1. The Adult Preventive Exam & the Use of the Health Prescription Dana Sprute, MD, MPH UT Southwestern Austin Family Medicine Residency Program June 6, 2011

2. Objectives Understand basic epidemiology principles upon which screening & prevention are based. Understand U.S. Preventive Services Task Force (USPSTF) recommendation for screening system. Identify behavioral & health risk factors in adults. Identify appropriate screening tools and their application in asymptomatic patients and those at risk. Apply screening principles during a comprehensive preventive history & physical exam for a healthy adult. Apply basic risk reduction counseling techniques during the adult preventive exam through the health prescription.

3. It’s all about probability The practice of clinical medicine is the artful application of science. --- Sir William Osler, 1921.

5. Why Should I Care About This? Clinical reasoning and algorithms are the result of application of principles of epidemiology to clinical medicine. Clinical decision making that is done every day is based on probabilities. –What is the probability that my patient has this disease? –What is the probability that finding this disease early will make a difference in outcome for my patient?

6. U. S. Preventive Services Task Force (USPSTF) USPSTF is convened by the Public Health Service to evaluate clinical research & assess the merits of preventive measures, including screening tests, counseling, immunizations, and preventive medications. USPSTF is an independent panel of experts in primary care and prevention who systematically review the evidence of effectiveness and develops recommendations for clinical preventive services. Provide screening recommendations based on evidence (Categories: A, B, C, D, I).

7. Is There Evidence to Support Intervention? USPSTF Recommendation Codes Based on quality of evidence & net benefit. A: Strong recommendation (Good evidence service improves health outcomes; substantial benefit). B: Recommends. (Fair evidence; moderate to substantial benefit) C: No recommendation. (Fair to good evidence; the balance of benefits and harms is too close to justify a recommendation). D: Recommends against. (Fair evidence of ineffectiveness; the harms outweigh the benefits). I: Insufficient. (Evidence is lacking, of poor quality or conflicting; balance of benefits and harms cannot be determined.)

8. U. S. Preventive Services Task Force (USPSTF) Guide to Clinical Preventive Services, 2010-2011 Recommendations of the U.S. Preventive Services Task Force http://www.ahrq.gov/clinic/pocketgd1011/ Device downloads: http://epss.ahrq.gov/PDA/index.jsp

9. Principles of Screening Bottom line: does it make a difference if you find it early & treat it?

10. Principles of Screening Screening makes the following assumptions: –A screening test is available that is sensitive and specific for a single disease. –An early diagnosis & subsequent treatment will decrease morbidity & mortality from the disease which is being screened for.

11. Basic Prevention Principles Primary Prevention: prevent disease before it occurs (e.g. vaccination). Secondary Prevention: prevent disease by controlling risk factors (e.g. prevent CVA by controlling HTN) Tertiary Prevention: prevent subsequent events once disease is present (e.g. prevent other cardiovascular events after known MI).

12. Epidemiology Basics: Incidence & Prevalence Incidence : –Incident case: newly diagnosed case. –Incidence rate: rapidity with which new cases of a specific disease occur within a population. –Usually expressed as # of new cases / year. Prevalence : –Number of existing cases of a specific disease in a population. –Usually expressed as # of cases/100,000.

13. Epidemiology Basics: Morbidity & Mortality Morbidity : adverse effects/outcomes due to disease (or screening test) except death. Mortality : death due to disease or testing. Effect of morbidity and mortality on population: –Morbidity or mortality from the disease must be of sufficient concern to public health. –A high-risk population must exist. –Effective early intervention must be known to reduce morbidity or mortality.

14. Epidemiology Basics: Sensitivity Definition: Percentage of persons with disease who have a positive screening test. Pitfalls: –Tests which have high sensitivity, but low specificity result in higher costs for evaluation of false positive tests. –Worry about the false negative in this test. These people will not be evaluated for disease.

15. Epidemiology Basics: Specificity Definition: Percentage of persons without disease with a negative screening test result. Pitfall: –Worry about the false positive in this test (which leads to costly and unnecessary additional testing, evaluation).

