preventative health care- chapter 7

EXAMPLE 4, ELDERLY FEMALE An 85-year-old female visits the clinic for her annual examination to have her migraine medication refilled. She has occasional migraine headaches that are relieved by sumatriptan. She lives alone, walks 2 miles daily, and reports no health problems. She has no problem getting out of a chair. Her height is 5 ft 10 in. and weight is 165 lb (BMI 23.7 kg/m2). Her family history shows no cancer or cardiovascular risks. She is 30 years post menopause, and other than a multivitamin each day, takes no medicine. She received a pneumococcal shot at age 65, a Tdap 4 years ago, and a zoster vaccine 5 years ago. She receives a flu shot each year. All of her children (4) and grandchildren (8, the youngest being age 5 years) live in the local area. Her blood pressure has never been high and today is 125/75 mm Hg. Influenza and pneumonia are risks for this patient since she is around her school-age grandchildren, and the influenza vaccine has low effectiveness in those age 85 years old. Risk reduction can best be achieved in this woman through advising influenza and pneumococcal vaccines for

her children and grandchildren and avoiding unnecessary screening tests. The only screening tests recommended for her are for osteoporosis, obesity (done), high blood pressure (done), and depression (which she refuses). She is current on all other recommended vaccines. This woman is best left alone, other than the screening for osteoporosis to prevent iatrogenic illnesses. The Family Physician as the Foundation of the Public Health System Although applied prevention in the clinical setting is important for individualized health and wellness, family physicians should realize that the largest improvements in the health of the public at large come from community-wide, public health interventions. Table 7-13 lists just some of the important public health interventions of the last century that have led to significant decreases in morbidity and mortality. Each state and local political jurisdiction has some kind of official public health presence. At the local level, these are referred to as local health departments, which are subunits of city, county, or other regional government jurisdictions. All states have state public health departments, and the major public health department at the national level is the CDC, although important public health functions are also carried out by other federal agencies. The major roles and functions of local, state, and national health departments include disease surveillance and reporting, infectious disease control, infectious disease outbreak response, emergency preparedness and response, and chronic disease prevention. The public health infrastructure, however, provides minimal direct clinical care, and depends on family physicians and other primary care providers to fulfill vital public health functions that contribute to improved community health. These functions are listed in Table 7-14. Screening tests, immunizations, and risk reduction have already been discussed in this chapter. Other important functions include

American Academy of Family Physicians "Choosing Wisely" List 1. Do not do imaging for low back pain within the first 6 weeks unless red flags are present. 2. Do not routinely prescribe antibiotics for acute mild-to-moderate sinusitis unless symptoms last for 7 or more days or symptoms worsen after initial clinical improvement. 3. Do not use dual-energy x-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors. 4. Do not order annual electrocardiograms (ECGs) or any other cardiac screening for low-risk patients without symptoms. 5. Do not perform Pap smears on women younger than 21 years of age or who have had a hysterectomy for noncancer disease. 6. Do not schedule elective, nonmedically indicated induction of labor or cesarean deliveries before 39 weeks, 0 days gestational age. 7. Avoid elective, nonmedically indicated inductions of labor between 29 weeks, 0 days and 41 weeks, 0 days, unless the cervix is deemed favorable. 8. Do not screen for carotid artery stenosis in asymptomatic adult patients. 9. Do not screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer. 10. Do not screen women younger than 30 years of age for cervical cancer with human papillomavirus (HPV) testing alone or in combination with cytology. 11. Do not prescribe antibiotics for otitis media in children ages 2 to 12 years of age with nonsevere symptoms when the observation option is reasonable. 12. Do not perform voiding cystourethrograms routinely in first febrile urinary tract infection in children ages 2 to 24 months. 13. Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal examination. 14. Do not screen adolescents for scoliosis. 15. Do not require a pelvic examination or other physical examination to prescribe oral contraceptive medications.

medications, adverse drug reactions, and the underlying inheritability of many conditions. Rapidly evolving scientific advances in genomics, along with reduced costs of genomic tests, holds the promise of one day each person knowing their whole genome. While theoretically this will lead to more accurate targeting of drug therapy, fewer adverse drug reactions, and targeted risk reduction activities, the full translation of this new science into useful and effective clinical interventions is pending the demonstration of clinical utility and improved clinical outcomes.

