Adult Preventive Health Care Guidelines

1. Adult Preventive Health Care Guidelines Debbie King FNP PNP

2. Introduction • Clinical preventive guidelines were developed to assist practitioners in making decisions about appropriate health care for specific clinical circumstances. • Are not fixed protocols • Intended for providers to consider • Not intended to replace professional medical judgment

3. Clinicians Handbook of Preventive Care • http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hsarchive&part=A4489 • The criterion for inclusion of a preventive service in the Clinician's Handbook is a recommendation for its routine use in the care of asymptomatic persons by a major US authority such as: a Federal health agency (eg, Centers for Disease Control and Prevention, National Institutes of Health), a non-Federal expert panel (eg, US Preventive Services Task Force), a national professional organization (eg, American Academy of Family Physicians, American Academy of Pediatrics), or a national voluntary health organization (eg, American Cancer Society, American Heart Association). Recommendations of the Canadian Task Force on the Periodic Health Examination have also been included.

4. Clinicians Handbook of Preventive Care • Because the Clinician's Handbook focuses on preventive care for the general population without special risk factors, the following types of preventive care have not been included: tertiary prevention (treatment to prevent progression of known disease), prenatal and perinatal care, and preventive care for certain high-risk groups. Preventive services not recommended by at least one major authority have been excluded. However, the exclusion of a medical procedure does not suggest that it is ineffective in diagnosing and treating disease. The clinician should exercise judgement on a case-by-case basis with respect to preventive services not addressed in the Clinician's Handbook

5. The National Coordinating Committee on Clinical Preventive Services American Public Health Association Association of Academic Health Centers Association of American Medical Colleges Association of Health Services Research Association of Schools of Public Health Association of State and Territorial Health Officials Association of Teachers of Preventive Medicine Blue Cross Blue Shield Association Institute of Medicine National Alliance of Nurse Practitioners National Association of Community Health Centers National Association of County and City Health Officials North American Primary Care Research Group Society of General Internal Medicine Society for Public Health Education Society of Teachers of Family Medicine • Ambulatory Pediatric Association • American Academy of Family Physicians • American Academy of Pediatrics • American Academy of Physician Assistants • American Association of Colleges of Nursing • American Association of Health Plans • American College of Obstetricians and Gynecologists • American College of Occupational and Environmental Medicine • American College of Physicians • American College of Preventive Medicine • American Hospital Association • American Medical Association • American Nurses Association • American Osteopathic Association

6. Federal Liaisons to the National Coordinating Committee on Clinical Preventive Services • Department of Health and Human Services • Agency for Health Care Policy and Research • Centers for Disease Control and Prevention • Food and Drug Administration • Indian Health Service • Health Resources and Services Administration • Health Care Financing Administration • National Institutes of Health • Office of the Assistant Secretary for Planning and Evaluation • Substance Abuse Mental Health Services Administration • Department of Defense • Department of Transportation • US Coast Guard • Department of Veterans Affairs • Office of Personnel Management

7. Criteria for US Clinician handbook of Preventive Services Inclusion • 1. The condition must have a significant effect on the quality and quantity of life; • 2. Acceptable method of treatment must be available; • 3. The condition must have an asymptomatic period during which detection and treatment significantly reduce morbidity and mortality; • 4. treatment in the asymptomatic phase must yield a therapuetic result superior to that obtained by delaying treatment until symptoms appear; • 5. Tests that are acceptable to patients must be available, at a reasonable cost, to detect the condition in the asymptomatic period and • The evidence of the condition must be sufficient to justify the cost of the screening

8. Prevention • Primary • Seat belt use • Secondary • Lead screening • Tertiary • Treatment for any condition

9. Recommending Bodies • US Preventive Services Task Force • Composed of 16 health care practitioners, from a variety of speciality • Recommends preventive care to eligible patients and benefits outweigh harm • Recommends to provide service that improves important health outcomes and benefits outweigh harm • Makes no recommendation for or against routine provision of care, if the service benefit verses harm is too close to call • Bibliography: www.ahrq.gov/clinic/pocketgd/gcps1.htm

10. Recommending Bodies- Con’t • US Preventive Services Task Force-con’t • Recommends against routinely providing service to asymptomatic patients if the service will be ineffective or harm does outweigh benefits • Concludes that the evidence is insufficient to recommend for or against routinely providing the service if balance of benefits and harms cannot be determined

11. Recommending Bodies • American Academy of Family Physicians • Bibliography Sources • (AAFP). Summary of recommendations for clinical preventive services. Revision 6.2. Leawood (KS): American Academy of Family Physicians (AAFP); 2006 Aug. 15 p. • ADAPTATION • The starting point for the recommendations is the rigorous analysis of scientific knowledge available as presented by the United States Preventive Services Task Force (USPSTF) in their Guide to Clinical Preventive Services, 2nd Edition and ongoing releases of evidence reports and recommendations from the 3rd Edition.

