesity, 61.9% for tobacco use) to less than one-half (41.0% for alcohol misuse). There is significant room for improving care delivery, but primary care practices probably also need additional resources to raise screening and counseling rates.

The Care and Learn Model: a Practice and Research Model for Improving Healthcare Quality and Outcomes.

The Agency for Healthcare Research and Quality conducted internal work to formulate a model that could be used to analyze the Agency's research portfolio, identify gaps, develop and prioritize its research agenda, and evaluate its performance. Existing models described the structure and components of the healthcare system. Instead, we produced a model of two functions: caring and learning. Central to this model is the commitment to and participation of people-patients, communities, and health professionals-and the organization of systems to respond to people's problems using evidence. As a product of caring, the system produces evidence that is then used to adapt and continuously improve this response, closely integrating caring and learning. The Agency and the health services research and improvement communities can use this Care and Learn Model to frame an evidence-based understanding of vexing clinical, healthcare delivery, and population health problems and to identify targets for investment, innovation, and investigation.

Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services.

As of 2015, only 8 percent of US adults ages thirty-five and older had received all of the high-priority, appropriate clinical preventive services recommended for them. Nearly 5 percent of adults did not receive any such services. Further delivery system-level efforts are needed to increase the use of preventive services.

EvidenceNOW: Balancing Primary Care Implementation and Implementation Research.

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to generate knowledge about how America's health care delivery system can provide high-quality care, and to ensure that health care professionals and systems understand and use this evidence. In 2015 AHRQ invested in the largest primary care research project in its history. EvidenceNOW is a $112 million effort to disseminate and implement patient-centered outcomes research evidence in more than 1,500 primary care practices and to study how quality-improvement support can build the capacity of primary care practices to understand and apply evidence.EvidenceNOW comprises 7 implementation research grants, each funded to provide external quality-improvement support to primary care practices to implement evidence-based cardiovascular care and to conduct rigorous internal evaluations of their work. An independent, external evaluator was funded to conduct an overarching evaluation using harmonized outcome measures and pooled data. The design of EvidenceNOW required resolving tensions between implementation and implementation research goals.EvidenceNOW is poised to develop a blueprint for how stakeholders can invest in strengthening the primary care delivery system and to offer a variety of resources and tools to improve the capacity of primary care to deliver evidence-based care. Federal agencies must maximize the value of research investments to show improvements in the lives and health of Americans and the timeliness of research results. Understanding the process and decisions of a federal agency in designing a large clinical practice transformation initiative may provide researchers, policy makers, and clinicians with insights into future implementation research, as well as improve responsiveness to funding announcements and the implementation of evidence in routine clinical care.

Learning Collaboratives: Insights And A New Taxonomy From AHRQ's Two Decades Of Experience.

Learning collaboratives are increasingly used as mechanisms to support and hasten the diffusion and implementation of innovation, clinical evidence, and effective models of care. Factors contributing to the collaboratives' success or failure are poorly understood. The Agency for Healthcare Research and Quality (AHRQ) has sponsored collaboratives for nearly two decades to support improvements in health care quality and value by accelerating the diffusion and implementation of innovation. We examined AHRQ's experience with these collaboratives to characterize their attributes, identify factors that might contribute to their success or failure, and assess the challenges they encountered. Building on the literature and insights from AHRQ's experience, we propose a taxonomy that can offer guidance to decision makers and funders about the factors they should consider in developing collaboratives and planning their evaluation, as well as to researchers who seek to conduct research that will ultimately help decision makers make better investments in diffusing innovation and evidence.

Conflicts of Interest in Clinical Guidelines: Update of U.S. Preventive Services Task Force Policies and Procedures.

The U.S. Preventive Services Task Force (USPSTF) provides independent, objective, and scientifically rigorous recommendations for clinical preventive services. A primary concern is to avoid even the appearance of members having special interests that might influence their ability to judge evidence and formulate unbiased recommendations. The conflicts of interest policy for the USPSTF is described, as is the formal process by which best practices were incorporated to update the policy. The USPSTF performed a literature review, conducted key informant interviews, and reviewed conflicts of interest policies of ten similar organizations. Important findings included transparency and public accessibility; full disclosure of financial relationships; disclosure of non-financial relationships (that create the potential for bias and compromise a member's objective judgment); disclosure of family members' conflicts of interests; and establishment of appropriate reporting periods. Controversies in best practices include the threshold of financial disclosures, ease of access to conflicts of interest policies and declarations, vague definition of non-financial biases, and request for family members' conflicts of interests (particularly those that are non-financial in nature). The USPSTF conflicts of interest policy includes disclosures for immediate family members, a clear non-financial conflicts of interest definition, long look-back period and application of the policy to prospective members. Conflicts of interest is solicited from all members every 4 months, formally reviewed, adjudicated, and made publicly available. The USPSTF conflicts of interest policy is publicly available as part of the USPSTF Procedure Manual. A continuous improvement process can be applied to conflicts of interest policies to enhance public trust in members of panels, such as the USPSTF, that produce clinical guidelines and recommendations.

