Introduction to Health Promotion and Disease Prevention Flashcards
Main preventative care services
Immunizations
Screening
Behavioral counseling
Chemoprevention (meds and immunization)
Colorectal screenings
Primary Prevention
Healthy patients (do not have disease yet)
Goal of primary prevention
prevent disease from occurring at all
Treat or remove the cause of disease
Occur in clinical settings, community activities, public health
Example of primary prevention
Immunizations or behavioral counseling: smoking cessation
Promoting public health through lectures is an example of
primary prevention
Onset of diabetes to diagnosis
7 years
Secondary prevention
Patients already have the disease, but usually early stage and asymptomatic
Goal of secondary prevention
Early detection and cure, prevent disease progression
screening
early diagnosis
effective treatment and management
Example of secondary prevention
HIV screening
Tertiary prevention
patient already has the disease
Goal of tertiary prevention
Prevent progression/deterioration
treatment
focus on long term outcomes rather than short term outcomes
Example of tertiary prevention
diabetic management: glycemic control, foot care, retinal evaluations
Primary prevention _____________
prevents disease from occurring
Secondary prevention ___________
detects and cures disease in the asymptomatic phase
Tertiary prevention _____________
reduces complications of the disease
Cardiac primary prevention
patients do not have ischemic heart disease or vascular disease
Cardiac secondary prevention
patients have known disease: treatment to prevent progression
OR
patients at very high risk of disease
Neurology primary prevention
prevention of stroke with people with risk factors
Neurology secondary prevention
Patients who have had a stroke, patients who have had a TIA, patients who are at a very high risk of ischemic stroke
The same tests can be used for _______ levels of prevention and for diagnosis
all
Primary prevention: Colonoscopy
screening to find and remove pre-cancerous polyp
Secondary prevention: Colonoscopy
screening to find and remove an early colon cancer
Tertiary prevention: colonoscopy
follow-up of a patient who has been treated for colon cancer
Primary Prevention KEY
Patients do not have the disease, goal is to prevent the development of the disease
Secondary and tertiary prevention KEY
patients already have the disease or are at extremely high risk (specialty specific)
Primum non nocere
First, do no harm
Non-maleficence is important for patients
who do not have disease
What do we consider in screening?
- How great is the burden of disease?
- How good is the screening test?
- How good is the treatment?
Burden of disease
How common is it (epidemiology, etiology)?
How much suffering does it cause?
The 5 Ds
Death
Disease
Disability
Discomfort
Dissatisfaction
How good is the test?
Sensitivity and specificity
Positive predictive value and negative predictive value
Simplicity
Cost
Safety
Acceptability
How good is the test: PPD
not useful in early stages of disease because IGg, cheap, simple, can be more complicated because more than one appointment needed
Disease State: True Positive
(+ test/+ disease state)
Disease State: False Positive
(+ test/ - disease state)
Disease State: False negative
(- test/ + disease state)
Disease state: true negative
(- test/ - disease state)
Sensitivity
probability that a patient + with disease will have a + test
If sensitivity if high
Most people with disease all have a positive test
Few false negatives
negative test, likely they do not have a disease
SNOUT
high sensitivity rules out if the test is negative
Specificity
The probability that a patient without the disease will test negative
Very few false positives
If someone has a positive they probably have the disease
Strep test specificity or sensitivity higher?
specificity higher
SPIN
specificity rules in
Positive predictive value
Likelihood that a person with a positive test has the disease
Dependent on the prevalence
“how truly positive is the test”
Negative predictive value
Likelihood that a person with a negative test does NOT have the disease.
Dependent on prevalence
When ordering screening test keep in mind
prevalence of disease
positive predictive value of your test
negative predictive value
Goal for screening tests
-minimal prep by the patient
-easy to administer
-quick-rapid turn around
-cheap (is it covered by insurance)
-no special appointments
-Should be VERY safe
-patients need to be willing to have the test
Considerations for how good is the treatment
- is there a treatment that works?
- what are the risks/harms of the treatment?
- cost/benefit
- does it matter if you get treated earlier (asymptomatic) vs. (symptomatic)
Harms of preventative care
- adverse effects of screening tests or treatment
- dealing with false positive tests
- risk of overdiagnosis
- finding an “incidentaloma”
Harms of false positive tests
- need for additional testing
- additional cost
- may involve higher risk procedures
- stress and anxiety for patients, even if further work-up is negative
A good study
account for bias and adequately assess risk and benefits
Lead time bias
People who are diagnosed with screening survive longer after diagnosis than patients who present with symptoms, even if early treatment doesn’t make a difference
just because we find them early doesn’t mean they live longer
Lead time bias should use ______
mortality rates rather than survival rates
Types of bias
- Lead time bias
- Length time bias
- Compliance bias
Length time bias
- Has to do with growth rates
- slower growing cancers (which have a better prognosis) are more likely to be found by screening
- fast growing cancer (which have a worse prognosis) usually present between screenings or before screening starts
slow growing cancer
prostate
fast growing cancer
pancreatic cancer, lung cancer
Compliance bias
patients have a better prognosis than non-compliant patients, regardless of screening
Not clear: more interested in their health, usually healthier
Sometimes treatment is worse than disease
USPSTF
United States preventative task force
Created in 1984
Independent volunteer panel of national experts in disease prevention and evidence-based medicine
Internal validity
- whether the results of the research are correct for the patients who are studies
Problems with internal validity
chance: random error
bias: systematic error
Systematic error bias
problems with:
randomization
blind
losing patients to follow-up
publication bias
External validity
how well does this study apply to patients who were NOT in the study
Task forces
make evidence-based recommendations about clinical preventative services
USPSTF does NOT make recommendations about
immunizations
USPSTF Recommendation: Grade A
recommends this service. High certainty that the net benefit is substantial
USPSTF Recommendation: Grade B
recommends this service. High certainty that the bet benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial
USPSTF Recommendation: Grade C
recommends selectively. Offer to individual patients based on professional judgement or patient preference. Moderate certainty that the bet benefit is small
USPSTF Recommendation: Grade D
recommends against this service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits
USPSTF Recommendation: Grade I
current evidence is insufficient to assess the balance or benefits of harms in the service. Evidence is lacking, poor quality or conflicting and the risk/benefit can not be determined
Level of certainty: High
Consistent results from well-designed/conducted studies in representative populations. Result is unlikely to be changed with results from future studies
Level of certainty: Moderate
evidence sufficient to determine the effects of preventative service on health outcomes with constraints (number, size, quality of studies. inconsistent findings. limited generalizability). Findings could change as further studies performed.
