Prevention Flashcards
Top 5 causes of death and % among all people in US
- heart disease (24.6%)
- cancer (23.3%)
- chronic lower respiratory dzs (5.6%)
- stroke (cerebrovascular dzs) (5.3%)
- accidents (unintentional injuries) (4.8%)
Life expectancy at birth in US (1900 vs 2010)
1900: 47.3 years
2010: 78.7 years
Top 10 causes of death in US
- heart disease
- cancer
- chronic lower respiratory dzs
- cerebrovascular accident/stroke
- accident (unintentional injury)
- Alzheimer’s disease
- diabetes
- influenza/pneumonia
- nephritis, nephrotic syndrome, and nephrosis
- intentional self harm (suicide)
other:
- septicemia
- essential (primary) htn and hypertensive renal dz
- homicide
Causes of death in US: causes in the top 10 that are more common in men
heart disease, cancer, chronic lower respiratory dzs, accidents (unintentional injuries), influenza/pneumonia, nephritis/nephrotic syndrome/nephrosis, intentional self-harm (suicide)
Causes of death in US: causes in the top 10 that are more common in women
Alzheimer’s disease?, diabetes
Causes of death in US: causes in the top 10 that are about equal men and women
stroke (cerebrovascular accident)
Causes of death in US: causes in the top 10 that are more common in black population than white population
heart disease, cancer, stroke (cerebrovascular accident), nephritis/nephrotic syndrome/nephrosis
Causes of death in US: causes in the top 10 that are more common in white population than black population
chronic lower respiratory diseases, accidents (unintentional injuries), intentional self-harm (suicide)
Causes of death in US: causes in the top 10 that are about equal in black population and white population
Alzheimer’s disease, diabetes, influenza/pneumonia
Sex gap in life expectancy
decreasing since its peak in early 1970s
Most common cancers in women
+
(most common causes of cancer deaths in women)
breast > lung > colon
+
(lung>breast>colon)
Most common cancers in men
+
(most common causes of cancer deaths in men)
prostate > lung> colon
+
(lung > prostate > colon)
Cancer prevention
colonoscopy, don’t smoke, Pap smear…
Young people: cause-specific mortality rates!
HIV/AIDS, accidents, liver disease, suicide, homicide
Old people: cause-specific mortality rates!
chronic lower respiratory diseases, Alzheimer’s disease, renal disease, septicemia
Leading causes of death for both young and old people!
diseases of heart, cancer, diabetes
Risk factors in younger cohort
unprotected sex, violence, more impulsive behaviors
Risk factors in older cohort
long term neurological damage, chronic heart disease, renal disease
Which ethnic/racial group in US has highest life expectancy at birth?
Hispanics
but examine data on hispanics w caution due to discrepancy in identification (self and by research) and diversity
True or false : the vast majority of leading causes of death in all ages, races, and sexes are preventable
True!
