1️⃣ Preventive Screening Guidelines & Follow-Up

This section outlines the standard screening intervals for asymptomatic, average-risk patients. Any high-risk factors (e.g., genetic mutations, family history, abnormal prior screens) must trigger a personalized, high-risk pathway.

1.1 Cervical Cancer Screening (Pap Smear / HPV)

  • Target Population: Average-risk individuals with a cervix aged 21–65.
  • Screening Intervals:
  • Ages 21–29: Pap smear (cytology alone) every 3 years. (Primary HPV screening is not recommended under age 25).
  • Ages 30–65: Preferred: Co-testing (Pap + HPV) or Primary HPV testing every 5 years. Alternative: Cytology alone every 3 years.
  • Follow-Up Cadence for Abnormals:
  • Low-grade abnormalities (e.g., ASC-US with negative HPV): Repeat co-testing in 1 year or resume routine screening in 3 years depending on age and clinical history.
  • High-grade/HPV-positive abnormalities: Refer to the ASCCP Risk-Based Management Consensus Guidelines for immediate colposcopy vs. short-interval repeat.
  • Discontinuation: Age >65 with adequate prior negative screenings (3 consecutive negative cytologies or 2 consecutive negative co-tests within 10 years, with the most recent within 5 years) and no history of CIN2+.

1.2 Breast Cancer Screening (Mammograms)

  • Target Population: Cisgender women and individuals assigned female at birth aged 40–74.
  • Screening Interval: Biennial (every 2 years) screening mammography starting at age 40 (per updated USPSTF guidelines).
  • Follow-Up Cadence:
  • BI-RADS 1 or 2 (Normal/Benign): Routine screening in 2 years.
  • BI-RADS 3 (Probably Benign): Short-interval diagnostic mammogram and/or ultrasound in 6 months.
  • BI-RADS 4 or 5 (Suspicious/Highly Suggestive of Malignancy): Immediate referral for image-guided core biopsy.
  • BI-RADS 0 (Incomplete): Recall patient immediately for additional diagnostic imaging (views/ultrasound).

1.3 Colorectal Cancer Screening (Colonoscopy & Alternatives)

  • Target Population: Average-risk adults aged 45–75.
  • Screening Options & Intervals:
  • Colonoscopy: Every 10 years (Gold Standard).
  • FIT (Fecal Immunochemical Test): Annually.
  • Cologuard (sDNA-FIT): Every 3 years.
  • CT Colonography or Flexible Sigmoidoscopy: Every 5 years.
  • Follow-Up Cadence post-Colonoscopy:
  • No adenomas/hyperplastic polyps <10mm: Repeat in 10 years.
  • 1–2 small (<10mm) tubular adenomas: Repeat in 7–10 years.
  • 3–4 tubular adenomas (<10mm): Repeat in 3–5 years.
  • 5–10 adenomas, adenoma >/= 10mm, or high-grade dysplasia: Repeat in 3 years.
  • More than 10 adenomas: Repeat in 1 year or less (evaluate for genetic syndromes).

1.4 Bone Mineral Density Screening (DEXA)

  • Target Population: * Women aged 65 and older.
  • Postmenopausal women younger than 65 with increased risk (calculated via FRAX score >/= 9.3%).
  • Screening & Follow-Up Interval:
  • Normal bone density or Mild Osteopenia (T-score -1.01 to -1.49): Repeat every 10–15 years.
  • Moderate Osteopenia (T-score -1.50 to -1.99): Repeat every 3–5 years.
  • Advanced Osteopenia (T-score -2.00 to -2.49): Repeat every 2 years.
  • Osteoporosis (T-score </= -2.5 or history of fragility fracture): Initiating pharmacotherapy; repeat DEXA every 2 years to monitor treatment efficacy.

1.5 Abdominal Aortic Aneurysm (AAA) Screening

  • Target Population: Men aged 65–75 who have ever smoked (defined as >/= 100 lifetime cigarettes).
  • Screening Modality: One-time screening abdominal ultrasound. (Selective screening may be considered in men who have never smoked; screening is not routinely recommended for women).
  • Follow-Up Cadence based on Aorta Diameter:
  • <3.0 cm (Normal): No further screening.
  • 3.0–3.9 cm (Small): Repeat ultrasound annually (every 12 months).
  • 4.0–4.9 cm (Medium): Repeat ultrasound every 6 months.
  • 5.0–5.4 cm: Repeat ultrasound or CT angiogram every 3 months.
  • >/= 5.5 cm (or expansion rate >0.5 cm in 6 months): Immediate vascular surgery referral for elective repair.

