POM II - Preventive Medicine - Exam 4

Primary prevention

-keeps disease from occurring - eliminate disease agents/increase resistance to diseases

-often accomplished at community level

-can also be at the clinical level

Community primary prevention

-fluoridation of water

-seatbelt or helmet laws

-school immunization requirements

Clinical primary prevention

-immunizations to prevent communicable diseases

-smoking cessation

-bariatric surgery to prevent complications of obesity

Secondary prevention

-detect/address existing disease prior to appearance of sx

-2 steps: screening, then FU dx and tx

Clinical Secondary Prevention

-BP measurement

-PAP

-Mammograms

-Colonoscopies

Tertiary Prevention

-prevent further deterioration or reduce clinical complications after a dz dx

-another term for tx, but with the focus on health effects occurring months or days in the future

Tertiary Prevention Examples

-surgical procedures to stop spread/progression of dz

-use of beta blockers to decrease risk of death in pts s/p MI

-cardiac rehab after MI

-diabetes education classes

-support groups

Non-modifiable RF

-ethnicity

-family hx

-gender

-age

Modifiable RF

-BMI

-Blood glucose

-cigarette use

-condom use

-diet

-occupation

immunization

to prevent/attenuate disease in children and adults

screening

identification of an asx dz, harmful condition, or risk factor

behavioral counseling

to help motivate lifestyle changes

chemoprevention

-use of drugs to prevent dz

-Ex: folic acid to prevent neural tube defects, low dose ASA to prevent MI, statins to reduce cholesterol

Incidence

-# new cases that develop in a given period of time

-expressed as annual per 100,000

-risk of disease

Prevalence

-# cases of dz in a given population in a particular period of time

-expressed as a %

-how wide spread

Proportional mortality

method of relating the # of deaths from a particular condition to all deaths within the same population group for the same period

Mortality

-another term for death

-mortality rate - number of deaths due to a disease divided by the total population

Risk

-statistical expectation value of an unwanted event

-media and pharma often use RR (makes data look more impressive)

Relative Risk

ratio of the risk of dz among people with a risk factor, to those without (compares risk of 2 different groups of people)

Absolute Risk

ratio of people who have a medical event compared to all of the people who could have an event (your risk of developing dz over a time period)

Sensitivity

positive test / all disease positive

Specificity

negative test / all disease negative

High sensitivity

-few false negatives

-all people who have the disease are picked up by the screen

test sensitivity

in medical dx, _____________ is the ability of a test to correctly identify those with the disease (true positive rate)

High specificity

-few false positives

-individuals without the disease are not erroneously labeled and have to undergo unwarranted testing

Test Specificity

the ability of the test to correctly identify those without the disease (true negative rate)

Positive predictive value

-proportion of patients with a positive test who have the disease

-(+) test : (+) disease

Negative predictive value

-proportion of patients with a negative test that do not have the disease

-(-) test : (-) disease

prevalence

predictive values depend upon the ___________ of a disease within a population

Positive Predictive value

positive disease / all test positive

Negative Predictive Value

negative disease / all test negative

Universal (population)

screening of every individual within a population (all children of a certain age)

Selective (targeted or risk-based)

-screening individuals in which there is a reason to believe that the screening may be positive (cervical cancer)

-increases the positive predictive value of a test

Infant Leading Causes of Death

-congenital malformations, deformations, and chromosomal abnormalities

-low birth wt/short gestation

-SIDS

Age 1-9 Leading Causes of Death

-accidents

-cancer

-homicide

Adolescents/YA Leading Causes of Death

-Accidents

-Suicide

-Homicide

Evidence Based Prevention - Criteria

-burden of suffering caused by the condition

-effectiveness, safety, and cost of the preventive intervention or treatment

-performance of the screening test

Screening - Adverse Effects

-injury (like perf in a colonoscopy)

-negative labeling

-false positive tests -> unnecessary FU and over-diagnosis

-detection of incidentalomas

Health Literacy

-communicate risks and benefits of screening in a way pt can understand

-pts tend to overestimate the benefits and underestimate the harms of interventions and screening tests