Healthcare expenditures in billions of dollars (2007)
Overall: $2200 tobacco related* diabetes** hypertension heart dz and stroke (2009)*** obesity (2008)*** cancer*
Healthcare expenditures in US (chronic dz, final year of life)
major driver of health costs: expensive, hi-tech interventions for end-stage chronic conditions
nearly 25% of Medicare expenditures spent on interventions during the final year of life
% of health care expenditures on prevention
2-3%
Cost savings (cost effectiveness) of prevention interventions
about $2.9 billion in community based dz prevention programs would save 16.5 billion annually
but
some sources say public health expenditures are actually more (2x as much) when including sectors outside of formal pub health system (eg nutrition assitance)
Savings and prevention at community level
$1 in biking trails and walking paths save nearly $3 in medical expenses;
$1 in wellness programs by companies would save $3.3 in medical and $2.7 in absenteeism costs;
$1 in targeting poor eating and physical activity generated $1.2 of savings
Population level interventions
vaccination in early 20th century brought greater than 90% reduction in mortality at very low cost per capita;
water fluoridation saves $38 in dental restorative treatments for every $1 spent
other examples of low cost public health prevention: cigarette taxes, smoking prohibitions in restaurants and bars, bans on restaurant use of trans-fat cooking
Major goals of prevention
- reduce burden of suffering for major preventable dzs
2. control expenditures by reducing need for intensive mgmt of late stage illness
Healthy people 2020 : Four overarching goals
- attain high quality, longer lives free of preventable disease, disability, injury, and premature death
- achieve health equity, eliminate disparities, improve health of all groups
- create social and physical environments that promote good health for all
- promote quality of life, healthy development, and healthy behaviors across all life stages
Access to health services
12 topic areas, 26 leading health indicators
- persons with medical insurance
- persons with a usual primary care provider
Clinical preventive services
12 topic areas, 26 leading health indicators
- adults who receive a colorectal cancer screening based on most recent guidelines
- adults with htn whose blood pressure is under control
- adult diabetic populations w an A1c value > 9%
- ## children aged 19-35 months who receive recommended doses of diphtheria, tetanus, and pertussis (DTaP); polio; measles, mumps, and rubella (MMR); haemophilus influenza type b (Hib), hepatitis B; varicella; and pneumococcal conjugate (PCV) vaccines
Environmental quality
12 topic areas, 26 leading health indicators
- air quality index (AQI) > 100
- children aged 3-11 yrs exposed to secondhand smoke
Injury and violence
12 topic areas, 26 leading health indicators
- fatal injuries
- homicides
Maternal, infant, and child health
12 topic areas, 26 leading health indicators
- infant deaths
- preterm births
Mental health
12 topic areas, 26 leading health indicators
- suicides
- adolescents who experience major depressive episodes (MDEs)
Nutrition, physical activity, and obesity
12 topic areas, 26 leading health indicators
- adults who meet current federal physical activity guidelines for aerobic physical activity and muscle-strengthening activity
- adults who are obese
- children and adolescents who are considered obese
- total vegetable intake for persons aged 2 years and older
Oral health
12 topic areas, 26 leading health indicators
- persons aged 2 years and older who used the oral health care system in past 12 months
Reproductive and sexual health
- sexually active females aged 15-44 yrs who received reproductive health services in past 12 months
- persons living with HIV who know their serostatus
Social determinants
12 topic areas, 26 leading health indicators
- students who graduate w a regular diploma 4 years after starting ninth grade
Substance abuse
12 topic areas, 26 leading health indicators
- adolescents using alcohol or any illicit drugs during past 30 days
- adults engaging in binge drinking during past 30 days
Tobacco
12 topic areas, 26 leading health indicators
- adults who are current cigarette smokers
- adolescents who smoked cigarettes in past 30 days
What are classic preventive serives
- immunizations
- chemoprophylaxis
- screening for early detection of disease
- education and counseling of patients about behaviors that impact their health
Levels of prevention strategies
primary, secondary, tertiary
Primary prevention strategies
- avoid development of disease
- remove risk factor
involves interventions that prevent disease from occurring
- discussing w pt strategies (advantage of using helmet when riding bike, smoking assessment and counseling, tetanus vaccine, seat belt use)
Secondary prevention strategies
- early detection
treatment - prevent progression
–> involves screening interventions that detect asymptomatic dz and improve outcomes
(Pap smears, blood pressure assessment, colonoscopy, fasting lipid panel serum in person without known lipid issues)
Tertiary prevention strategies
- reduce complications of established dz
–> intervention to reduce complications of established dz
(ophthalmology exams in diabetic pts or statin use in post-MI pts, EKG to assess for LVH in a known htn pt)
R.I.S.E.