12. American Family Site • Recommendations for clinical preventive services. PDA tool. Leawood (KS): American Academy of Family Physicians (AAFP); 2006 Aug. Electronic copies: Available from the American Academy of Family Physicians (AAFP) Web site. • Recommended adult immunization schedule. United States, October 2006 - September 2007. 3 p. Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Family Physicians (AAFP) Web site.

13. KEY • KEY – American Academy of Family Physicians = AAFP • US Preventive Services Task Force=USPSTF • Frequency= periodically, use clinician’s judgment as to frequency

14. Primary Care: Is There Enough Time for Prevention? Kimberly S. H. Yarnall, MD, Kathryn I. Pollak, PhD, Truls Østbye, MD, PhD, Katrina M. Krause, MA and J. Lloyd Michener, MD • Results. To fully satisfy the USPSTF recommendations, 1773 hoursof a physician’s annual time, or 7.4 hours per workingday, is needed for the provision of preventive services. • Conclusions. Time constraints limit the ability of physiciansto comply with preventive services recommendations. • Correspondence: Requests for reprints should be sent to Kimberly S. H. Yarnall, MD, Box 3886, Duke University Medical Center, Durham, NC 27710 (e-mail: yarna001@mc.duke.edu ).

15. Access to US Preventive Services Task Force recommendations from your I Touch • Go to uCentral • Then to 5-Minute Clinical consult • Then to Appendix 1: US Preventive Services Task Force Recommendation • Then to Grade Definitions after May 2007 and review this section • Then back to appendix and begin to use based on age

16. Screening Services for High Risk Patients • TB (PPD) • AAFP- Strongly recommends for close contacts to persons with TB, healthcare works, immigrants, HIV +, alcoholics, IV drug users, residents of long term care facilities, underserved low income people • USPSTF- recommends screening for TB for asymptomatic high-risk persons

17. Screening Services for High Risk Patients • HIV • AAFP- strongly recommends screening in men who had sex with men after 1975, past or current IV drug users, persons who exchange sex for money or drugs and their partners, those with current or past sex partners who were IV drug users, bisexual or HIV positive persons seeking treatment for STD • USPSTF-strongly recommends that clinicians screen for human immunodeficiency virus all adolescents and adults at increased risk for HIV infection, and pregnant women

18. Screening Services for High Risk Patients • STD’S • AAFP- recommends counseling adolescents and adults regarding the risks for STD’s and how to prevent them • USPSTF strongly recommends that clinicians screen persons at increased risk for syphilis infection

19. Basic Adult Prevention Guidelines • Coronary Artery Disease/MI- all adults • AAFP-strongly recommends counseling adults at increased risk, regarding the benefits and risks of aspirin prophylaxis, AND- recommends against routine screening with resting ECG, exercise treadmill, or electron-beam computerized tomography scanning for coronary calcium or severe coronary artery stenosis or the prediction of CHD events in adults at low risk for CHD events

20. Basic Adult Prevention Guidelines • Coronary Artery Disease/MI- all adults • AAFP-found insufficient evidence to recommend for or against- routine screening with resting ECG, exercise treadmill, or electron-beam computerized tomography scanning for coronary calcium or severe coronary artery stenosis or the prediction of CHD events in adults at increased risk for CHD events

21. Basic Adult Prevention Guidelines • Coronary Artery Disease/MI • The USPSTF recommends against routine screening with resting electrocardiography, exercise treadmill test, or electron-bean computerized tomography scanning for coronary calcium for either the presence of severe coronary artery stenosis or the prediction of coronary heart disease events in adults at low risk for CHD events

22. Basic Adult Prevention Guidelines • Abdominal Aortic Aneurysm-Men 65-75 who ever smoked • SUPSTF- recommends one time screening by ultrasonography

