Putting Prevention into Practice (Short Form)

Using the United States Preventive Services Task Force

Recommendations

Acknowledgements

Robert M. Gum, DO, MPH, FACPM, Statewide Campus Regional Assistant Dean, WVSOM

James F. Cawley, MPH, PA-C, Professor and Vice Chair, Department of Prevention and Community Health School of Public Health and Health Services The George Washington University

V. James Guillory, DO, MPH, FACPM, Professor of Public Health, Public Health Program, KUMC

John C. Pellosie, Jr., D.O., MPH, FAOCOPM, Chair of Preventive Medicine, NSUCOM

H.S. Teitelbaum, DO, PhD, MPH, Professor and Chair, Department of Preventive and Community Medicine, LMU-DCOM

Thoughts on Prevention

"To find health should be the object of any doctor.  Anyone can find disease.“

– ---Andrew Taylor Still, D.O.

“Prevention is one of the few known ways to reduce demand for health and aged care services. “

– ---Julie Bishop, JD

“The purpose of risk assessment is not to categorize individuals according to a test result nor even as to their overall risk, but rather to identify those who can be helped, or helped most, by preventive action.”

– ---Geoffrey Rose, MD, PhD

Objectives

Encourage focus on prevention 05 Identify basic health screening principles 06 Discuss the role of evidence-based medicine 07 Define the USPSTF grading system 08 Implement wellness intervention 09 Discuss counseling and delivery to patients 10 Describe new federal initiatives 11 Demonstrate USPSTF-related Resources

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Slide #

Why Prevention?

In prevention the goal is to preserve and promote health and well being

Prevention in public health moves interventions from the individual level to a population level

Effective prevention leads to a healthier community– Why Now?

Federal support exists for prevention

Levels of Prevention

Primary Prevention

Avoidance/prevention of disease or injury (inclusive of mental health) Immunizations

Secondary Prevention

Early detection and treatment Mammography

Tertiary Prevention

Reduction of disability and prompt rehabilitation Management of existing conditions.

End-stage renal failure

The Role of Evidence Based Medicine

The USPSTF reviews the scientific evidence regarding the effectiveness, risks, and benefits of specific health care services.

A conclusion that there is no evidence of the effectiveness of a service is different from a conclusion that the service is ineffective.

What the Grades Mean

Implementing Wellness Interventions

Work interprofessionally

Counsel patient effectively

Recognize the body is capable of self-healing and health maintenance

Using the ePSS program saves time and simplifies the task.

Work with legislators to support wellness services

Counseling Strategies

Tailor teaching to patients needs

Purpose, effects and when to expect effects

Suggest small changesUse influence of profession

Encourage comments from patient

Combine strategies

Involve office staff

Monitor progress

Be specific

Add new behaviors rather than eliminate established behaviors

Link the new to old behaviorsListening

Assess readinessfor change

Cultural sensitivity

Community resources

Refer appropriately

New Federal Initiatives Change in Reimbursements

Reimbursement for services has been an impediment to consistently providing preventive/wellness services in a busy clinic environment. Recent legislation has removed this barrier.

Free Preventive Care Under Medicare—Eliminates co‐payments for preventive services and exempts preventive services from deductibles

under the Medicare program.  Effective beginning January 1, 2011.

Free Preventive Care Under New Private Plans—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles.  Effective 6 months after enactment [9/23/10].

New England Journal of Medicine, Promoting Prevention through the Affordable Care Act, 10.1056/JEJM1008560

Tools for Different Audiences

Physicians and healthcare providers Electronic and print resources and tools Downloadable point of care prompts –

electronic Preventive Services Selector: www.epss.ahrq.gov

How to: www.uspreventiveservicestaskforce.org Patients

Explanation of recommendations Checklists to monitor individual preventive needs www.healthfinder.gov has tools for patients.

Download the ePSS

Using the ePSS in a clinical setting-an example:

• Patients are typically screened by a member of the health care team in initial portion of an encounter• A nurse typically takes vital signs and measures the

patient’s height and weight prior to seeing the provider• This provides an opportunity to complete a brief preventive

medicine/wellness questionnaire• Print for inclusion in the health record or electronic review

by the healthcare provider

• Reviewed by the healthcare provider• Concurs or changes recommendations• Brief discussion with the patient for those answers or

findings that require treatment or need to be addressed with a comment that a member of the clinic staff will address some concerns in more detail

Using the ePSS in a clinical setting-an example:

• Designated member of the health care team reviews in greater detail• Further counseling is provided by a member of the clinic staff• Printed instructions should be provided to the patient for further

reference and explanation of the healthcare team recommendations

• The VA Model is a working example similar to what was just described.• A member of the healthcare team completes an in-depth screening

using the VA electronic medical records system. The patient answers are documented for the healthcare provider’s review.

• The healthcare provider reviews the patient responses and addresses the health risks with the patient, recommending lifestyle modification and/or treatment

• When appropriate the patient returns to the nurse for further discussion and counseling. Referral is made as indicated to a specialist

Case 1: Male, 57 y/o, smoker, sexually active

Case 1: Male, 57 y/o, smoker, sexually active

Case 2: Male, 77 y/o, nonsmoker, sexually active

Case 2: Male, 77 y/o, nonsmoker, sexually active

Case 3: Male, 17 y/o, nonsmoker, sexually active

Case 3: Male, 17 y/o, nonsmoker, sexually active

Patient Case 1

Your physician assistant (PA) reports to you the story of a 45-year-old man seen in the practice for an annual examination.

The patient’s only complaint is occasional elbow pain that he attributes to using a new tennis racquet. He reports no medical illnesses and his only prior surgery is a hernia repair 10 years ago.

He takes one low-dose aspirin per day, does not smoke and reports having an occasional alcoholic beverage. He reports no family history of early heart disease or cancer. Last year, his total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) were normal.

He is married and in a monogamous relationship. Since testing negative for STIs (including HIV) many years ago, he reports no potential for new exposures.

On examination, he is not overweight and not hypertensive. The patient asked the PA about the recommended preventive services for a person at his age and your PA is unsure of the appropriate source of prevention guidelines.

Patient Case 1

Patient Case 1

Patient Case 2

A 40-year–old woman presents to your clinic for a periodic examination and its seen initially by the nurse practitioner (NP).

The patient reports no medical illnesses and has had no prior surgeries. She does not smoke or drink any alcoholic beverages.

Her paternal grandfather was a heavy smoker and died of lung cancer at age 65. Otherwise, she has no other family history of cancer. She is married and in a mutually monogamous relationship.

A colleague at work was diagnosed with breast cancer 5 years before and since that time this patient has performed periodic self-breast examinations.

She reports no changes in her breasts, but asks the NP if she should get a mammogram.

The NP asks you about your interpretation of current USPSTF recommendations regarding screening mammography.

Patient Case 2

Patient Case 2

For More Information

If you have any questions or would like more information please contact:– Barbara Kass, Health Communications Specialist, Office of

Communications and Knowledge Transfer; AHRQ at barbara.kass@ahrq.hhs.gov

Helpful URLs– AHRQ’s USPSTF website (http://www.preventiveservices.ahrq.gov

) has downloadable electronic Preventive Services Selector (ePSS) app

– Printable patient counseling information for clinicians and patients, available at http://epss.ahrq.gov/ePSS/Tools.do

– Technical Assistance paper with patient cases for health professions education http://www.ahrq.gov/qual/kt/tfmethods/impuspstf.htm

– PowerPoint slide deck for educators and clinicians: “Understanding the Methods Used by the USPSTF in Developing Recommendations” http://www.ahrq.gov/qual/kt/tfmethods/tfmethods.htm