CURRENT SCREENING RECOMMENDATIONS

1. CURRENT SCREENING RECOMMENDATIONS Marie Denise Gervais, M.D. Department of Family Medicine Assistant Clinical Professor UM/Miller School of Medicine AMHE July 2010

2. "The superior physician helps before the early budding of the disease..." Chinese Emperor Huang Ti ~ 2600 BC

3. Aims and Objectives • Define prevention and its role in clinical practice • Review the 5 criteria of a screening test • Discuss current screening recommendations • Overview of the ressources available to facilitate access to screening in underserved population

4. What is Prevention? • 1° True Prevention • Healthy Patients • Lifestyle, Immunization • 2° Early Detection • Asymptomatic Patients • Screening • Pap, Mammography • 3° Minimize Complications / Disability • Disease already present • Stroke Rehab, DM/ACE-I; Post-MI Statin

5. Why Practice Prevention? • Increase quality and years of healthy life • Eliminate health disparities • Utilize the team approach to patient care • Improve clinician, staff and patient satisfaction • In keeping with Healthy People 2010

6. Definition of a Screening Test • A test or standardized procedure used to detect a disease or condition in an asymptomatic person • Accurate • Effective

7. 5 Criteria for Screening Tests • 1. Does it involve a disease that affects length or quality of life? • 2. Is there an available treatment that is effective & acceptable to the patient? • 3. Does early detection & treatment improve morbidity/mortality? • 4. Is the screening procedure effective, acceptable to patients and reasonably inexpensive? • 5. Is the disease common enough to justify screening large populations?

8. Challenge of Implementation • Linking clinical practice to the quality of the evidence • Selecting screening guidelines • Keeping up to date • The 15 minute office visit

9. United States Preventive Service Task Force • USPSTF guidelines • Evidence-Based • Formal Methodology • Reliable Conclusions • Best Evidence Available • Continually Updated • http://www.ahcpr.gov/clinic/uspstfix.htm • http://www.ahrq.gov/clinic/cps3dix.htm • I-phone application: AHRQ ePSS

10. “A” Recommendation • Strongly recommends that clinicians routinely provide the service • High certainty of substantial benefits in important health outcomes • Benefits substantially outweighharms

11. “B” Recommendation • Recommends that clinicians routinely provide the service • High certainty of moderate benefits in important health outcomes • Benefits outweigh harms

12. “C” Recommendation • Recommends against routinely providing the service • At least fair evidence of improved health outcomes for individual patients • Moderate certainty that the net benefits are small

13. “D” Recommendation • Recommends against providing the service to asymptomatic patients • At least fair evidence that the service is ineffective or that harms outweigh benefits

14. “I” Insufficient Evidence • Evidence of effectiveness is lacking, of poor quality, or conflicting • balance of benefits and harms cannot be determined • Discuss it with the patient

15. In SummaryUSPSTF Recommendations • A- outreach • B- inreach/ case finding • C- shared decision making • D- should not promote • I – do not promote

16. CURRENT SCREENING RECOMMENDATIONS 2010

17. BREAST CANCER Screening Test: Mammogram C & S CBE • B Female >40 yrs every 1-2 year…C • Nov 2009:>50 • I for CBE… • I for teaching CBE …D

18. BREAST CANCER CHEMOPREVENTION Chemoprevention: Tamoxifen, Raloxifene • B in high risk for BRCA and low risk for adverse effects • D in women at low risk

19. BRCA TESTING FOR BREAST AND OVARIAN CANCER • D routine testing for low risk females • B in women with positive family history BRCA 1 and BRCA2 mutations

20. CERVICAL CANCER Screening Test: Pap • A : All sexually active females with a cervix ACOG 2009: start at age 21;q2y until30 then q 3y after 3 neg. • D recommendation >65 & h/o nl Pap or TAH for benign tumor • I for HPV testing

21. COLORECTAL CANCER Screening Test: - Fecal Occult Blood Test yearly - Flex Sig Q 5 yrs - B.E Q 5 years - Colonoscopy Q 10 years • A for all >50-75; C 75-85; D>85 • C preferred test • I for fecal DNA and virtual colonoscopy

22. PROSTATE CANCER Screening Test: Prostatic Serum Antigen (PSA) • I recommendation men<75y/o • D “ “ >75y/o

23. LUNG CANCER Screening Test: CXR, CT, Sputum cytology • I recommendation

24. Screening for Abdominal Aortic Aneurysm • B recommendation One time screening for AAA by ultrasound in men aged 65 to 75 who have ever smoked.