23. Basic Adult Prevention Guidelines • Diabetes-- all adults- • AAFP- recommends screening for DM II in adults with hypertension and hyperlipidemia. This insufficient evidence to recommend for or against screening adults who are at low risk for coronary vascular disease • USPSTF- concludes that the evidence is insufficient to recommend for or against routinely screening asymptomatic adults for DMII, impaired glucose tolerance or impaired fasting glucose

24. Basic Adult Prevention Guidelines • Menopause/Osteoporosis; Hormone Replacement TX-- All Women- • AAFP-strongly recommends counseling all perimenopausal women regarding the individualized short and long-term benefits and risks of postmenopausal hormone replacement therapy • USPSTF recommends against the routine use of combined estrogen progestin for the prevention of chronic conditions in postmenopausal women, recommends osteoporosis screening in women over 65 and women 60 and older at increased risk

25. Basic Adult Prevention Guidelines • Testicular CA– adolescent and adult males • AAFP –strongly recommends against routine screening for testicular cancer in asymptotic males • USPSTF recommends against routine screening for testicular cancer in asymptomatic males

26. Basic Adult Prevention Guidelines • Thyroid Cancer Screening –All adults • USPSTF concludes the evidence is insufficient to recommend for or against routine screening for thyroid disease

27. More Thyroid Screening Recommendations • II. The American Academy of Clinical Endocrinologists recommends screening symptomaticwomen and women >40yowith familyh/o thyroid disease • III. Not recc'd in asymptomatic individuals by USPSTF, ACOG, AAFP 2005 • The USPSTF found fair evidence that the thyroid stimulating hormone (TSH) test can detect subclinical thyroid disease in people without symptoms of thyroid dysfunction, but poor evidence that treatment improves clinically important outcomes in adults with screen-detected thyroid disease. Although the yield of screening is greater in certain high-risk groups (e.g., postpartum women, people with Down syndrome, and the elderly), the USPSTF found poor evidence that screening these groups leads to clinically important benefits. There is the potential for harm caused by false positive screening tests; however, the magnitude of harm is not known. There is good evidence that over-treatment with levothyroxine occurs in a substantial proportion of patients, but the long-term harmful effects of over-treatment are not known. As a result, the USPSTF could not determine the balance of benefits and harms of screening asymptomatic adults for thyroid disease

28. Basic Adult Prevention Guidelines • Skin Cancer screening—All adults • USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for skin cancer using a total body skin examination fro the early detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer

29. Basic Adult Prevention Guidelines • Dementia– elderly adults • USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for dementia in older adults • Depression– all adults • AAFP recommends screening adults for depression • USPSTF recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow-up

30. Basic Adult Prevention Guidelines • Obesity-all adults • AAFP recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions for a least three months to promote sustained weight loss for obese adults. The recommendation is to measure height and weight periodically for all patients • USPSTF recommends that clinicians screen all adult patients for obesity and off intensive counseling and behavioral interventions to promote sustained weight loss for obese adults

31. Basic Adult Prevention Guidelines • Vision Screening with Snellen Chart-65 years and older • AAFP recommends screening for visual difficulties in elderly adults by performing Snellen acuity testing • USPSTF recommends screening diminished visual acuity with the Snellen visual chart for elderly only.

32. Basic Adult Prevention Guidelines • Glaucoma-all adults • USPSTF-Insufficient evidence to recommend routine screening

33. Basic Adult Prevention Guidelines • Hearing screening-elderly adults • AAFP-recommends screening for hearing difficulties by questioning elderly adults about hearing impairment and counsel regarding the availability of treatment when appropriate-periodically question them about hearing, counsel them about the availability of hearing aids, make appropriate referrals

34. Basic Adult Prevention Guidelines • Hearing screening-elderly adults- con’t • USPSTF-insufficient evidence to recommend for or against routinely screening asymptotic adolescents and working-age adults for hearing impairment. Recommendations against such screening except for those exposed to excessive occupational noise levels, may be made on other grounds

35. Basic Adult Prevention Guidelines • Oral Cancer Screening-all adults • USPSTF- insufficient evidence to recommend routine screening of asymptomatic persons for oral cancer by PCP

36. Basic Adult Prevention Guidelines • Pap Smear and Pelvic Exam –any age if sexually active, otherwise 18 or older • AAFP- strongly recommends that a pap be completed at least every 3 years to screen for cervical cancer for women who have ever had sex and have a cervix • USPSTF-strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix

37. ACOG new guidelines • Jul 21, 2010 - Pap smears in women under 21 do more harm than good, new guidelines from the American College of Obstetricians and Gynecologists (ACOG) say. • In most cases such tests reveal only human papillomavirus (HPV) infections, which rarely lead to cervical cancer in women under 21 • Adolescents with compromised immunity should not wait until 21 to be screened. • Although this group makes up less than one percent of adolescents, they are much more vulnerable to cancer from HPV.