an excellt way to keep prevention integrated in everyday clinical practice
Risk assessment and identification
Immunization and chemoprophylaxis
Screening
Education and counseling
Leading causes of death in white women aged 15-24 (CDC, 2011)
- accidents (unintentional injuries)
- intentional self-harm (suicide)
- malignant neoplasms (cancer)
- assault (homicide)
- diseases of the heart
- congenital malformations, deformations, and chromosomal abnormalities
- influenza and pneumonia
- pregnancy, childbirth, puerperium
- cerebrovascular dzs
- diabetes
Leading causes of death in black women age 15-24 (CDC, 2011)
- accidents (unintentional injuries)
- assault (homicide)
- malignant neoplasms (cancer)
- diseases of the heart
- pregnancy, childbirth, puerperium
- intentional self-harm (suicide)
- influenza and pneumonia
- human immunodeficiency virus (HIV) disease
- congenital malformations, deformations, and chromosomal abnormalities
- chronic lower respiratory diseases
Elements of risk assessment and identification
- age
- past and current med hx
- past sx hx
- sexual hx
- social hx (substance use/abuse hx, safety)
- occupational hx
Vaccines for low risk but sexually active 24 yo white med student
influenza (healthcare worker), HPV vaccine series (sexually active female < 26), Hep B vaccine (healthcare worker); Tdap if not already; assess immunity to MMR and Varicella (serum titer)
if she were pregnant, do not give: HPV or MMR or Varicella vaccines
Diabetic patient vaccination
Zoster if > 60 yo
influenza (>6 months)
Pneumovax (PPV) (regardless of age)
Hep B vaccine (as soon as possible after dx of diabetes)
Tdap (if not received or if status unknown, esp if caring for kids; 1 Tdap to replace one of Td boosters)
Zoster vaccine
patients > 60 yo regardless of diabetes status or whether they’ve had zoster before
Influenza vaccine
all patients > 6 months old (but at first dose ever give 2 doses, 1 month apart, after which do annually)
Pneumovax (PPV) vaccine
- all diabetics regardless of age
- patients with chronic lung, heart or liver disease; alcoholism; cochlear implants, CSF leaks, asplenia (functional or anatomic?)
- adult cigarette smokers
- residents of nursing homes or long term care facilities
Hepatitis B vaccine
- all pts with diabetes < 65 yrs asap after dx of diabetes
more stuff for kids but this is from module
Hepatitis A vaccine
- only recommended for patients with risk for exposure to this virus
Tdap (tetanus diphtheria acellular pertussis vaccine)
- one time dose of Tdap to adults who have not received Tdap previously (or for whom vaccine status unknown) to replace one of 10-yr Td boosters
Varicella vaccine
- only recommended for pts w evidence of non-immunity
assume pts born before 1980 immune but for pregnant women and healthcare workers, serologic immunity must be confirmed
Conversation bw provider and pt about vaccines
- explore pt knowledge abt vaccines
- targeted counseling around fears and misconceptions
- review w patient whether vaccine may protect other ppl at home or at work
Side effects of vaccines (possible)
- local pain, irritation, fever, vasovagal syncope, occasionally cellulitis
- rarely unexpected allergy, anaphylaxis, or seizure
- ingredients:
gelatin (MMR)
yeast (Hep B)
growing evidence that influenza vaccine safe for pts w egg allergy
Contraindications of vaccines
pregnancy (rubella)
HIV (zoster)
Chemoprophylaxis
- administration of medication or natural substance for purpose of preventing dz or infection;
must consider 2 things:
- benefits of chemoprophylaxis must outweight any potential harm
- chemoprophylaxis must be cost effective
examples of chemoprophylaxis
- fluoridated water to prevent dental caries; statins to prevent cardiovascular and coronary heart dz; tmp smx for pneumocystic pneumonia in hiv pts w cd4 cell counts < 200; oral hormonal contraception to prevent undesired pregnancies; folic acid use in women of child bearing age to reduce risk of birth defects, esp in those wishing to be pregnant
Aspirin: an example of chemoprophylaxis
- use in men and women of certain age groups w known cardiovascular dz has been sown to reduce risk of death and further vascular events (tertiary prevention)
benefits clearly outweight risks in pts w established cvd but for primary prevention of cvd has more balanced risks and benefits depending on individual factors
optimal dose for both primary and secondary prevention not yet established
Risks of aspirin
