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Primary & Preventive Ambulatory Health Care

Primary & Preventive Ambulatory Health Care. Mark B. Woodland, MS, MD Program Director Vice Dean of GME Drexel University College of Medicine Hahnemann University Hospital. Disclosures. I love being an OBGYN!. I have had an incredible career in OBGYN!. HIV Task Force GWU

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Primary & Preventive Ambulatory Health Care

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  1. Primary & Preventive Ambulatory Health Care Mark B. Woodland, MS, MD Program Director Vice Dean of GME Drexel University College of Medicine Hahnemann University Hospital

  2. Disclosures I love being an OBGYN!

  3. I have had an incredible career in OBGYN! HIV Task Force GWU Cigarette Black Box Warning 1st GYN to do LAVH in Philly Top Docs GYN Surgery Resident Educator Recognition PA ACOG Greater Philadelphia OBGYN Review Course CREOG National Recognition 116th President of Obstetrical Society of Philadelphia CREOG APGO Program Director

  4. Objectives • Understand Populations Characteristics and Disparities • Review Current Causes of Death and Morbidity • Update Assessment and Screening & Immunizations • Learn “go to” sites for up to date references

  5. Introduction • OBGYN’s are primary health care providers to women & their families. • Periodic assessments provide opportunity to positively affect their lives & life styles. • Tailor assessments to individuals based on risk factors reflective of age. • Periodic assessment allows for education as well as routine screening.

  6. Population Characteristics

  7. POPULATION CHARACTERISTICS 304 Million 51% Women <35 = 46% 35-65 = 40% >65 = 14%

  8. U.S. FEMALE BY RACE / ETHNICITY < 15 – more diverse 56% non-Hispanic white 21% Hispanic >65 – less diverse 80% non-Hispanic white only 6.5%Hispanic

  9. WOMEN AND POVERTY 2008: 37.3 million (35.9 million 2003) people living with incomes below the Federal poverty threshold <=18 years- 12% (14.4 million women) compared to 8.8% men 18-24 years - 19.7% 65% of female-headed households experienced poverty

  10. HOUSEHOLDS: WOMEN AS CAREGIVERS 52.8% married & living w/ spouse 12.5% head of house 12.5% (16.6% 2003) live w/ parent or relative 15% Live alone 7 % live w/ non-relative

  11. WOMEN IN HEALTH PROFESSIONS SCHOOLS Post-secondary educational degrees awarded to women rose from half a million in 1969–1970 to 1.7 million in 2005–2006. Also increased for men rate of growth among women has been faster Increase Proportion of women professional degree earners 5.3% in 1969–1970 49.8% in 2005–2006. Sex disparity in degrees awarded has decreased, but racial/ethnic disparity remains for health professions

  12. WOMEN IN THE LABOR FORCE

  13. WOMEN IN THE LABOR FORCE • More Women Working: >16 yrs= 59% (46.4% in 2003) • 73% of men • -women made up 62.9% of sales and office workers • -minority in production, transportation, and material moving (22.8%); farming, fishing, and forestry (20.5%); and in the military (14.3%) • Pay Disparity Persists Large discrepancy between annual median earnings of women and men working full-time • $34,103 vs $44,250 • exists within each sector

  14. Food Security & Women 2008 – 15.4% of women lived in households that were not fully food secure, and this varied by age Female-headed households with no spouse were more likely than male-headed households with no spouse to experience food insecurity (37.2 vs 27.6 % respectively)

  15. Women and Federal Nutrition Programs Supplemental Nutrition Assistance Program (SNAP), formerly the Federal Food Stamp Program 67.8% participants were women Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Number of women participating in WIC increased by 75.6%, and it continues to rise.

  16. Health Disparities Pennsylvania

  17. Appendix: 3 Leading Causes of Death By Age

  18. Leading Causes of Death By Age 2012

  19. US Life Expectancy

  20. Americas Life Expectancy

  21. US Leading Causes of Death 2007

  22. Education & Life Expectancy 2013

  23. Health Indicators: Cause of Death • Heart Disease 28.6% • Cancer 21.6% • Stroke 6% • Lower Respiratory Disease 5.2%

  24. Health Indicators: Heart Disease • Leading cause of death for women • Coronary Heart Disease most common cause • <45 W>M heart disease • Racial variance

  25. Heart Disease Death Rates by County

  26. Cancer Related Deaths

  27. Invasive Cancer Rates

  28. Appendix 3: Leading Causes of Morbidity by Age

  29. Health Indicators: Arthritis • Leading cause of disability in US • 20% of US Adults • 10% W 18-44 • 55% W 75+ • Racial difference may relate to age distribution

  30. Health Indicators: Diabetes • Leading cause of death and disability • Type 1 – “juvenile” • Type 2 – obesity, inactivity, FMHx • 20.6W/1000 <45 • -W>M • 148.6/1000 >75 • -M>W

  31. Health Indicators: AIDS • 75% of W w/ AIDS are NWH & NHB Women • 45% by heterosex • 19.5% by IV Drug Use • <2% by blood products • 5th Leading cause of death W 35-44

  32. Initial Assessment • Important skills include: • Recognize the # of “first visits” • Stress interactive & “people” skills • Emphasize the importance of age, race, ethnicity, cultural background, sexual orientation, personality, level of modesty, mental status etc with each exam. • Know what screening is recommended & what you feel comfortable to advise.