38. American College of Obstetricians and Gynecologists (ACOG). • As of Dec. 2009 ACOG recommends Less Frequent Screening • The revised recommendations now call for cervical screening once every 2 years vs annually for most women younger than 30 years and once every 3 years for most women 30 years and older.

39. Other Pap guidelines • ACOG = American College of Obstetrics and Gynecology • ACOG: Start 3y after sexual activity starts or 21yo, whichever comes first,; • ACOG now say women younger than 30 should undergo cervical cancer screening once every two years instead of an annual exam. And those age 30 and older can be screened once every three years. • ACS = American Cancer Society • ACS 2003:  Q1y (if using conventional cytology) or Q2y (if using liquid-based cytology) or Q3y (if > 30yo and has had 3 consecutive normals). Start 3y after sexually active or age 21, stop @ age 70 if have had 3 negative paps in a row and no abnormals in the prior 10y except don't ever stop in pts with h/o cervical Ca or in-utero exposure to DES or who are immunocompromised

40. Basic Adult Prevention Guidelines • Fecal Blood Occult Sigmoidoscopy and DRE/PSA or Colonoscopy and DRE/PSA for men and women over 50 • AAFP- strongly recommends that clinicians screen men and women age 50 and older for colorectal cancer • USPSTF strongly recommends that clinicians screen men and women age 50 and older for colorectal cancer

41. Basic Adult Prevention Guidelines • BP screen –18 and older • AAFP- periodically, use clinician’s judgment as to frequency • USPSTF- strongly recommends that clinicians screen adults age 18 and older for high blood pressure

42. Basic Adult Prevention Guidelines • Cholesterol Screening- Men 35-65 and women 45-65 • American Heart Association- for above ages, using a total cholesterol level, is considered appropriate but not mandatory. It may be considered 5-10 years sooner with a family history, or the person has two other characteristics that place the person at increased risk of CHD

43. Basic Adult Prevention Guidelines • Clinical Breast exam and mammogram 20-39, and 40 and over, and 50 and older • AAFP recommends women age 40 and older be screened for breast cancer with mammography every 1-2 years after counseling by their family physician regarding the potential risks and benefits of the procedure • USPSTF advise against regular mammography screening for women 40-49 years of age, provide mammograms only every other year for women between 50 and 74, and stop all breast cancer screening in women over 74.

44. Other recommendations by the USPSTF • Screen for alcohol misuse- for men, women and pregnant females • Recommend aspirin for the primary prevention of cardiovascular events for adults at increased risk for CHD • Recommend bacteriuria screening for pregnant women • Recommend Hepatitis B screening for pregnant women • Screen for tobacco use and tobacco –caused disease, counseling to prevent or cessation interventions for those who use tobacco, for men and women • Counseling; • Calcium for women- 1000mg for 18-39, 1200-1500mg for 40+ • Folic acid women planning to get pregnant- 0.4mg/day

45. Well Care- recommendations by the USPSTF • Comprehensive exam; a complete history and physical to include a multi-system examination, system history review, family and social history and assessment of pertinent risk factors. • Vital signs and BP screenings as well as a clinical breast exam for women. • Risk factor screening includes; family violence, substance abuse, and HIV • Nutrition and physical activity assessment also should be included

46. THURSDAY, Nov. 19 2009 (Health Day News) -- Screening for cancer and other preventive health measures can prolong lives, but only 25 percent of adults aged 50 to 64 in the United States are getting these recommended screenings, a new report shows. Prepared by the U.S. Centers for Disease Control and Prevention, AARP and the American Medical Association, the report also lays out ways to improve the health of these adults by increasing the breadth of preventive services. "This is really looking at untapped opportunities to improve the health of adults," said report co-author Lynda A. Anderson, director of the CDC's Healthy Aging Program. "It really talks about broadening the use of these potentially lifesaving preventive services." Areas of special attention in the report include influenza vaccine, cholesterol screening, colorectal cancer screening and for women, breast and cervical cancer screening. Also included are screenings for other behaviors that could hurt health such as binge drinking.