- intracranial and/or GI bleed (enteric coated or buffered aspiring doesnt help)
- in uncontrolled htn and concomitant use of other NSAIDs or anticoagulants may increase risk of serious bleeding
Aspiring to prevent CVD:
Grade A specific recommendations for aspirin in men 45-79 to prevent myocardial infarctions
- men 45-79 yrs when potential benefit due to reduction in MI outweighs potential harm due to an increase in GI hemorrhage
- aspirin does not prevent initial strokes in men*
Aspirin to prevent CVD: women age 55-79 to prevent ischemic strokes
Grade A specific recommendations
- aspiring for women 55-79 yrs when ptoential benefit of reduction in ischemic strokes outweighs potential harm of an increase in GI hemorrhage;
- aspirin does not prevent initial coronary heart disease events in women*
Aspirin to prevent CVD: women younger than 55 yrs, to prevent stroke
Grade D specific recommendations
- against use of aspirin for stroke prevention in women younger than 55 in whom risk of GI bleed is much higher than risk of stroke
Aspirin to prevent CVD: men younger than 45 yrs, to prevent MI
Grade D specific recommendations
- recommends against use of aspirin for MI prevention in men younger than 45 yrs, in whom risk of GI bleed much higher than risk of coronary heart dz events
Aspirin to prevent CVD: men and women age 80 years and older
- concludes that current evidence insufficient to assess balance of benefits and harms of aspirin for CVD prevention in men and women 80 yrs or older in whom risks of coronary heart dz and GI bleeding are both high
Assess individual risks for cardiovascular dz, harms/benefits of aspiring for primary prevention in:
men > 45 yrs
women > 55 yrs
World Health Organization criteria for good screening test
- condition should be important health problem
- there should be a treatment for the condition
- facilities for diagnosis and treatment should be available
- there should be a latent stage of disease
- there should be a test or examination for the condition
- test should be acceptable to population
- natural hx of dz should be adequately understood
- should be an agreed policy on whom to treat
- total cost of finding a case should be economically balanced in relation to medical expenditure as a whole
- case finding should be continuous process not just once and for all project; in step w natural hx of dz and prevalence of dz and needs of the population
Harms and challenges of screening
- even if abnormal results found early
- procedures and tests may be unsafe
- tests w high false negatives may clearly miss opp to reduce morb and mort of targeted dz and may have legal ramifications
- lack of follow up by pts or docs for results of true + test
- procedure may be too $$$, inaccessible to ppl who would most benefit; may be too painful or complx for pt to adhere
Labeling effect
any abnormal result whether false + or true + may cause distress, anxiety, depression
When not to screen
- service benefits no or v few ppl in target pop
- little or no effect in target pop
- condition has low prevalence in target pop
- screening is unfocused and maybe picks up abnormalities that arent clincially signficant - service causes net harm in target pop
- uncertain balance of benefits and harms
Hereditary hemochromatosis
recommends against routine genetic screening for hereditary hemochromatosis in asymptomatic general pop;
- rare in general pop, low proportion of ppl w high risk genotype of c282y homozygote at hfe locus (mutation common in white ppl w clincal sx), manifest the dz
- early therapeutic phlebotomy doesnt improve morbidity and mortality that significatnly in screening vs clinically detected ppl
- screening could identify large # of ppl who have high risk genotype but may never manifest clinical dz
unnecessary surveilance, labeling, unnecessary invasive workup, anxiety, potentially unnec treatments
this recommendatin applies to asymptomatic ppl not ppl with signs or symptoms that could include hereditaty hemochormatisosi in ddx or ppl w fam hx fo clincially detected or screening detected probands for herediatary hemochromatosis
Selective screening
screening of selected high risk groups
Even when benefits of performing a screening intervention are clear for specific pt or pop
may have controversy in when to initiate screening, whether to repeat screening, if repeat screening warranted if it even is, how frequent and at what intervals; when to cease screening
Breast cancer screening conundrum!
