Adult Preventive Health Care Guidelines

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Adult Preventive Health Care Guidelines

• Debbie King FNP PNP

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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

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Clinicians Handbook of Preventive Care

• http//www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book
  hsarchivepartA4489
• 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.

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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

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The National Coordinating Committee on Clinical
Preventive Services

• 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

• 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

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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

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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

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Prevention

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

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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.h
  tm

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Recommending Bodies- Cont

• US Preventive Services Task Force-cont
• 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

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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.

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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.

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KEY

• KEY American Academy of Family Physicians
  AAFP
• US Preventive Services Task ForceUSPSTF
• Frequency periodically, use clinicians judgment
  as to frequency

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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 hours of a physicians
  annual time, or 7.4 hours per working day, is
  needed for the provision of preventive services.
• Conclusions. Time constraints limit the ability
  of physicians to 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_at_mc.duke.edu ).

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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

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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

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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

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Screening Services for High Risk Patients

• STDS
• AAFP- recommends counseling adolescents and
  adults regarding the risks for STDs and how to
  prevent them
• USPSTF strongly recommends that clinicians screen
  persons at increased risk for syphilis infection

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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

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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

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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

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Basic Adult Prevention Guidelines

• Abdominal Aortic Aneurysm-Men 65-75 who ever
  smoked
• SUPSTF- recommends one time screening by
  ultrasonography

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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

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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

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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

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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

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More Thyroid Screening Recommendations

• II. The American Academy of Clinical
  Endocrinologists recommends screening symptomatic
  women and women gt 40yo with family h/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

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Basic Adult Prevention Guidelines

• Skin Cancer screeningAll 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

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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

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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

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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.

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Basic Adult Prevention Guidelines

• Glaucoma-all adults
• USPSTF-Insufficient evidence to recommend routine
  screening

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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-periodi
  cally question them about hearing, counsel them
  about the availability of hearing aids, make
  appropriate referrals

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Basic Adult Prevention Guidelines

• Hearing screening-elderly adults- cont
• 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

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Basic Adult Prevention Guidelines

• Oral Cancer Screening-all adults
• USPSTF- insufficient evidence to recommend
  routine screening of asymptomatic persons for
  oral cancer by PCP

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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

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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.

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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.

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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 gt 30yo and has had 3 consecutive normals).
  Start 3y after sexually active or age 21, stop _at_
  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

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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

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Basic Adult Prevention Guidelines

• BP screen 18 and older
• AAFP- periodically, use clinicians judgment as
  to frequency
• USPSTF- strongly recommends that clinicians
  screen adults age 18 and older for high blood
  pressure

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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

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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.

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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

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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

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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.