Top Ten Prevention Priorities For Adults

1. Top Ten Prevention Priorities For Adults Herold Merisier, MD, FAAFP Voluntary Assistant Professor of Family Medicine Miller School of Medicine, University of Miami Plantation, FL

2. “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

3. Preventive Measures • Multiple recommendations have been published to help physicians guide their patients • Abundance of recommendations • How do we prioritize the information?

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

5. 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

6. Cost Effectiveness • Average 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

7. Scoring Ranges

8. Top 5 Priorities CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

9. 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

10. 2. Tobacco Use Screening/Intervention • Screen adults for tobacco use • Provide brief counseling • Offer pharmacotherapy

11. Smoking Cessation: 5 A’s

12. Smoking Cessation: 5 R’s

13. Motivational Interviewing “Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence”

14. 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

15. Smoking Cessation: Rx • Nicotine Replacement Therapy • Gum • Patch • Inhaler • Nasal Spray • Lozenge • Bupropion (Zyban®) • Varenicline (Chantix®) • Combination Therapy

16. 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

17. 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

18. 3. Colorectal Cancer Screening CA Cancer J Clin 2008;58:130–160

19. 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

20. 5. Influenza/Pneumococcal Immunization CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

21. 6. Problem Drinking Screening and Brief Counseling CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

22. Moderate Alcohol Consumption • Lowers blood pressure • Raises HDL • Reduces risk of cardiovascular disease • Reduces risk of ischemic strokes • Lowers fasting blood glucose

23. Excessive Alcohol Intake • Cancer: pancreas, mouth, pharynx, larynx, esophagus and liver, breast • Pancreatitis • Liver cirrhosis • HTN, Stroke • Injuries (Motor Vehicle Accidents) • Dementia • Fetal Alcoholic Syndrome

24. Recommended Alcohol Intake Per Day * If you don’t drink, don’t start

25. 7. Vision Screening CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

26. 8. Cervical Cancer Screening CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

27. 9. Cholesterol Screening CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

28. 10. Breast Cancer Screening CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

29. Other Services CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med. 2006 Jul;31(1):90-6

30. Conclusion • Review the most valuable clinical preventive services • Help you select which services to emphasize • Provide practical recommendations for the application of these services

31. VilusVilsaint (DOB: August 13, 1895)