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

“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

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

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 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 Jul;31(1):90-6Am J Prev Med Jul;21(1):10-9

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

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

Scoring Ranges

Top 5 Priorities ServicesCPBCETotal Aspirin Chemoprophylaxis5510 Childhood Immunization5510 Tobacco-Use Screening/Intervention5510 Colorectal Cancer Screening448 Hypertension Screening538 Am J Prev Med Jul;31(1):90-6 CPB: Clinically Preventable Burden CE: Cost Effectiveness

1. Aspirin Chemoprophylaxis Risk reduction: Men, ages 45-79, to prevent MI’s Women, ages 55-79, to prevent strokes Optimal dose: mg/day Higher dose -> Higher risk of GI bleed Avoid: Patients with history of GI bleed Patients allergic to Aspirin

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

Smoking Cessation: 5 A’s InterventionIssue AskAbout tobacco use AdviseTo quit AssessWillingness to quit AssistIn quit attempt ArrangeFor follow-up

Smoking Cessation: 5 R’s AssessmentIssue RelevanceEncourage the smoker to identify why quitting is personally relevant RisksAsk the smoker to identify negative consequences of continued tobacco use RewardsAsk the smoker to identify and discuss specific benefits of quitting RoadblocksAssist the smoker to identify specific barriers and impediment to quitting RepetitionReinforce the motivational message at every opportunity Reassure that repeated quit attempts are not unusual

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

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:

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

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

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

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

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

5. Influenza/Pneumococcal Immunization ServiceDescriptionCPBCETotal Influenza Immunization Immunize adults aged ≥50 against influenza annually 448 Pneumococcal Immunization Immunize adults aged ≥ 65 against pneumococcal disease with one dose for most in this population 358 CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med Jul;31(1):90-6

6. Problem Drinking Screening and Brief Counseling ServiceDescriptionCPBCETotal Problem Drinking Screening and Brief Counseling Screen adults routinely to identify those whose alcohol use places them at increased risk and provide brief counseling with follow-up 448 CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med Jul;31(1):90-6

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

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

Recommended Alcohol Intake Per Day GenderBeer (12 ounces) Wine (5 ounces) Liquor (1.5 ounce) * If you don’t drink, don’t start

7. Vision Screening ServiceDescriptionCPBCETotal Vision ScreeningScreen adults aged ≥65 routinely for diminished visual acuity with Snellen visual acuity chart 358 CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med Jul;31(1):90-6

8. Cervical Cancer Screening ServiceDescriptionCPBCETotal Cervical Cancer Screening Screen women who have been sexually active and have a cervix within 3 years of onset of sexual activity or age 21 routinely with cervical cytology (Pap smears) 437 CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med Jul;31(1):90-6

9. Cholesterol Screening ServiceDescriptionCPBCETotal Cholesterol ScreeningScreen routinely for lipid disorders among men aged ≥ 35 and women aged ≥ 45 and treat with lipid-lowering drugs to prevent the incidence of cardiovascular disease 527 CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med Jul;31(1):90-6

10. Breast Cancer Screening ServiceDescriptionCPBCETotal Breast Cancer Screening Screen women aged ≥ 50 routinely with mammography alone or with clinical breast examination, and discuss screening with women aged 40 to 49 to choose an age to initiate screening 426 CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med Jul;31(1):90-6

Other Services ServicesCPBCETotal Chlamydia Screening246 Obesity Screening325 Osteoporosis Screening224 Diabetes Screening112 Diet Counseling112 CPB: Clinically Preventable Burden CE: Cost Effectiveness Am J Prev Med Jul;31(1):90-6

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

Vilus Vilsaint (DOB: August 13, 1895)