16. Risks of Screening False positive test False negative test Unnecessary additional testing Anxiety Labelling Unnecessary treatment

17. Screen based on: Disease prevalence in the community Personal & Family medical history Personal preferences or values Cost Convenience Resources/Systems Medicolegal concerns

18. U.S.Leading Causes of Death: 2007 CDC FastStats: Leading Causes of Death & Mortality, 2007 Heart disease Cancer Cerebrovascular disease Chronic lower respiratory diseases Accidents (unintentional injury) Diabetes mellitus Alzheimer’s disease Pneumonia & influenza Renal disease Septicemia Intentional self-harm (suicide) Chronic liver disease & cirrhosis Essential hypertension & HTN renal disease Parkinson’s Disease Assault (homocide)

19. Underlying Causes of Death in U.S. 2007 Tobacco: leading cause in U.S. and worldwide Diet & inactivity Alcohol abuse Microbial agents Toxic agents Firearms Sexual behavior Motor vehicle accidents Illicit drugs

20. Categories of Risk Cancer Medical Disease Infectious Disease Behavior Mental Health

21. Cancer

25. Medical Disease

27. Infectious Disease

29. Behavior

30. Mental Health

31. 2011 Recommended Adult Immunization Schedule Tetanus & diphtheria (Td); one booster TdaP for pertussis coverage Influenza Pneumococcal Pneumococcal Revaccination Hepatitis B Hepatitis A Measles, Mumps, Rubella (MMR) Meningococcal Varicella HPV Zoster H1N1

32. 2011 Adult Vaccine Schedule: CDC

34. “Recent” Vaccination Approval Human Papilloma Virus (HPV): –FDA approval of Gardasil 6/2006 –Vaccine directed against HPV 6, 11, 16 & 18 –First vaccine to prevent cervical cancer, precancerous genital lesions & genital warts caused by 6, 11, 16 & 18. –Approved for use in females 9-26 yrs of age. Females not yet sexually active Females not infected with HPV (therefore, best to vaccinate prior to onset of sexual activity). –Recombinant vaccine –Given in 3 injections over 6-month period (months 0, 2 & 6). –4 studies included 21,000 women aged 16-26; 100% effective in prevention of cancer & precancerous lesions (cervix, vagina & vulva) & warts in uninfected women. –Safety: adverse effects include mild or moderate local reactions.

35. “Recent” Vaccination Approval Zoster (Reactivation Varicella) –Zostavax –Live attenuated varicella zoster vaccine –Recommended for adults > 60yo once. –Contraindications: immunodeficiency (cancer, HIV), pregnancy, untreated TB –Precautions: defer during acute illness

36. “Recent” Vaccination Change Meningoccocal Vaccination: Meningococcal Conjugate Quadrivalent Vaccine (MCV4) Licensed in the United States for persons 2–55 years of age in 1981 –Low risk: first dose age 7-11; Vaccinate at risk: –college freshmen living in a dormitory –military recruit –damaged spleen or splectomy –terminal complement deficiency; HIV infection –Microbiologists routinely exposed to Neisseria meningitidis ( revaccinate Q5yrs ) –traveling or residing in countries in which the disease is common (subsaharan Africa; required for travel to Mecca during Hajj). Licensed in 1981 MPSV4 (polysaccharide) is recommended for individuals who are at elevated risk aged over 55 years.

37. “Age 50 Vaccination Check” Advisory Committee for Immunization Practices (ACIP) & AAFP recommend all 50 year old adults: –Receive Td booster if they have not had a booster within the last 10 years. Substitute one dose of TdaP for Td booster (pertussis component). –Be screened for high-risk conditions such as chronic cardiac or pulmonary diseases (except asthma) that indicate the need for pneumococcal vaccine. –Start annual influenza vaccination (if not already initiated). 2009 Changes –Pneumovax indicated for tobacco smokers & asthma Texas Department of Health & CDC recommend: –Due to reactivation of pertussis in previously vaccinated adults in Texas, give one adult booster as TdaP (acellular pertussis). –2008: 255 cases of pertussis in Travis County

38. H1N1 Indications CDC, Advisory Committee on Immunization Practices, 7/2009 July 2009, ACIP Recommendation: these groups receive the vaccine before others if supply is limited: –pregnant women, –people who live with or care for children younger than 6 months of age, –health care and emergency services personnel who have direct patient contact, –children ages 6 months to 4 years, and –children ages 5 to 18 years who have chronic medical conditions.