Periodic "Check up"

-no strict guidelines/evidence for optimal frequency

-a good place to implement prevention/screenings

-every 1-3 yrs pts <=49 yrs

-annually >=50 yrs

US Preventive Services Task Force

-created 1984

-independent group of national experts in prevention and EBM that make evidence-based recommendations about clinical preventive services

National Guideline Clearinghouse

public resource for evidence-based clinical practice guidelines sponsored by US department of health and human services

Advisory Committee on Immunization Practices

vaccine recommendations via the CDC

USPSTF Grade A

-USPSTF recommends the service. There is high certainty that the net benefit is substantial

-offer or provide this service

USPSTF Grade B

-USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is a moderate certainty that the net benefit is moderate to substantial

-offer or provide this service

USPSTF Grade C

-USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small

-offer or provide this service for selected patients based on individual circumstances

USPSTF Grade D

-USPSTF recommends the against the service

-there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits

-discourage use of this service

USPSTF Grade I

-USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. evidence is lacking, of poor quality, or conflicting, balance of benefits and harms cannot be determined

USPSTF High Certainty

-available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations

-these studies assess the effects of the preventive service on health outcomes

-this conclusion is therefore unlikely to be strongly affected by the results of future studies

USPSTF Moderate Certainty

-available evidence is sufficient to determine effects of the preventive service on health outcomes, but confidence in the estimate is constrained by certain factors

-as more info becomes available, the magnitude or direction of the observed effect could change, and this change could become large enough to alter the conclusion

USPSTF Low Certainty

-available evidence is insufficient to assess effects on health outcomes

-more info may allow estimation of effects on health outcomes

Healthy People 2030

provides science-based 10-year national objectives for improving the health of all americans

Healthy People 2030 - Goals

-attain healthy, thriving lives and well-being free of preventable disease, disability, injury, and premature death

-eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all

-create social, physical, and economic environments that promote attaining teh full potential for health and well-being for all

-promote healthy development, healthy behaviors, and well-being across all life stages

-engage leadership, key constituents, and the public across multiple sectors to take action and design policies that improve the health and well being for all

ID - Prevention

-immunization

-improved sanitation

-better nutrition

-Dz screening -> HIV, TB

-Dz education

-Behavioral counseling for sexually active adolescents/adults

Aortic Aneurysm Screening

-recommends one-time screening by US in men aged 65-75 yrs who have ever smoked

-selectively offered for AAA in men aged 65-75 who have never smoked

-current evidence is insufficient to assess balances and harms in women aged 65-75 who have ever smoked

-recommends against routine screening in women who have never smoked

low dose ASA; 50-59 yrs

The USPSTF recommends initiating ______________ use for the primary prevention of CVD and colorectal CA in adults aged __________ who have a 10% or greater 10-year CVD risk, are not at increased risk for bleeding, have a life expectancy of at least 10 yrs, and are willing to take daily.

BP Screening

-the USPSTF recommends screening for high blood pressure in adults aged 18 years or older

-recommends obtaining measurements outside the clinical setting for dx confirmation before starting treatment

Healthy Diet and PA - CVD

recommends offering or referring adults who are overweight or obese and have additional CVD risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention

Lipid Screening

identification of dyslipidemia and calculation of 10-yr CVD event requires universal ____________ in adults aged 40-75 yrs

low-mod statin

the USPSTF recommends that adults with a hx of CVD use a _________ for the prevention of CVD events and mortality when all of the following criteria are met:

(1) they are aged 40-75

(2) they have one or more CVD RF

(3) they have a calculated 10-yr risk of a CV event of 10% or greater

DM Screening

-recommends screening for abnormal blood glucose as part of CV risk assessment in adults aged 40-75 yrs who are overweight or obese

-clinicians should offer or refer patients with abnormal blood glucose to intensive behavioral counseling interventions to promote a healthful diet and physical activity