  33. Routine Screening • Advocate to decrease the risk of certain behaviors. • ACOG recommends periodic screening summarized in Table 1 of the Syllabus

  34. Screening Summary Sheet

  35. Reproductive Health Screening

  36. Colorectal & Eye/Ear Health Screening

  37. Skin/Oral Health Screening & Immunizations

  38. History Reason for visit Health Status (Med, Surg, FMHx) Diet Physical Activity Use of CAM Substance Use Abuse/Neglect Sexual Practices Urinary/fecal Incontinence [Dental, Sight, Seat Belts] Physical Exam Ht. Wt. BP Skin Sexual Characteristics Pelvic Exam (begin with sex or at 18) Breasts (>19) Abdomen (>19) Neck: Lymph Nodes, thyroid (>19) Oral Cavity (>40) [>19] [History directed ie heart flutter, cough] [Feet] Table 1 Periodic Assessment Screening

  39. Table 1 Periodic Assessment Screening • Laboratory Testing • Pap (annually after sex starts or >18, physician/pt discretion after 3 normal) • Colorectal- digital rectal (HR or annual >40); >50 add colonoscopy (q10), sigmoidoscopy (q5) or barium enema (q5-10) • Cholesterol (HR or every 3-5 start at 45-75) • Fasting Glucose (HR or 3-5 start at 45) • TSH (>19) • Mammogram (HR or q1-2 >40 q1 >50) • [ACOG – HR, Baseline @35, then q1>40] • Urinalysis (>65)

  40. Sexuality Development (<18) HR Behaviors Pregnancy Planning STI – partner selection & barrier protection Sexual Function – (>19) Preconceptual (>19) Fitness & Nutrition Diet (eating disorders) Exercise Folic Acid (0.4mg/d upto 50) Calcium [start at 1st visit] [calorie in = calorie out] Table 1 Periodic Assessment Screening Evaluation & Counseling

  41. Psychosocial Relationships Interpersonal Family Peer Sexual identity (13-18) Abuse/neglect [violence] School Experience (13-18) Work (>19) Lifestyle (>19) Sleep (>19) Retirement (>40) [NOW] Depression (>65) [All ages] Cardiovascular Family History Hypertension Dyslipidemia Obesity Diabetes mellitus Lifestyle (>19) [Cancer] Breast Ovarian Colon Lung Lymphoma Table 1 Periodic Assessment Screening Evaluation & Counseling

  42. Immunizations Periodic Tetanus-diptheria booster (11-16 then q10) Hep B Vaccine (13-18) Influenza (annual >50) [or HR] Pneumoccal (once >65) [HPV Series (9-26)] HR Groups Influenza Pneumococcal Hep. A Hep. B Measles-mumps-rubella Varicella Table 1 Periodic Assessment ScreeningEvaluation & Counseling

  43. Depression Screening • 5-9% of adults experience severe depression. • Occurs at least once in 20% of all individuals during their life. • WHO estimates major depression the 4th most important cause of disability and may progress to # 2 by 2020.

  44. Depression Screening US Preventive Services Task Force (USPSTF) • Screening improves accuracy of identification of illness like depression. • Accurate diagnosis leads to significant decrease in morbidity. • Recurrent screening allows for improved relational skills with a patient. • History is the important screen in this case. • Watch for ”anhedonia”

  45. Skin Cancer Screening • Melanoma • Increased from 5.7 -13.3/100,000 from 1973 – 1995 • Lifetime risk 0.21% for women • Women >65 represent 14% of new diagnosis • ACOG recommends annual >13 (USPSTF does not secondary to insufficient evidence) • Dermatogists total body screen 94-98% sensitivity & specificity

  46. Tobacco Use Screening • Up to 30% of reproductive age women smoke • Responsible for 30% of all cancers • Responsible for 55% of cardio deaths • 70% of smokers see doctors annually • 70% want to quit • 35% never addressed by doctor • <15% were offered smoking cessation • Only 3% were given follow up appointment to discuss • Smoking in pregnancy outweighs any pharmacotherapy risk • Every patient should be asked

  47. 5 “A’s” of Tobacco Screening • Ask about tobacco use • Advise to quit or clear • Assess willingness to quit • Assist in quitting through counseling (may want to offer pharmacy) • Arrange follow-up intervention

  48. Health Behaviors: Smoking

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