25. HYPERTENSION • A recommendation Patients > 18y/o • I recommendation in children

26. CHOLESTEROL Screening Test: Total Cholesterol &HDL • Brecommendation • Arecommendation M >35 F >45 • B (with risk factors) M 20-35 F 20-45 • C ( without risk factors)

27. Screening for Coronary Heart Disease Screening Test: EKG, ETT, CT • D in adults at low risk for CHD • I in adults at increased risk for CHD

28. TYPE 2 DM Screening Test: Fasting plasma glucose, 2 hour post load plasma glucose, Hemoglobin A1C. • B in adults with hypertension (>135/80) and hyperlipidemia • I in asymptomatic adults

29. Primary Prevention for Coronary Artery Disease Chemoprevention: Aspirin • A in adults at increased risk for CHD • Men: >45-79 for MI. Younger…D • Women: >55-79 for ischemic stroke. Younger…D

30. OBESITY Screening Test: Body Mass Index (BMI) • B in adults… also Adolescent and Children 2010 Intensive counseling to promote sustained weight loss in obese patients • I in overweight patients

31. Thyroid Disease Screening Test: TSH • I recommendation

32. OSTEOPOROSIS Screening Test: Bone Mineral Density • B > 65yrs or at 60 yrs in those at increased risk of osteoporotic fractures

33. HEPATITIS Screening Test: Hep B antigen, Hep C ab • Hepatitis B • A in pregnancy at prenatal visit • D in asymptomatic adults • Hepatitis C • D in average risk • I in high risk

34. CHLAMYDIAL INFECTION • A recommendation Screen all sexually active women age 25 years or younger and other asymptomatic women at risk for infection

35. GONORRHEA • B recommendation All sexually active women, including the pregnant women if they are at risk for infection.

36. HIV • A recommendation All adolescents and adults at increased risk for HIV infection

37. So How Are We Doing? National Health Statistics

38. Life Expectancy up – 78.2 yrs Infant Mortality down – 6.3% Childhood Immunizations - 76% Adult Influenza immunization - 65% Pneumococcal immunization - 53% Screening MMG - 70%

39. Up childhood Obesity Up 1st Trimester prenatal care Up incidence Chlamydia Down incidence GC Syphilis Decreased population who Smoke Decreased Cancers in men but not women No change in Suicide rate No change in Drug Use

40. Chronic Illness Care • HTN: 27 % adequately treated • DM: 54% have HbA1c > 7.0% • CAD: 14% have recommended LDL level • TOBACCO: 50% counseled on cessation

41. So How Are We Doing? • Access to screening and follow up remain a challenge for minority groups • Burden of disease is not shared equally • Incidence and mortality rates differ by cancer among racial groups

42. So How Are We Doing? • African American males have higher incidence rates than all other racial and ethnic groups for cancers of the colon and rectum, lung and prostate (ACS 2004) • Breast, lung and colon cancer are the most commonly diagnosed cancers in African American women (ACS 2004)

43. Breast cancer screening In 2003, prevalence of mammography screening was 40.2% in women with no health insurance and 52.3% in immigrant women who had lived in the US for less than 10 years. • Black women are dying more frequently from this disease (34% versus 27%) • Women of Hispanic origin has the lowest mammography use reported at every age category

44. Cervical cancer screening Lowest prevalence of screening among women with no health insurance (61.0%). • Invasive cervical cancer is diagnosed in more advanced stages in Haitian and English-Speaking Caribbean immigrants than in US born black women

45. Colorectal cancer screening Is underutilized • 42.2% of adults 50 and older had either a home test FOBT within the past year or an endoscopic procedure within the past 5 years • Utilization is lowest among minority groups, no health insurance

46. FOR AN EFFECTIVE PREVENTIVE SYSTEM • Establish preventive protocols • Define roles of staff • Audit delivery of preventive services • Readjust SYSTEM

47. RESOURCE MATERIALS • FLOW SHEETS • Reminders on charts • Reminder postcards • Patient education materials • EMHR

48. Affordable Care Act • Always consider all “A and B” ratings • All are relevant for implementing the affordable care act

49. “A Ratings in adults”

50. “A Ratings in adults”