Four-Step Approach to Prevention in a Clinical Encounter Step 1: Risk assessment based on: Age Gender Family history Medical history Occupation Socioeconomics Environment Behaviors: ■ Diet ■ Physical activity ■ Sexual practices ■ Alcohol, tobacco, and drug use ■ Risk taking Step 2: Risk reduction including: Counseling and behavior modification Chemoprevention Step 3: Screening A and B recommendations from the USPSTF Step 4: Immunizations Immunizations recommended by the ACIP

services can be provided as part of a periodic health assessment and wellness examination, which for most people does not need to be performed annually. They can also be approached incrementally, with the physician addressing a limited number of them at each visit. Neither approach has been proven superior to the other. Continuity of care is the family physician's ally in providing comprehensive preventive care, in that a little bit of prevention can be achieved at each visit and important prevention messages can be reinforced. With either approach, a four-step process (Table 7-2) can be used to consider 1. Risk assessment 2. Risk reduction 3. Screening 4. Immunizations

PRIORITIZING PREVENTIVE SERVICES Given the large number of possible preventive interventions that can be implemented, it is often necessary to prioritize them and address the most important ones first and the others as time and continuity allow. Patient preferences are important to consider. Difficult choices are sometimes necessary when patients have multiple risks and comorbid conditions. Chronic diseases often occur concurrently, and the guidelines for each often are written from the assumption that only one disease is present. Research is being conducted on what preventive interventions will yield the greatest gains to patients with multiple chronic conditions and risks (Taksler et al., 2013). Family physicians and patients should prioritize together.

table 93

Family Medicine and Prevention Prevention is a large part of family medicine. Family physicians provide preventive health care on a daily basis and are frequently consulted by patients on how to stay healthy and avoid disease. Family physicians are also a part of the foundation of the nation's public health system, being the first contact for patients with illnesses of public health importance, a source of surveillance for disease prevalence, and a resource for dissemination of information that can protect the health of the public. This chapter will discuss all these roles and describe how to maximize the effectiveness of preventive services delivered.

Definitions of Prevention Prevention can be divided into three categories: primary, secondary, and tertiary. Family physicians should consider how all three categories may benefit each patient. Primary prevention results in the prevention of a disease or condition from occurring. Examples include vaccinations, which prevent an array of infectious diseases, and smoking cessation, which prevents myriad illnesses that result from sustained tobacco use. Primary prevention can be, but is not always, cost saving for society (more money is saved than spent). It often involves community-wide intervention (clean water and sanitation), and the benefits are often unseen and unappreciated by the public. Secondary prevention involves screening asymptomatic individuals for a disease to detect it early, and with early intervention achieve a better outcome than with later detection and treatment. When testing is performed in those who are symptomatic, to diagnose or rule out a suspected condition, this is not screening, it is diagnostic testing. Screening applies only to those who are asymptomatic. Many disagreements over the value of screening result from not understanding this fundamental difference between screening and diagnostic testing. Contrary to common belief, secondary prevention does not save money. It can lower morbidity and mortality and usually compares favorably in cost-benefit analyses to medical interventions such as cardiac bypass surgery, but it does not result in more money saved than spent. It can be, however, money well spent. Tertiary prevention involves interventions that occur after a disease or condition is evident, in an attempt to make the affected person healthier and improve quality of life. An example is cardiac rehabilitation after myocardial infarction. Tertiary prevention also is not cost saving. Because tertiary prevention can prevent a repeat event, such as a second heart attack, it is frequently, although incorrectly, referred to as secondary prevention.

Intergenerational Aspects of Prevention in the Family Family physicians have the opportunity to appreciate and achieve intergenerational benefits of preventive interventions within families and households. Influenza and pneumococcal vaccines in infants and children provide added protection to elderly family members—who are at the highest risk of morbidity and mortality from these respiratory infections—through herd immunity and reduced disease transmission. Pertussis immunization of adolescents and adults of all ages provides a cocoon of protection around infants who have high rates of serious complications from pertussis and are not fully protected by the vaccine until they have received a full primary series. Other infectious diseases can spread among family members, and ways to minimize this have already been discussed in this chapter. In addition, chronic diseases tend to be common among family members because of common genes and common environments, and interventions to prevent these conditions can spread their effects through the household. For example, smoking cessation helps prevent disease not only in the smoker but also in the whole family by preventing exposure to secondhand smoke. Improved diets and increased physical activity can be family activities, which lead to improved health for those with obesity and diabetes and contribute to a reduced risk for everyone else in the household.