so many options!
mammogram, self exam, clinical breast exam, ultrasonography, MRI, scintimammography, positron emission tomography
what age: <40 vs 40-49 vs 50-74 vs 75+
women w avg or high breast cancer risk factors, those w denser breasts ,genetic brca1 or brca2 etc
Breast cancer screening recommendations for US women, 2009, USPSTF
- women aged 50-74: biennial screening (grade b)
- women < 50: regular, biennial screening mammography based on individaul and take into account patient values (harm vs benefit) (grade c)
- women 75+ : evidence insufficient to assess additional benefits and harms of screening mammography (grade I)
- women 40+: current evidence insufficient to assess additional benefits and harms of clinical breast exam beyond screening mammography (Grade I)
- current evidence insufficient to assess additional benefits and harms of either digital mammography or MRI instead of film mammography as screening modalities (Grade I)
Behavior change and lifestyle modifications
- reduction or elimination of destructive behaviors (smoking)
- promotion of healthier lifestyles (food choices)
- adherence to medical regimens (take meds as directed)
Pre contemplation
patient chars: patient denies or minimizes issue, may be defensive about discussing
motivational interview strategy: request permission to discuss issue, express concern, ask pt to think or read about issue bw visits
Contemplation
patient chars: pt considered pros and cons of issue, is willing to discuss it
MOtivational interview strategy: ask about pt opinions on issue, or help pt weigh pros and cons
Preparation/determination
patient chars: pt commits to a time and plan to address the issue
Motivational interviewing strategy: provider can summarize pts reasons for behavior change, negotiate a start date to begin the behavior change, and encourage the patient make “public” announcement about the change
Action
patient chars: pt regularly engages in activities to change behavior
motivational interviewing strategy: provide support, modify plan if not optimal, schedule follow up contact to provide support
Maintenance
patient chars: patient integrates new behavior into a regular way to live; pt is vigilant about relapsing
motivational interview strategy: continue to give support and admiration for behavior change, ask about commitment to change in future, ask about pt expectations
Relapse
patient chars: pt has returned to one of previous stages after period of resolution
motivational strategy: reassure that relapses occur on pathway to long term change; can offer opportunities to learn in preparing for next action stage
Five As to facilitate smoking cessation
- ask about tobacco use at every office visit
- include questions about tobacco use when assessing pts vital signs; place tobacco use status stickers on pt charts and or note tobacco use in electronic med records - advise all smokers to quit; advice should be :
- clear (i think its inportant for you to quit now); strong (as your doc i need to tell you that smoking cessation is one of most imp decisions you can make for your health); personalized (physicians should talk about impact on pts life, family, finances) - assess patients willingness to quit
- if pt is willing to make quit attempt offer meds, brief counseling self help resouerces, schedule followup
- if pt unwiling, id why pt is ambivalent explore what he or she likes or doesnt like about smoking, potential advantages and disadvantages of quitting - assist pt in his or her attempt to quit
- set quit date; request encouragement from fam and friends; anticipate triggers and cues to smoking ; suggest changes in envt (throw away cigs, lgithers, asthrays; vaccuum car and home; avoid other smokers and alcohol) - arrange follow up contact
- followup should occur within 1st week after quit date; 2nd followup within 1st month; congratulate success; if relapse occurs, review circumstances and elicit new commitment to quit; followup can be by phone email or inp person
Nicotine replacement therapy
- gum, transdermal patch, inhaler, nasal spray
effective
bupropion (sustained release): safe, effective
other oral meds but worse side effects
Pregnant women who smoke
intensive counseling 5-15 mins; use messages and self help materials tailored for pregnant smokers;
Intimate partner violence
- lifetime prevalnce 31% of women; contributes to poor physical and mental health, esp among women;
disparieties in breast and cervical cancer screening can be correlated w hx of exposure to violence and intimate partner violence assoc w negative preg outcomes