Facilitative Components of Collaborative Learning: A Review of Nine Health Research Networks.

OBJECTIVE: Collaborative research networks are increasingly used as an effective mechanism for accelerating knowledge transfer into policy and practice. This paper explored the characteristics and collaborative learning approaches of nine health research networks. DATA SOURCES/STUDY SETTING: Semi-structured interviews with representatives from eight diverse US health services research networks conducted between November 2012 and January 2013 and program evaluation data from a ninth. STUDY DESIGN: The qualitative analysis assessed each network's purpose, duration, funding sources, governance structure, methods used to foster collaboration, and barriers and facilitators to collaborative learning. DATA COLLECTION: The authors reviewed detailed notes from the interviews to distill salient themes. PRINCIPAL FINDINGS: Face-to-face meetings, intentional facilitation and communication, shared vision, trust among members and willingness to work together were key facilitators of collaborative learning. Competing priorities for members, limited funding and lack of long-term support and geographic dispersion were the main barriers to coordination and collaboration across research network members. CONCLUSION: The findings illustrate the importance of collaborative learning in research networks and the challenges to evaluating the success of research network functionality. Conducting readiness assessments and developing process and outcome evaluation metrics will advance the design and show the impact of collaborative research networks.

Understanding Research Gaps and Priorities for Improving Behavioral Counseling Interventions: Lessons Learned From the U.S. Preventive Services Task Force.

Behavioral counseling interventions can address significant causes of preventable morbidity and mortality. However, despite a growing evidence base for behavioral counseling interventions, there remain significant research gaps that limit translating the evidence into clinical practice. Using U.S. Preventive Services Task Force (USPSTF) examples, we address how researchers and funders can move the research portfolio forward to achieve better application of behavioral counseling interventions to address substantial health burdens in the U.S. This paper describes the types of gaps that the USPSTF encounters across its behavioral counseling intervention topics and provides suggestions for opportunities to address these gaps to enhance the evidence base for primary care-based behavioral counseling recommendations. To accomplish this, we draw from both the USPSTF experience and issues identified by researchers and clinicians during the USPSTF-sponsored Behavioral Counseling Intervention Forum. We also discuss the dilemma posed by having "insufficient" evidence with which to make a behavioral counseling intervention-related recommendation, and describe two case examples (screening for alcohol misuse in adolescence and screening for child maltreatment), detailing the research gaps that remain. Recommendations are outlined for researchers, funders, and practice implementers to improve behavioral counseling intervention research and application.

Mass media health communication campaigns combined with health-related product distribution: a community guide systematic review.

CONTEXT: Health communication campaigns including mass media and health-related product distribution have been used to reduce mortality and morbidity through behavior change. The intervention is defined as having two core components reflecting two social marketing principles: (1) promoting behavior change through multiple communication channels, one being mass media, and (2) distributing a free or reduced-price product that facilitates adoption and maintenance of healthy behavior change, sustains cessation of harmful behaviors, or protects against behavior-related disease or injury. EVIDENCE ACQUISITION: Using methods previously developed for the Community Guide, a systematic review (search period, January 1980-December 2009) was conducted to evaluate the effectiveness of health communication campaigns that use multiple channels, including mass media, and distribute health-related products. The primary outcome of interest was use of distributed health-related products. EVIDENCE SYNTHESIS: Twenty-two studies that met Community Guide quality criteria were analyzed in 2010. Most studies showed favorable behavior change effects on health-related product use (a median increase of 8.4 percentage points). By product category, median increases in desired behaviors ranged from 4.0 percentage points for condom promotion and distribution campaigns to 10.0 percentage points for smoking-cessation campaigns. CONCLUSIONS: Health communication campaigns that combine mass media and other communication channels with distribution of free or reduced-price health-related products are effective in improving healthy behaviors. This intervention is expected to be applicable across U.S. demographic groups, with appropriate population targeting. The ability to draw more specific conclusions about other important social marketing practices is constrained by limited reporting of intervention components and characteristics.

The Agency for Healthcare Research and Quality Multiple Chronic Conditions Research Network: overview of research contributions and future priorities.