Genomics and Prevention The human genome project has led to a better understanding of the genomic basis of responses to specific

RISK ASSESSMENT Each patient has a set of risks that can affect his or her health in the near or long term. These risks are based on age, gender, family history, medical history, current chronic diseases, occupation, socioeconomic factors, environment, and behaviors (diet; physical activity; sexual practices; alcohol, tobacco, and drug use; and risk taking). Some of these risks are modifiable; others are not. This information can be obtained at the first encounter or shortly thereafter, but it needs to be updated periodically. Knowing a patient's risks helps to focus risk reduction advice where it will have the greatest impact. Table 7-3 lists the leading causes of death in the United States. The two leading causes of death are cardiovascular diseases and cancer. Figure 7-4 shows the time trends in these leading causes of mortality and demonstrates that age-adjusted death rates for cardiovascular diseases are declining while those for cancer and injuries are remaining relatively stable. Cancer will soon be the leading cause of death, and unintentional injuries has replaced cerebral vascular disease as the third leading cause. These data show that the largest improvements in population mortality can

be achieved by concentrating on the causes of cardiovascular diseases, cancer, and injuries. The actual causes of death in the United States are listed in Table 7-4 and include unhealthy behaviors, most notably tobacco use, poor diets, lack of physical activity, and misuse of alcohol. Table 7-5 lists the risk factors for the leading causes of death and the number of deaths attributed to each. These behaviors and risk factors are prime targets for preventive interventions in the clinical setting. Figure 7-5 demonstrates that the leading causes of death are quite different in younger age groups than older. In addition, race/ethnicity and socioeconomic factors change the magnitude of these causes. Family physicians knowing the epidemiology of disease and risks in their communities can focus in on the risks that have the greatest impact on their patients. When assessing the risks linked to each of these leading causes of death and disability, it is important to remember that a "risk factor" identified in an observational study may not translate into reduced disease if that risk is eliminated.

index [BMI] 20.9 kg/m2). He is well developed and muscular. His blood pressure is 125/75 mm Hg. Because he presents out of concern for his abdominal pain, this problem needs to be addressed first. However, doing a quick assessment (Step 1), it can be determined that his major health risks are smoking, alcohol misuse (which is likely contributing to his abdominal pain), unsafe sex, and risk-taking behavior. You can mention each of these to him quickly and focus on smoking, strongly advising him to quit, offering nicotine replacement, and providing information on smoking cessation support groups. You make a note to address the other two risks, which are related, at the follow-up visit. You advise a healthier diet and the addition of aerobic exercise to his weight lifting, even though the value of this advice in changing behavior is uncertain (Step 2). Using the USPSTF ePSS you determine the recommended screening tests are human immunodeficiency virus (HIV), syphilis (although this may not be indicated if the rate of heterosexual syphilis in the community is low), lipid disorders (since he is at higher risk for cardiovascular disease due to his smoking), high blood pressure (done at this first visit and to be repeated at each follow-up visit), obesity (done with the initial height and weight measurement), and

depression (which can be deferred to a future visit). HIV testing and a nonfasting cholesterol and high-density lipoprotein (HDL) cholesterol level can be performed on a blood sample taken in the office, in addition to any diagnostic blood tests needed (Step 3). You can ask him to try to find his childhood vaccine record at his parent's house to bring to the next visit and offer him influenza vaccine and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) today (Step 4). EXAMPLE 2, OLDER ADULT MALE A 61-year-old male is in the clinic for a routine visit for several medical conditions including hypertension, hypercholesterolemia, obesity, and osteoarthritis of his right knee. His medications include lovastatin, hydrochlorothiazide, enalapril, and acetaminophen. He has had no recent hospitalizations or surgery. He smoked in the past but quit 15 years ago, currently drinks a glass of wine several times a week, uses no illicit drugs and denies past use, has been married to his wife for 35 years, and has no extramarital sexual partners. He has three children, all grown and out of the house, and three grandchildren, one of them

Evidence as the Foundation of Prevention Solid evidence supporting the effectiveness and safety of an intervention is important. Family physicians are busy and

need to use their time effectively, concentrating on providing services that actually result in improvements for their patients. In addition, with primary and secondary prevention, the interventions involve healthy, asymptomatic people. The physician does well to remember that it is hard to improve on the healthy, asymptomatic patient. It can be done, but in attempting to make someone healthier we should ensure that not only are we being effective, we are also being safe and not causing harm in the process. For this reason the evidence threshold for action should be higher for prevention than for therapy. If a patient has a serious illness, the therapeutic imperative provides a rationale for using treatments that might be supported only by moderate quality studies and intermediate outcomes, if that is the best evidence that exists. For prevention, if the safety and effectiveness of the intervention is not based on high-quality evidence, it is better to wait for better evidence and concentrate on the many interventions available that are backed by strong evidence. It is difficult enough to fit all the proven interventions into a tight clinical schedule without spending time on those we are not sure make a difference