Level of certainty: Low
current evidence is insufficient to assess effects on health outcomes due to limited size/number of studies, flaws in study/methods, gaps in chain of evidence, findings not generalizable, lack of information on important health outcomes
More information may allow estimation of effects on health outcomes
CDC advises
on immunization practices
Adult immunization recommendations
Influenza
TDAP
Zoster
MMR
Varicella
Pneumococcus
Adult influenza
annually
Adult TDAP
Single dose for adults 19+ and 10 year booster annually
Adult zoster
adults >50 years (live vaccine)
Adult MMR
1-2 doses if born in 1957 or later
Adult Varicella
> 13 years if no evidence of immunity
Adult HPV
females: up to age 26 (up to 45 with shared decision making)
Male: up to age 21
Men who have sex with men: up to age 26
Adult meningococcal vaccine
adults up to age 21 who are living in college dorms
Adult Hep B vaccine
adults age 19-59 with diabetes
other adults at high risk (HCW)
Adult pneumococcus
2 separate vaccines:
Pneumovax (PPSV-23)
Prevnar (PCV-13)
> 65 all get PPSV-23
not recommended 19-64 and healthy not recommended
19-64 with chronic conditions: PPSV-23
19+ with immunocompromise PCV-13 and then PPSV-23
PPSV-23
Pneumovax
PCV-13
Prevnar
Main types of vaccines
live attenuated vaccines
inactivated vaccines
subunit vaccines
toxoid vaccines
conjugate vaccines
mRNA vaccines
Live attenuated vaccines
live version of the organism that has been weakened (attenuated) so that it doesn’t cause disease in patients with healthy immune systems
- can cause disease in patients who are immunocompromised
- usually need 1-2 doses for lie-long immunity
Examples of live attenuated vaccines
MMR, Varicella/Zoster
Inactivated vaccines
use a killed version of the germ
- may need several boosters to get long-term immunity or maintain immunity
Examples of inactivated vaccines
polio injection (IPV), Hep A
Subunit vaccines
contain part of the germ (essential antigen), does not cause infection and has less side effects
Example of subunit vaccine
petrussis
toxoid vaccines
prevent disease that are due to toxins that are produced by bacteria, use a weakened form of the toxin (toxoid)
Example of toxoid vaccine
tetanus, diphtheria
Conjugate vaccines
some bacteria have outer coating of polysaccharides that can prevent an immature immune system (infant and children) from recognizing them
link antigens or toxoids that the immune system does recognize to the polysaccharides (immune response to polysaccharides)
Example of conjugate vaccines
Hib (meningitis for infants/toddlers)
Major contraindications to vaccines
- anaphylaxis to vaccine or component of vaccine (ex: eggs in flu)
- pregnancy (no live attenuated vaccines)
- severe immunodeficiency
Allergen in influenza vaccine
eggs
Allergen in varicella vaccine
gelatin
Allergen in hepatitis B vaccine
baker’s yeast, neomycin
Allergen in MMR, polio vaccines
streptomycin
Live vaccines are contraindicated in:
immunocompromised, pregnancy
MMR, varicella, live zoster, live influenza
Delay vaccines if patient is moderately or severely ______
ill
postpone vaccine if patient has received _____________
immunoglobulin
Side effects of vaccines
Guillain-barre, high fevers (104.5), seizures, prolonged/inconsolable crying
Cervical cancer screening recommendations
ages 21 (25-65)
Frequency and tests depends on age for PAP (maybe will be discontinued), HPV testing (co-testing)
Cytology is done every _____ years
3
Colorectal screening recommendation
age 50-75 Grade A
age 45-49 Grade B
Breast cancer screening
biennial mammography
age 5-74 Grade B
Prostate cancer screening
age 55-69, PSA, individual decision, Grade C
Lung cancer screening
smokers/former smokers age 50*-80 years old
USPSTF types of counseling
tobacco cessation
healthy diet and physical activity
obesity screening
STI
fall prevention
skin cancer behavioral
USPSTF types of screening
blood pressure (starts at 18)
depression
HIV
alcohol use
diabetes
intimate partner violence
osteoporosis
AAA
chlamydia and gonorrhea
hepatitis
USPSTF types of chemoprevention
- use of statins (hyperlipidemia to prevent MI)
- tobacco cessation
- ASA to prevent ASCVD (atherosclerotic disease) and colorectal cancer (helps prevent polyp formation)