2️⃣ Routine Labs, Medications, & Chronic Disease Follow-up

For all stable conditions listed below, once clinical and laboratory targets are met, patients transition to a 6-to-12-month maintenance surveillance cadence with matching routine medication refills.

Category Primary Metric / Test Standard Baseline / Follow-up Cadence Stable Maintenance Surveillance (6–12 Months) & Refill Protocol Trigger for Short-Interval Follow-Up
Routine Labs (Healthy Adult) Lipid Panel, A1c, BMP/CMP, CBC, TSH Every year based on age, cardiovascular risk factors, and metabolic status. N/A: Purely screening. If stable/normal, resume routine baseline testing every year. Pre-diabetes (A1c 5.7–6.4%): Repeat in 3–6 months with lifestyle intervention.
Oral Contraceptive Pills (OCPs) Blood Pressure (BP), Weight, Medication tolerability

Baseline: BP/Weight check before prescribing.


 

Follow-Up: 3 months after initiation (telehealth or in-clinic BP check).

Stable: Once stable at 3 months, transition to annual (12-month) surveillance (BP + tolerability check).


 

Refills: Authorize a 12-month supply (typically 1 x 84-day pack with 4 refills) upon meeting annual criteria.

 BP >140/90 mmHg at any point requires immediate cessation of estrogen-containing OCPs and transition to progestin-only/non-hormonal methods.
Migraine Headache MIDAS score, headache diary, medication overuse evaluation Acute Phase: Follow-up every 4–8 weeks until therapeutic control is reached.

Stable: Transition to surveillance every 6–12 months (assessing efficacy, diary, and side effects).


 

Refills: Authorize stable prophylaxis/abortive medications for 6–12 months based on clinician discretion.

 Use of triptans/NSAIDs >/=  10–15 days/month (risk of medication overuse headache) or escalation in migraine frequency/intensity.
Thyroid Disease (Hypo/Hyper) TSH, Free T4 Dose Adjustment: Repeat TSH in 6–8 weeks after any dose change.

Stable: Once euthyroid state is achieved, transition to TSH surveillance every 6–12 months.


 

Refills: Issue standard 6-to-12-month refills of thyroid hormone replacement to match the next scheduled lab/clinical check.

 Pregnancy (check TSH every 4 weeks in the first half of pregnancy), severe symptoms, or initiation of interacting medications (e.g., calcium, iron, amiodarone).
New Prescriptions (General) Medication-specific labs, efficacy, adverse effects Telehealth/Portal follow-up at 2–4 weeks (clinical check-in). First comprehensive follow-up at 3 months.

Stable: If clinically stable and target goals are met at 3 months, transition to 6-to-12-month maintenance surveillance.


 

Refills: Transition to standard 90-day maintenance fills, authorized for up to 6–12 months to align with the next surveillance visit.

 Any report of adverse side effects, failure to meet therapeutic targets, or abnormal renal/hepatic lab monitoring.

3️⃣ Clinical Protocol Workflows

3.1 Chronic Disease Maintenance & Refill Workflow

To optimize clinical efficiency and ensure patient safety, besa Health utilizes the following standardized pathway for transition from acute management to long-term surveillance:

[Prescription Initiation] ──> [2-4 Week Evaluation] ──> [2-3 months evaluation] -> 

[Is Patient Stable?] 
                                                                │
                   ┌────────────┴───────────┐
                            ▼ YES                                                 ▼ NO
                                          [Transition to Maintenance]                               [Adjust Regimen]
                          • 6-to-12-Month Surveillance Cadence                       • Maintain short-interval
                          • Standardize 90-day maintenance refills                     follow-up (4-8 weeks)
                          • Authorize total refills to match next visit                  • Repeat relevant safety labs

 

  1. Surveillance Cadence: Once a chronic disease (e.g., hypothyroidism, stable migraines) or maintenance medication (e.g., OCPs) is deemed stable by the provider, the patient is transitioned to a 6-to-12-month clinical surveillance cadence.
  2. Refill Synchronization: * Refills must be synchronized with the patient's next scheduled clinical surveillance or laboratory checkpoint.
  • For highly stable patients on a 12-month surveillance track, providers should issue a 90-day supply with 4 refills (totaling a 12-month supply) to minimize administrative burden while securing clinical follow-up.

Refill Request Guardrail: If a patient requests a prescription refill but is overdue for their 6-to-12-month surveillance visit or safety laboratory check, the clinical team may issue a one-time, 30-day "bridge" refill to prevent therapy interruption while actively scheduling the required surveillance appointment.

 

 

 

If you have any questions or would like more information, please reach out to the Delegating Physician.