screening for intimate partner violence
- all women of childbearing age; provision of or referral to services for women screening +
insufficient evidence for elderly or vulnerable adults
in gay and lesbian relationships it is as common as in heterosexual
INtimate partner violence screen
in person and quesitonnarie similar efficacy if use same tool
HITS (hurt, insult, threaten, scream); also validated in spanish
or
HARK (humiliation, afraid, rape, kick)
but ideal screening interval unclear
Incidence
of new cases of dz in particular population during specified time period
usually expressed per 10,000 or 100,000 ppl (over a day, month, year, or longer period)
Prevalence
total # of cases of dz in a particular population at specifie instant in time (including new and previously dx cases)
usually expressed as % of pop (ex: 30 cases of prostate cancer in 1000 male sanitation workers is 3% prevalence in this population)
Age-adjusted rate
statistical process allowing a rate of death, dz or injury or other health outcome be compared in 2 populations w diff age distributions
ex: older ppl may have higher rate of colon cancer than young ppl and youth may have higher rate of suicide than elderly
so based on % alone a community w more elderly ppl may appear to have more colon cancer while community w more youth may appear to have more suicides
Case fatality rate
of deaths from a dz among pts dx w that dz;
ex: if 6 children die of asthma out of 1000 asthmatic children in a given year, case fatality rate = 6/1000 = .6%
LIfe expectancy
- avg length of survival in given population
usually reported as # of yrs survived since birth (same as expected age of death)
broader terms: life expectancy is time remaining to live at a given starting age (not just birth)
life expectancy at birth is highly sensitive to rate of death in first year of life per # of live births (infant mortality rate)
Positive predictive value
true positive/(true positive + false positive)
% of ppl w a +test result who have the dz
aka
post test probability that an individual has a dz after a + test
Negative predictive value
true negative/(true negative + false negative)
% of ppl with a neg test who do not have the dz
aka
post test probability that someone does not have a dz after a neg test
Sensitivity
true positive/(true positive + false negative)
prob of test finding dz among those who have dz
aka
proportion of ppl with a dz who have a + test result
Specificity
true negative/(false positive + true negative)
prob of test finding no dz among those who do not have dz
aka
proportion of ppl free of a dz who have a neg test
Positive and negative predictive values are…
susceptible to changes in dz (outcome) prevalence in population studied
Reliability
degree to which a consistent measurement is yielded by repeated application of a test;
test is reliable if the avg measurement error is small over time
Validity
degree to which a test actually measures what it claims to measure
ABsolute risk reduction
ARR = (EER-CER)
risk difference bw control group event rate (CER) and experimental group event rate (EER)
Relative risk reduction
(EER-CER)/CER
EER= experimental group event rate
CER=control group event rate
Number needed to treat
NNT= 1/ARR
number of patients who need to be treated in order to prevent one additional bad outcome (Inverse of absolute risk reduction, not the relative risk reduction!)
round up the NNT bc you cant treat a fraction of a person!
Experimental event rate (EER)
event rate in experimental group
EER = A/(A+B)
Control event rate (CER)
event rate in control group
CER=C/(C+D)
Relative risk (RR) aka Risk Ratio
- compare probability of an event in 2 distinct groups
- event rate in exposed group divided by event rate in unexposed group
cohort studies or other prospective studies where incidence is known and causality might be inferred
RElative risk reduction (RRR)
proportional reduction in rates of bad outcomes bw experimental and control participants in a trial
often used bc numerical value appears huge but often overestimates clinical relevance
ABsolute risk
- individual risk of developing dz over a time period
having 1/10 risk of developing a certain dz in your life; also 10% risk or 0.1 risk (same thing)
Absolute risk reduction (ARR)
risk difference bw control group event rate and experimental group event rate
ARR = CER-EER = C/(C+D) - A/(A+B)
Odds ratio (OR)
comparison of probability of an event to probability that that event does not take place!