BACKGROUND: By 2030, 171 million Americans are expected to have more than one chronic condition. The cohort of individuals with multiple chronic conditions (MCC) is growing and two thirds of healthcare costs for the US population are currently spent on the 20% of people who have MCC. OBJECTIVES: Recognizing the need for increased investment in MCC programs and research, Health and Human Services (HHS) developed the HHS Strategic Framework on MCC. The Agency for Healthcare Research and Quality (AHRQ) contributed to the goals of the framework by funding the MCC Research Network, comprising 45 diverse grants and representing one of the largest federal investment in MCC studies to date. RESULTS: The initial body of research emerging from the AHRQ MCC Research Network included: co-management of commonly co-occurring conditions (including by caregivers); care for patients with low-prevalence combinations of MCC; the effect of MCC patients on provider performance metrics; guidelines for preventive services; medication management in individuals with MCC; as well as MCC-specific methodological and analytical techniques. CONCLUSIONS: The authors describe a subset of research contributions made in each topic area and make 3 recommendations for future MCC research: (1) include person-centered and person-driven measures and outcomes, (2) consider the person in the context of their relationships and community, and (3) include mental healthcare as an essential part of overall healthcare.

Folic acid supplementation for the prevention of neural tube defects: an update of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Neural tube defects (NTDs) are among the most common birth defects in the United States. In 1996, the U.S. Preventive Services Task Force (USPSTF) recommended that all women planning a pregnancy or capable of conception take a supplement containing folic acid to reduce the risk for NTDs. PURPOSE: To search for new evidence published since 1996 on the benefits and harms of folic acid supplementation for women of childbearing age to prevent neural tube defects in offspring, to inform an updated USPSTF recommendation. DATA SOURCES: MEDLINE and Cochrane Central Register of Controlled Trials searches from January 1995 through December 2008, recent systematic reviews, reference lists of retrieved articles, and expert suggestions. STUDY SELECTION: English-language randomized, controlled trials; cohort studies; case-control studies; systematic reviews; and meta-analyses were selected if they provided information on the benefits and harms of folic acid supplementation in women of childbearing age to reduce NTDs in offspring. DATA EXTRACTION: All studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria. DATA SYNTHESIS: Four observational studies reported benefit of reduction of risk for NTDs associated with folic acid-containing supplements. Differences in study type and methods prevent the calculation of a summary of the reduction in risk. The one included study on harms reported that the association of twinning with folic acid intake disappeared after adjustment for in vitro fertilization and underreporting of folic acid intake. LIMITATIONS: The evidence on dose was limited. No evidence was found on the potential harm of masking vitamin B(12) deficiency in women of childbearing age. The search focused on the association of NTDs with supplementation only and therefore does not provide a comprehensive review of the effects of folic acid on all possible outcomes or of the effects of dietary intake of folic acid. CONCLUSION: New observational evidence supports previous evidence from a randomized, controlled trial that folic acid-containing supplements reduce the risk for NTD-affected pregnancies. The association of folic acid use with twin gestation may be confounded by fertility interventions.

Screening for syphilis infection in pregnant women: evidence for the U.S. Preventive Services Task Force reaffirmation recommendation statement.

BACKGROUND: In 2004, the U.S. Preventive Services Task Force strongly recommended that clinicians screen all pregnant women for syphilis infection. PURPOSE: To update the evidence on screening pregnant women for syphilis infection. DATA SOURCES: MEDLINE searches from 1 January 2003 through 31 July 2008, recent systematic reviews, reference lists of retrieved articles, and expert suggestions. STUDY SELECTION: English-language studies were selected to answer the following 2 questions: Does screening for syphilis in pregnancy reduce the prevalence of congenital syphilis in neonates? Are there harms of screening for syphilis or harms of treatment with penicillin in pregnancy to women or neonates? Randomized, controlled trials; meta-analyses; systematic reviews; cohort studies; and ecologic studies were selected for the potential benefits question. Randomized, controlled trials; meta-analyses; systematic reviews; cohort studies; case-control studies; and large case series were selected for the potential harms question. DATA EXTRACTION: Information on the study design, selection criteria, demographic characteristics, and clinical outcomes was extracted from each study. DATA SYNTHESIS: One study on benefits evaluated the effect before and after the implementation of a universal syphilis screening program for pregnant women and found reductions in rates of congenital syphilis. Two studies on screening accuracy for syphilis reported false-positive rates of less than 1%. One study that used a large insurance claims database reported an incidence of anaphylaxis after oral penicillin of 0.1 per 10,000 dispensings. In a study from Hungary, oral penicillin in pregnancy was not associated with orofacial clefts. LIMITATIONS: This was a targeted literature search and could have missed small studies on the benefits and harms of screening for syphilis in pregnancy. We did not review evidence on interventions to improve rates of prenatal screening. CONCLUSION: New evidence from a study of universal screening supports previous evidence on the effectiveness of screening for syphilis in pregnancy to prevent congenital syphilis. Harms include testing and follow-up for false-positive test results and adverse effects from penicillin treatment.

Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Coronary heart disease and cerebrovascular disease are leading causes of death in the United States. In 2002, the U.S. Preventive Services Task Force (USPSTF) strongly recommended that clinicians discuss aspirin with adults who are at increased risk for coronary heart disease. PURPOSE: To determine the benefits and harms of taking aspirin for the primary prevention of myocardial infarctions, strokes, and death. DATA SOURCES: MEDLINE and Cochrane Library (search dates, 1 January 2001 to 28 August 2008), recent systematic reviews, reference lists of retrieved articles, and suggestions from experts. STUDY SELECTION: English-language randomized, controlled trials (RCTs); case-control studies; meta-analyses; and systematic reviews of aspirin versus control for the primary prevention of cardiovascular disease (CVD) were selected to answer the following questions: Does aspirin decrease coronary heart events, strokes, death from coronary heart events or stroke, or all-cause mortality in adults without known CVD? Does aspirin increase gastrointestinal bleeding or hemorrhagic strokes? DATA EXTRACTION: All studies were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria. DATA SYNTHESIS: New evidence from 1 good-quality RCT, 1 good-quality meta-analysis, and 2 fair-quality subanalyses of RCTs demonstrates that aspirin use reduces the number of CVD events in patients without known CVD. Men in these studies experienced fewer myocardial infarctions and women experienced fewer ischemic strokes. Aspirin does not seem to affect CVD mortality or all-cause mortality in either men or women. The use of aspirin for primary prevention increases the risk for major bleeding events, primarily gastrointestinal bleeding events, in both men and women. Men have an increased risk for hemorrhagic strokes with aspirin use. A new RCT and meta-analysis suggest that the risk for hemorrhagic strokes in women is not statistically significantly increased. LIMITATIONS: New evidence on aspirin for the primary prevention of CVD is limited. The dose of aspirin used in the RCTs varied, which prevented the estimation of the most appropriate dose for primary prevention. Several of the RCTs were conducted within populations of health professionals, which potentially limits generalizability. CONCLUSION: Aspirin reduces the risk for myocardial infarction in men and strokes in women. Aspirin use increases the risk for serious bleeding events.

Screening for skin cancer: an update of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Skin cancer is the most commonly diagnosed cancer in the United States. The majority of skin cancer is nonmelanoma cancer, either basal cell cancer or squamous cell cancer. The incidence of both melanoma and nonmelanoma skin cancer has been increasing over the past 3 decades. In 2001, the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence to recommend for or against routine screening for skin cancer by using whole-body skin examination for early detection of skin cancer. PURPOSE: To update the evidence of benefits and harms of screening for skin cancer in the general population. DATA SOURCES: MEDLINE and Cochrane Library searches from 1 June 1999 to 9 August 2005 for English-language articles; recent systematic reviews; reference lists of retrieved articles; and expert suggestions. STUDY SELECTION: English-language studies were selected to answer the following key question: Does screening in asymptomatic persons with whole-body examination by a primary care clinician or by self-examination reduce morbidity and mortality from skin cancer? Randomized, controlled trials and case-control studies of screening for skin cancer were selected. One author selected English-language studies to answer the following contextual questions: Can screening with whole-body examination by primary care clinicians or by self-examination accurately detect skin cancer? Does screening with whole-body examination or by self-examination detect melanomas at an earlier stage (thinner lesions)? DATA EXTRACTION: All studies for the key question were reviewed, abstracted, and rated for quality by using predefined USPSTF criteria. DATA SYNTHESIS: No new evidence from controlled studies was found that addressed the benefit of screening for skin cancer with a whole-body examination by a physician. One article of fair quality, which reanalyzed data from a 1996 study identified for the 2001 report for the USPSTF, provides limited but insufficient evidence on the benefit of skin self-examination in the reduction of morbidity and mortality from melanoma. LIMITATIONS: Direct evidence linking skin cancer screening to improved health outcomes is lacking. Information is limited on the accuracy of screening by physicians or patients using real patients and lesions. CONCLUSION: The limited evidence prevents accurate estimation of the benefits of screening for skin cancer in the general primary care population.