Top Ten Prevention Priorities For Adults

Herold Merisier, MD, FAAFPVoluntary Assistant Professor of Family Medicine

Miller School of Medicine, University of MiamiPlantation, FL

“The doctor of the future will give no medicine, but will

interest his patients in the care of the human frame, in diet, and in the cause and prevention of

disease.”

Unknown Author

Preventive MeasuresMultiple recommendations have been

published to help physicians guide their patients

Abundance of recommendations

How do we prioritize the information?

MethodologyThe National Commission on Prevention

Priorities (NCPP) of the U.S. Preventive Services Task Force (USPSTF)

Ranking of clinical preventive services up to Dec. 2004

Each service received 1 to 5 points on each of two measures: clinically preventable burden cost effectiveness for a total score ranging from 2 to 10

Am J Prev Med. 2006 Jul;31(1):90-6Am J Prev Med. 2001 Jul;21(1):10-9

Clinically Preventable Burden

Total quality- adjusted years of life (QALYs) gained

If the clinical preventive service were delivered at recommended intervals

To a U.S. birth cohort of 4 million individuals over the years of life for which a service was recommended

Cost EffectivenessAverage net cost per QALY gained

In a typical practice

By offering the clinical preventive service at recommended intervals to a U.S. birth cohort over the recommended age range

Scoring Ranges

Top 5 Priorities

Services CPB CE Total

Aspirin Chemoprophylaxis 5 5 10

Childhood Immunization 5 5 10

Tobacco-Use Screening/Intervention

5 5 10

Colorectal Cancer Screening 4 4 8

Hypertension Screening 5 3 8

Am J Prev Med. 2006 Jul;31(1):90-6

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

1. Aspirin Chemoprophylaxis

Risk reduction: Men, ages 45-79, to prevent

MI’s Women, ages 55-79, to

prevent strokes

Optimal dose: 81-162 mg/day

Higher dose -> Higher risk of GI bleed

Avoid: Patients with history of GI

bleed Patients allergic to Aspirin

2. Tobacco Use Screening/Intervention

Screen adults for tobacco use

Provide brief counseling

Offer pharmacotherapy

Smoking Cessation: 5 A’s

Intervention Issue

Ask About tobacco use

Advise To quit

Assess Willingness to quit

Assist In quit attempt

Arrange For follow-up

Smoking Cessation: 5 R’s

Assessment Issue

Relevance Encourage the smoker to identify why quitting is personally relevant

Risks Ask the smoker to identify negative consequences of continued tobacco use

Rewards Ask the smoker to identify and discuss specific benefits of quitting

Roadblocks Assist the smoker to identify specific barriers and impediment to quitting

Repetition Reinforce the motivational message at every opportunityReassure that repeated quit attempts are not unusual

Motivational Interviewing

“Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping

clients to explore and resolve ambivalence”

Motivational Interviewing

Motivation to change is elicited from the client, and not imposed from without

It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence

Direct persuasion is not an effective method for resolving ambivalence

Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles

Available at: http://www.motivationalinterviewing.org

Smoking Cessation: RxNicotine Replacement Therapy

Gum Patch Inhaler Nasal Spray Lozenge

Bupropion (Zyban®)

Varenicline (Chantix®)

Combination Therapy

3. Colorectal Cancer Screening

Second leading cause of cancer death in the US after lung cancer

CRC largely can be prevented by the detection and removal of adenomatous polyps

Survival is significantly better when CRC is diagnosed while still localized

3. Colorectal Cancer Screening

Fecal occult blood test: gFOBT (Guaic Fecal Occult Blood Test) FIT (Fecal Immunochemical Test) sDNA (Stool DNA)

Flexible sigmoidoscopy

Screening colonoscopy

Barium enema

3. Colorectal Cancer Screening

CA Cancer J Clin 2008;58:130–160

4. Hypertension Screening

Leading cause of heart attack, stroke, and heart failure

Evidence lacking regarding optimal interval for screening adults for hypertension

JNC 7 recommends screening: Every 2 years in persons with

blood pressure < 120/80 mm Hg

Every year with systolic blood pressure of 120 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg

5. Influenza/Pneumococcal Immunization

Service Description CPB CE Total

Influenza Immunization

Immunize adults aged ≥50 against influenza annually

4 4 8

Pneumococcal Immunization

Immunize adults aged ≥ 65 against pneumococcal disease with one dose for most in this population

3 5 8

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

Am J Prev Med. 2006 Jul;31(1):90-6

6. Problem Drinking Screening and Brief Counseling

Service Description CPB CE Total

Problem Drinking Screening and Brief Counseling

Screen adults routinely to identify those whose alcohol use places them at increased risk and provide brief counseling with follow-up

4 4 8

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

Am J Prev Med. 2006 Jul;31(1):90-6

Moderate Alcohol Consumption

Lowers blood pressure

Raises HDL

Reduces risk of cardiovascular disease

Reduces risk of ischemic strokes

Lowers fasting blood glucose

Excessive Alcohol IntakeCancer: pancreas, mouth, pharynx, larynx,

esophagus and liver, breast

Pancreatitis

Liver cirrhosis

HTN, Stroke

Injuries (Motor Vehicle Accidents)

Dementia

Fetal Alcoholic Syndrome

Recommended Alcohol Intake Per Day

Gender Beer(12 ounces)

Wine(5 ounces)

Liquor(1.5 ounce)

* If you don’t drink, don’t start

7. Vision ScreeningService Description CPB CE Total

Vision Screening Screen adults aged ≥65 routinely for diminished visual acuity with Snellen visual acuity chart

3 5 8

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

Am J Prev Med. 2006 Jul;31(1):90-6

8. Cervical Cancer Screening

Service Description CPB CE Total

Cervical Cancer Screening

Screen women who have been sexually active and have a cervix within 3 years of onset of sexual activity or age 21 routinely with cervical cytology (Pap smears)

4 3 7

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

Am J Prev Med. 2006 Jul;31(1):90-6

9. Cholesterol ScreeningService Description CPB CE Total

Cholesterol Screening

Screen routinely for lipid disorders among men aged ≥ 35 and women aged ≥ 45 and treat with lipid-lowering drugs to prevent the incidence of cardiovascular disease

5 2 7

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

Am J Prev Med. 2006 Jul;31(1):90-6

10. Breast Cancer Screening

Service Description CPB CE Total

Breast Cancer Screening

Screen women aged ≥ 50 routinely with mammography alone or with clinical breast examination, and discuss screening with women aged 40 to 49 to choose an age to initiate screening

4 2 6

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

Am J Prev Med. 2006 Jul;31(1):90-6

Other ServicesServices CPB CE Total

Chlamydia Screening 2 4 6

Obesity Screening 3 2 5

Osteoporosis Screening 2 2 4

Diabetes Screening 1 1 2

Diet Counseling 1 1 2

CPB: Clinically Preventable BurdenCE: Cost Effectiveness

Am J Prev Med. 2006 Jul;31(1):90-6

ConclusionReview the most valuable clinical preventive

services

Help you select which services to emphasize

Provide practical recommendations for the application of these services

Vilus Vilsaint (DOB: August 13, 1895)