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 recommendationsHow 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 PrioritiesServices CPB CE TotalAspirin Chemoprophylaxis 5 5 10Childhood Immunization 5 5 10Tobacco-Use Screening/Intervention

5 5 10

Colorectal Cancer Screening 4 4 8Hypertension 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 IssueAsk About tobacco useAdvise To quitAssess Willingness to quitAssist In quit attemptArrange For follow-up

Smoking Cessation: 5 R’s

Assessment IssueRelevance Encourage the smoker to identify why quitting is

personally relevantRisks Ask the smoker to identify negative consequences

of continued tobacco useRewards Ask the smoker to identify and discuss specific

benefits of quittingRoadblocks Assist the smoker to identify specific barriers and

impediment to quittingRepetition 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 sigmoidoscopyScreening colonoscopyBarium 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 TotalInfluenza 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 TotalProblem 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 HDLReduces risk of cardiovascular diseaseReduces risk of ischemic strokesLowers fasting blood glucose

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

esophagus and liver, breast Pancreatitis Liver cirrhosisHTN, Stroke Injuries (Motor Vehicle Accidents)DementiaFetal 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 TotalVision 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 TotalCervical 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 TotalCholesterol 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 TotalBreast 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 TotalChlamydia Screening 2 4 6Obesity Screening 3 2 5Osteoporosis Screening 2 2 4Diabetes Screening 1 1 2Diet 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 emphasizeProvide practical recommendations for the

application of these services

Vilus Vilsaint (DOB: August 13, 1895)