39. Medicare Covered Preventive Services Breast cancer: MMG every 12 months. Cervical cancer: PAP & pelvic exam every 24 months. Colorectal cancer: FOB every 12 months –Flexible sigmoidoscopy every 24 months –Colonscopy every 10 years; if high risk, every 24 months –Barium enema every 48 months; if high risk, every 24 months Prostate cancer: DRE & PSA every 12 mon Glaucoma: every 12 months. Osteoporosis: DEXA every 24 months Vaccinations: Annual flu, pneumovax, Hep B Added in 2005: One-time wellness PE, blood tests to screen for heart disease and diabetes.

40. Medicaid Covered Preventive Services Breast cancer : –Women 35-39: Baseline MMG –Women 40-49: Every 2 yrs in conjunction with breast exam. –Women > 50: MMG every 12 months in conjunction with breast exam. Cervical cancer : –Annually with a covered family planning visit –More often if medically necessary (e.g., cervical dysplasia, high risk HPV) Colorectal cancer : for patients > 50 –FOB every 12 months –Flexible sigmoidoscopy every 48 months –Colonoscopy every 24 months for high risk Prostate cancer : PSA every 48 months for men > 50 Vaccinations : –Influenza annually –Pneumovax (once in lifetime) THSteps : Ages 0-18; See table of periodicity.

41. Case 1 25 yo female for “well woman exam.” PMH: Healthy, hx MVA Family Hx: Breast CA (mother), Diabetes (father) Social Hx: G2P2002, Single, Employed at WalMart as a clerk. + Tobacco Use (5pk yr hx), rare ETOH. 2 sexual partners past year. VS: BP 112/72, Ht: 65”, Wt: 180, BMI: 30, LMP: 2wks late. PE: WNL, tattoo

42. Case 1: Screening & Counseling Recommendations 25 yo female for “well woman exam.” CA: Breast (B), pos fam hx, when to screen?; Cervix (A) MD: Lipid (A), ?DM (B if sxs or risk), HTN (A), Obesity (I) ID: Chlamydia (A), GC (B), HIV (A), Syphilis, Behavior: Family Violence (I), Nutrition (I/B), Physical Activity (I), Tobacco (A) MH: Depression (B) Vaccination: dT (or TdaP), annual influenza, Hep B, Hep A Other health issues: contraception, Hep C (tattoo)

43. Case 2 45 yo male with no medical problems here to establish care. PMH: urolithiasis age 32 FH: Prostate CA (father), CAD (mother), Colon CA (bro age 50) SH: Married, 3 children, plumber, walks 2x/wk, smoker, ETOH (4 beers QD), National Guard duty Q3months. VS: BP: 142/88, Ht: 70”, Wt: 195, BMI: 28 PE: WNL

44. Case 2: Screening & Counseling Recommendations 45 yo male with no medical problems. CA: Colon CA (A) pos fam hx, Prostate CA (I) pos fam hx MD: Lipid (A), CAD (D, unless risk factors), DM (I/B), HTN (A), Obesity (B/I) ID: Behavior: Tobacco Use (A), Alcohol Misuse (B), Nutrition (I), Physical Activity (I) MH: Depression (B) Vaccination: dTaP, annual influenza, pneumovax (smoker), Hep B & Hep A (occupational risk), meningococcal

45. Case 3 65 yo female for her “Medicare physical.” PMH: HLP, HTN, pneumovax 7 yrs ago FH: Both parents died “of old age” SH: Widowed 8yrs, lives alone, G4P3013, daughter in Austin. Retired teacher, Denies ETOH, Tob 20pk yr hx-D/C 6yrs ago. VS: BP 110/62, Ht: 62”, Wt: 118, BMI: 21 PE: WNL