odds ratio divides odds of finding or not finding an outcome in exposed by odds of finding or not finding an outcome in unexposed group
case control studies or studies where incidence unknown only associations can be measured (expressed using odds ratio for comparison)
AD/BC
Number needed to treat (NNT)
of patients who need to be treated in order to prevent one additional bad outcome!
it is the inverse of absolute risk reduction
NNT = 100%/ARR
2 important caveats to remember about NNT
- when likelihood of an outcome is low, NNT will be high
2. NNT will decrease as either the likelihood of outcome increases or as benefit of treatment increases
Ask the following 4 questions when reviewing a study on screening to decide whether the screen is beneficial or harmful
- is there evidence based on RCTs that early dx really leads to improved survival or quality of life or both?
- are early dx patients willing partners in treatment strategy?
- how do benefits and harms compare in diff ppl w diff screening strategies?
- do frequency and severity of target disorder warrant the degree of effort and expenditure?
US Preventive Services Task Force
gold standard recommendations for clinical preventive services
made for asymptomatic ppl
assesses:
- quality of evidence supporting a specific preventive service
- magnitude of net benefit in providing the service
USPSTF Grading definitions for recs: A
A: recommends this service; high certainty net benefit is substantial; offer or provide this service
USPSTF Grading definitions for recs: B
B: recommends this service; high certainty that net benefit is moderate or there is moderate certainty that net benefit is moderate to substantial; offer or provide this service!
USPSTF Grading definitions for recs: C
C: recommends against routinely providing this service; may be considerations that support providing service in an individual patient; at least a moderate certainty that net benefit is small;
offer or provide this service only if other considerations support the offering or providing this service in an individual pt
USPSTF Grading definitions for recs: D
D: recommends against this; mod or high certainty the service has no net benefit or that harms outweigh benefits
discourage use of this serivce
USPSTF Grading definitions for recs: I
I: current evidence insufficient to assess balance of benefits and harms of service; evidence lacking, of poor quality, or conflicting, and balance of benefits and harms cant be determined
read clincal considerations section, explain uncertainty about benefits and harms service to pts if it is offered
24 yo sexually active otherwise healthy woman question; which USPSTF recommendations apply to her
- screen for chlamydia infection for all sexually active non pregnant women aged 24 or younger and for older non pregnant women who are at increased risk (A)
other risk factors for chlamydia (besides sexual activity and age): hx of chlamydia or other STI, new or multiple sex partners, inconsistent condom use, exchanging sex for money or drugs
risk factors for pregnant women are the same as nonpregnant women
AA and hispanic women have higher prevalence of infection than general population in many settings
among men and women increased prevalence also in incarcerated population, military recruits, pateints at public STI clinics
24 yo sexually active otherwise healthy woman question; which USPSTF recommendations do NOT apply to her
- recommends against screening for asymptomatic bacteriuria in men and nonpregnant women (grade D); ineffective in improving clinical outcomes; potential harms (abx, bacterial resistance, side efx)
- routine counseling of all pts in primary care setting to reduce driving under influence (I, insufficient); alcohol use involved in nearly 40% of all traffic related fatalities;
- recommends against routine serological screening for HSV in asymptomatic adolescents and adults (grade D);
no evidence that screening for HSV antibody improves health outcomes or symptoms or reduces transmission of dz; there is good evidence that serologic screening tests can id ppl who have been exposed to HSV and antiviral therapy improves health outcomes in symptomatic ppl (eg multiple recurrences) but no evidnece in therapy in asymptomatic infection
harms: false +, labeling, anxiety - insufficient evidence for or against behavioral counseling in primary care to promote physical activity (I); no data in kids or adolescents
specialty centered
Recommending societies
represent a medical specialty or subspecialty; consider whether their members may gain from providing a preventive service
Disease centered
Recommending societies
rep a dz advocacy group; consider whether screening recs may be advocated as means to increase awareness about a dz regardless of costs or risks
Payer-centered
Recommending societies
rep a payer group; consider whether screening recs based on cost savings rather than risk-benefits to patietns;
Prevention centered
Recommending societies
conduct rigorous assessments of scientific evidence for effectiveness of broad range of clinical preventive services at a pop level and also consider costs;