Smoking and Cessation Counseling

recommends that clinicians ask all adults about tobacco use, advice them to stop using tobacco, and provide behavioral interventions and US FDA-approved pharmacotherapy for cessation to adults who use tobacco

50%; 30%

the lifetime risk of an osteoporotic fracture is approx ______ in women and ______ for men

Osteoporosis Primary Prevention

-calcium and vit D supplementation

-exercise

Osteoporosis - Screening

-recommends screening for osteoporosis in women aged 65 yrs and older and in younger women whose fracture risk is equal to or greater than that of a 65-yr old white women who has no additional risk factors

-current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men

-FRAX

Physical Activity Benefits

-prevent onset of DM

-beneficial effect on lipid levels

-associated with lower risk of colon CA in men and women

-associated with lower risk of br and repro organ CA in women

-wt bearing/high impact activities -> increased bone density -> lower rates of osteoporosis

-decreased rates of pain d/t OA

-lowers systolic and diastolic BP

-reduced depression, anxiety, stress; improves sleep

-helps to maintain healthy weight

Physical Inactivity Prevention

-lack of physical activity is 2nd most important contributor to preventable deaths (tobacco is #1)

-sedentary lifestyle -> 28% of deaths from leading chronic dz

-USDHHS and CDC recommends adults get 150 min moderate-intensity or 75 minutes of vigorous-intensity exercise per week

Physical Inactivity - Motivational Interviewing

-Ask (identify who can benefit)

-Assess (current activity level)

-Advise (individualize plan)

-Assist (provide written exercise prescription, support)

-Arrange (appropriate referral and f/u)

Obesity Screening

-recommends screening all adults for obesity

-clinicians should offer or refer patients with a body mass index of 30 kg/m^2 or higher to intensive, multicomponent behavioral interventions

Lifestyle mods - obesity

-diet

-physical activity

-behavior therapy

Weight Bias

-providers can hold strong negative attitudes/stereotypes about people with obesity

-this can influence their perceptions, judgment, interpersonal behavior, and decision-making

-providers may spend less time in appointments with patients at higher body weight

-providers may have less respect for patients with obesity than those without

Primary Cancer Prevention

-tobacco cessation

-restricting UV light exposure (sunscreen, clothing)

-physical exercise and reducing obesity -> less breast/colon CA

-minimize occupational exposure to carcinogens

-chemoprevention

-vaccines to prevent CA

against

the USPSTF recommends (for/against) teaching breast self-exams

Clinical breast exam

insufficient evidence to recommend for or against clinical breast exam

Mammography

-recommends biennial screening mammography for women aged 50-74 yrs

-the decision to start screening mammography in women prior to age 50 yrs should be an individual one. Women who place a higher value on the potential benefits than the potential harms may chose to begin biennial screening between 40-49

Cervical Cancer Screening

-recommends screening for cervical cancer in women aged 21-65 years with cytology (pap smear) every 3 years or for women aged 30-65 years who want to lengthen the screening interval, screening with a combo of cytology and HPV testing every 5 yrs

Colorectal Cancer Screening

-recommends screening starting at age 45 years and continuing until age 75 years

-decision to screen for CRC in adults aged 76-85 yrs should be an individual one, taking into account the patient's overall health and prior screening history

CRC Screening Strategies

-fecal occult blood tests every year

-FIT-DNA every 1 or 3 years

-colonoscopy every 10 years

-CT colonography every 5 yrs

-flexible sigmoidoscopy every 5 years

-flexible sigmoidoscopy every 10 yrs plus FIT every 1 yr

Lung Cancer Screening

-recommends annual lung cancer screening using low-dose CT in current smokers aged 55-80 years with a 30-pack year smoking history, or in smokers who quit within the past 15 years

-recommends stopping screening once a person has not smoked for 15 years or a health problem that significantly limits life expectancy has developed

Prostate CA Screening

recommends against prostate specific antigen PSA-based screening for prostate cancer