Genomic tests should be evaluated for effectiveness just as should other screening tests. So far, evidence-based groups that have assessed genetic and genomic tests used for predicting risk for chronic diseases, such as diabetes, coronary heart disease, and obesity, have not endorsed their use because they have not proven to be clinically useful; they do not provide much information beyond that obtained from a family history and traditional risk factors (EGAPP Working Group, 2010, 2013). In addition, it is not clear

that people will take any action to improve their health or risks based on this information. However, testing for two conditions that cause higher risks for cancer have been found to result in improved outcomes: breast cancer genes and Lynch syndrome. The USPSTF recommends that women with high-risk family histories for breast and uterine cancer be counseled about the BRCA gene test (USPSTF, n.d.). Patients who have a BRCA gene can reduce their chances of breast and ovarian cancer with bilateral mastectomy and oophorectomy. Firstdegree relatives of those with Lynch syndrome, discovered to be the cause of colon cancer, can be tested to see if they carry the same mutation, and if they do, they can benefit from earlier and more frequent colonoscopy. This has led to a recommendation to test all of those with newly diagnosed colon cancer for Lynch syndrome and counseling of firstdegree relatives of those with this inherited disorder (EGAPP Working Group, 2009). Family physicians will need to stay current with advances in genomics and use discretion when deciding when to use genomic tests and genomic-based interventions, adopt them when the evidence merits it, and avoid unnecessary and potentially harmful testing

Advice to Patients to Prevent Spread of Infectious Disease ■ The patient should stay at home while most infectious to avoid infecting others. If patients have to leave the home, they should strictly follow respiratory hygiene. ■ At home, place patients in a separate room or separate them physically from other household members as much as possible. ■ Limit the number of household members having contact with the patient. ■ Follow hand hygiene after contact with the patient or the patient environment and waste products. This includes handwashing with soap and water or use of an alcohol-based hand rub. ■ Consider having the patient wear a surgical mask. ■ Immunize household members if appropriate. ■ Wash dishes, utensils, and laundry in warm water and soap. ■ Consider chemoprophylaxis for household members if it is available and recommended. ■ Household members should watch for symptoms and seek care at their first appearance. ■ Nonhousehold members should not enter the home. If nonhousehold members need to enter the home, they should avoid close contact with the patient.

unnecessary and harmful testing and treatments. This at first glance seems clear cut, but there is good evidence that in daily medical practice many tests and treatments provided are not necessary and result in harm (Kale et al., 2013; Korenstein et al., 2012) Antibiotics for upper respiratory infections is one example. The AAFP and other specialty organizations have joined forces in an initiative called "Choosing Wisely." Each organization has developed a list of testing or interventions that should not be performed, or done only in specific circumstances. The AAFP list of 15 such interventions is contained in Table 7-19. Unnecessary testing and treatments are costly and harmful, and avoiding them is good preventive medicine

THE NATIONAL HEART, LUNG, AND BLOOD INSTITUTE The National Heart, Lung, and Blood Institute (NHLBI) in the National Institutes of Health produces guidelines on prevention and control of the major risks for cardiovascular diseases in adults, including two influential clinical guidelines; one on cholesterol and one on high blood pressure

(NHLBI, 2001, 2004). These and other guidelines regarding cardiovascular diseases can be found on their website (www.nhlbi.nih.gov/guidelines). The NHLBI, unfortunately, does not use methodology as strong as the USPSTF to produce their guidelines. Many of the recommendations are based on expert opinion, and the strength of the evidence supporting each recommendation is not readily apparent. They are, however, widely viewed as the standard of care. Both the cholesterol and high blood pressure guidelines are in the process of revision as this chapter is being written. THE AMERICAN ACADEMY OF FAMILY PHYSICIANS Clinical prevention recommendations to guide family physicians are made by the AAFP Commission on the Health of the Public and Science, and their recommendations are considered and approved by the AAFP Board of Directors. The AAFP has taken a strong evidence-based approach and tends to endorse the recommendations from the USPSTF and the ACIP, although not always. The AAFP approach to child preventive services is more conservative than that of the American Academy of Pediatrics (AAP), and it does not endorse AAP recommendations if they differ from those of the USPSTF or if they are not evidence based. The AAFP recommendations for clinical preventive services are listed at their website (www.aafp.org/patient-care/clinical -recommendations/cps.html