some ppl may feel these orgs dont take individual pts concern into account or weight cost effectiveness too highly
many pcp’s feel the recs are robust
Preventable factors that contribute to leading causes of death and disability
economic and educational disparities, pub policy, envts that dont promote health, poor delivery yof clinical and community preventive services, unhealthy behaviors and other lifestyle risk factors
Socioecologic framework
behaviors and health are influenced over life span at multiple levels from individual to families to larger systems and groups and then more broadly to populations and the ecosystem
Levels of intervention
- socioecologic framework allows one to map out effective prevention strategies for a specific health issue targeted to one or more level (clinical, community, public health level)
- individual level interventions like screening, counseling, immunizations occur in clinical setting bw clinician and pt
- social, fam, community network interventions (often aimed at behavior change and social support systems) include: exercise programs at palce of worship, wt loss competitions bw emplyee teams in workplace, or nutrition education programs for schoolchildren)
- community level interventions that influence working and living conditions may target spec communities (racial, geogrpahic, ethnic) and include envtal interventions (provide recreational facilities in neighborhoods or implement water fluoridation)
- large geographic areas or pop interventions may involve policies and programs within or outside health sector (expanding health insurance access, revise minimum sentences for drug possession, pass ordinances restricting public tobacco smoking, implement vehicle emission regulations, enforce intimate partner violence laws)
Community task force
- similar to uspstf role as expert panel on individuals, but for the community!
- assess and make evidence based recs for effective prevention strategies in community or population level
- considers interventions: envtal improvements, health policyt, education, service delivery, system improvements
- recs can be implemented in schools, work places, entire community
0 often used to shape national initiatives to achieve and maintain health promotion goals
Integration of clinical preventive services and community level interventions
- integrating preventive interventions determined to be effective fits w socio ecologic model
- using multiple strategies at interrelated levels –> optimal individual and community health outcomes
- ex: tobacco control; uspstf recommends screening all adults in clinical settings for tobacco use and providing cessation interventions
- screen all pregnant women and provide pregnancy tailored counseling and interventions
- community preventive services recommended: ban or restrict smoking in public or work places, increase tobacco prices, deploy telephone quitter support
- “optimal success”: in reducing tobacco use prevalnce has occured when in addition to clinical serivces commuity level interventions hav ebeen made accessible and aviaalble
Community Oriented Primary Care (COPC) example
- define the community
- identify specific health problem (review census and local health data)
- prioritize health needs w community (surveys, focus groups)
- involve community members in implementing interventions
- student and community agency are going to evaluate impact of intervention, intend to modify based on outcomes
COPC steps/overview
- define the community
- id target pop by collecting relevatn demographic, historical, political cultural, economic data
- several limitations to data but some of this info can come from US census bureau - id health problem
- id health needs of target pop (community dx)
- review local and national databases for socioeconmic, demogrpahic, and morbidity and mortality rates
- health issues in target pop that are out of proportion to national distribution should be benchmarked
- ex: ny doh - prioritize health needs
- conduct neighborhood surveys and focus groups to enable comunity partipcation in prioritization of which ehalth issues to address
- include community members on oversight team that makes final decisions on setting prioriteis - implement appropriate interventions to address health needs
- involve community members in implementaiton by including them on teams in overseeing and deplyoing intervetnion
- may involve training community members in spec skills (human reasource mgmt, health education, etc.) or formation of partnerships w existing comm agencies and resources
- interventions might include healthy school menus, worksite injury prevention programs, community garden devt, vocational training for at risk youth, campaigns for changes in local envt policy (limiting school bus idling and exhaust, moving waste transfer stations or dumps) - evaluate impact of intervention (s)
- maintian ongoing surveillance, evaluation, assessment of outcomes of copc program
- train and/or partner w community members to include them on surveillance , evaluation, assessment team - modify future interventions
- based on evaluation and reassess outcomes