46. Case 3: Screening & Counseling Recommendations 65 yo female with HTN & HLP. CA: Breast (B), Cervix (A if at risk; D > 65 if no risk), Colon (A), Ovarian (D), Lung (I) MD: ASA (A), Lipid (A), ?CAD (D unless risk), ?DM (B if sxs/risk), HTN (A--controlled, reinforce), Osteoporosis (B) ID: ?STI Behavior: ?Physical Activity, ?Nutrition MH: Depression (B), ?Dementia (I) Vaccination: dT, pneumovax, annual influenza, HepA/B

47. Case 4 67 yo male for “physical.” Requests Viagra. PMH: HTN (controlled), COPD, ED FH: Diabetes (many), Osteoporosis SH: Truck driver, divorced 30 yrs, 4 children (from whom he is estranged), + tobacco (45pk yr hx), + ETOH (case Qwk). Sedentary. VS: BP 124/82, Ht: 70”, Wt: 165, BMI: 23. Has lost 14# since last visit 6months ago. PE: Distant BS, Abdominal bruit.

48. Case 4: Screening & Counseling Recommendations 67 yo male w/ HTN, COPD, wt loss, abd bruit. CA: Colon (A), ?Lung (I), ?Prostate (I), Skin (I) MD: ASA (A), Lipid (A), CAD (D unless risk), DM (B if sxs/risk), HTN (A), Osteoporosis (B: + FH) ID: ?STI. Use of viagra (?sexual hx) Behavior: ETOH (B), Nutrition (I/B), Tobacco (A) MH: Depression (B) Vaccinations: dT, pneumovax, annual influenza, HepA/B Other testing considerations: CAD, USG r/o AAA, w/u wt loss (CA, depression). What about the Viagra?

49. So….Screen & Intervene based on: Risk –Diseases for which early screening can reduce morbidity & mortality –Genetic (nonmodifiable risk) –Behavioral (modifiable risk) Prevalence of disease Personal preference Resources

50. Use the Health Prescription Helpful counseling tool. Helpful tool to organize your approach to counseling & screening during a preventive exam. Helpful educational tool for patients. Useful way to document what you did.

51. Website Resources www.ahrq.gov/clinic/prevenix.htm: US Preventive Services Task Force http://epss.ahrq.gov/PDA/index.jsphttp://epss.ahrq.gov/PDA/index.jsp(download guidelines to PDA). http://www.ahrq.gov/clinic/pocketgd1011/http://www.ahrq.gov/clinic/pocketgd1011/ (Guide to Clinical Preventive Services, 2007, USPSTF). www.cdc.govwww.cdc.gov: Centers for Disease Control & Prevention. www.immunizationed.orgwww.immunizationed.org: Society of Teachers of Family Medicine. Http://preventiveservices.ahrq.gov: Agency for Healthcare Research & Quality. www.ctfphc.org: Canadian Task Force on Preventive Health Care. www.ahrq.gov/clinic/ppipix.htm: Putting Prevention into Practice www.cancer.org: American Cancer Society www.smokefree.gov: US Dept of Health & Human Services www.immunizationed.org/downloads/adult-schedule.pdf (download to PDA).

52. References U.S. Preventive Services Task Force, Guide to Clinical Preventive Services, 2010- 2011. Recommendations of the U.S. Preventive Services Task Force “Adult Prevention” AAFP Home Study Monograph 308, January 2005. Centers for Disease Control, DHHS, National Center for Health Statistics. FastStats, Leading Causes of Death in the US, 2007. Centers for Disease Control, DHHS. Recommended Adult Immunization Schedule United States, 2009 & Recommended Immunizations for Adults with Medical Conditions United States, 2009. Summary of Recommendations published by the Advisory Committee on Immunization Practices (ACIP). Morbidity & Mortality Weekly Report, Centers for Disease Control. Recommended Adult Immunization Schedule—United States, 2010-11. American Cancer Society: www.cancer.org. ACS Cancer Detection Guidelines CDC, Advisory Committee on Immunization Practices, 7/2009 Texas Department of State Health Services: Selected Health Facts, 2008, Travis County.