Testicular CA Screening

recommends against screening for testicular CA in adolescent or adult males

Injuries

-Top cause of death in people <65

-homicide, MVA -> young adults

-accidental falls -> older adults

-other: suicide, smoke/fire, bicycle accidents, violence, firearms

Injuries - Patient Ed

-seatbelt use

-helmets

-distracted driving

-drinking or substance use and driving

-depression/suicide screening

DV Screening

-recommends that clinicians screen women of childbearing age for intimate partner violence and provide or refer women who screen positive to intervention services

Elderly or Vulnerable Adults

-current evidence is insufficient to assess the balance of benefits and harms of screening all elderly or vulnerable adults (physically or mentally dysfunctional) for abuse and neglect

Adults >18 - ETOH and Illicit Drugs

recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse

<18 yrs - ETOH and Illicit Drugs

current evidence is insufficient to assess the balance of benefits and harms of screening and behavioral counseling interventions in primary care settings to reduce alcohol misuse in adolescents

ETOH and illicit drugs - Screening tools

-ASSIST -> brief interview about alcohol, tobacco products, illicit drugs

-AUDIT -> alcohol use disorders identification test for adolescents

-CAGE -> alcohol screening tool

-T-ACE -> 4-item alcohol screening tool for pregnant women

Illicit Drug Use Screening

-current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use

-remember who your higher-risk people tend to be

-men, young and unmarried individuals, Native Americans, low SES

RX Drug Abuse

-use caution in prescribing commonly abused classes of meds

-pain relievers, tranquilizers, stimulants, sedatives

-use opioid risk mitigation strategies

-risk assessment tools, treatment contracts, urine drug testing

HBV Needlestick Injury

-6-30% seroconversion rate

-in 1991 OSHA required all healthcare workers with reasonably anticipated exposure to blood be immunized

-among the individuals who are not immune, the risk of transmission depends on the HBsAg, HBeAg, and HBV DNA status of the source

HCV Needlestick

-1.8% seroconversion rate

-most frequent infection resulting from needlestick and sharps injuries

HIV Needlestick

-0.3% seroconversion rate or 1 in 300 chance

Occupational and Environmental Exposures

-part of routine history on every patient

-jobs, hobbies

-ROS

-could chief complaint be r/t home, work, or environmental exposures?

-any other environmental exposures?

Ethnicity and Dz Risk

-Glaucoma -> Black

-Lead poisoning -> Black/Non-Hispanic

-HIV -> Black MSM

-Oral CA -> Black Male

-TB -> foreign born immigrants

-SLE -> black female

-Hemoglobinopathies -> black

-Prostate CA -> black men

-DM -> native american, asian, hispanic, black

-Osteoporosis -> white, asian, or hispanic

-Chronic Hep B Carrier -> immigrants from SE Asia, China, and sub-Saharan Africa

Family Hx - Dz Risk

-multiple affected individuals in multiple generations

-occurrence of the dz at an earlier age than usual

-degree of relatedness

-presence of associated conditions in the family

Well-Child Check

-Infancy (prenatal - 9 mo) -> 7 visits

-Early Childhood (12 mo - 4 yrs) -> 7 visits

-Middle Childhood (5 yr - 10 yr) -> yearly

-Adolescence (11 yr - 21 yr) -> yearly

Preventive Peds Benefits

-improves health and welfare of children

-improves provider-parent-child relationship

-improves reimbursement

Medicare

-begins at age 65

-does not pay for yearly HME

-will pay for annual wellness visit

-if a patient has secondary insurance, may cover HME

Annual Wellness Visit

-includes Health Risk Assessment

-must address demographics, self-assessment of health status, psychosocial risks, behavioral risks, ADLs, instrumental ADLs

-establish a list of current providers

-obtain PMH/FamHx/Med list

-depression screen

-functional assessment/safety assessment

-Assess BP, ht, wt, BMI

-assess cognitive impairment

-provide written screening schedule