Figure 7-1 illustrates the pyramid of evidence that is found in the medical literature. At the top of the pyramid, and providing the highest quality evidence, are high-quality systematic reviews and meta-analyses. Next come randomized controlled trials, followed by lesser quality-controlled trials. Below that are observational studies, which are much more subject to bias. Among observational studies, cohort and case-control studies provide more reliable information than cross-sectional studies. Correlational (ecological) studies and case reports are at the base, providing interesting information that should not be used as proof of effectiveness or causation but are useful for generating questions and providing direction for more in-depth research. A description of each type of study is provided in Chapter 9

Accepted practice should not be altered based on a single observational study and rarely on a single randomized, controlled trial. Single studies are frequently cited to support one view or another, and this practice is called "cherry picking." The astute family physician will want to know that results are reproducible, will realize that more than one study on the topic probably exists, and will ask, "What does the totality of the evidence show?" There are well-developed methods for assessing the quality of individual studies and for assessing the totality of the evidence. The individual family physician does not need to possess these skills and certainly does not possess the time necessary to properly research each possible prevention intervention; there are organizations and authoritative groups that perform these functions. However, the family physician should know what makes for a high-quality, truly evidence-based recommendation, and know which organizations can reliably be depended on to produce them. The Institute of Medicine (IOM) has published guidance on how to conduct a high-quality systematic review (IOM, 2011c) and how to produce a high-quality, dependable guideline (IOM, 2011a). A high-quality guideline is based on a high-quality systematic review, preferably conducted by a noninterested, independent party. A high-quality systematic review should involve methods of finding all the

Important Public Health Functions of Family Physicians ■ Provide and promote recommend immunizations ■ Provide screening tests recommended by the U.S. Preventive Services Task Force (USPSTF) ■ Avoid providing unproven and/or harmful screening tests ■ Use effective methods to modify risky behaviors ■ Accurately diagnose and treat diseases of public health importance, such as sexually transmitted infections, influenza, and tuberculosis ■ Either provide treatment for exposed family members and other contacts of infectious diseases or refer to the public health department ■ Adhere to reporting requirements for infectious diseases, cancers, and other reportable conditions ■ Enforce infection control practices in the clinical setting ■ Provide advice to infectious patients on how to avoid spreading disease ■ Avoid unnecessary and harmful testing and treatments

Commonly Referenced Guidelines on Diseases of Public Health Importance Diseases Guideline Location Sexually Transmitted Diseases ■ Treatment guidelines and updates http://www.cdc.gov/std/ treatment/2010/default.htm Tuberculosis ■ Diagnosis, treatment of active and latent tuberculosis http://www.cdc.gov/tb/ publications/guidelines/ Treatment.htm#treatment Influenza ■ Vaccinations ■ Diagnosis and treatment ■ Outbreak control ■ Pre- and postexposure chemoprevention

table 88

Controlled clinical trials are needed to provide proof of improved outcomes from risk reduction. An example of a risk reduction intervention for which evidence exists is blood pressure control. It was shown in observational studies that hypertension is a risk for coronary heart disease and cerebral vascular disease. Following that discovery, controlled clinical trials showed that controlling blood pressure resulted in a reduction in these conditions. An example of a risk reduction effort that did not pan out is the use of antioxidants to prevent cancer. Observational studies indicated that lower intake of certain vitamins with antioxidant properties was associated with higher rates of certain cancers. However, controlled clinical trials of increased antioxidant intake failed to demonstrate reduced cancer rates (Boffetta et al., 2010; Gasiano et al., 2009; Zhang, 2008). Looking back at Table 7-5, there is good evidence that reducing risks 1 through 6 and 10 result in improved health outcomes. The evidence of benefit from reducing risks 7 through 9 is not as strong

Recommended screening includes being tested for colorectal cancer (with colonoscopy, sigmoidoscopy, or fecal occult blood testing), HIV and hepatitis C virus, hyperlipidemia (not applicable since he is on treatment), high blood pressure (not applicable since he is on treatment), obesity (done), depression using one of the scales linked on the USPSTF website (www.integration.samhsa.gov/images/ res/PHQ%20-%20Questions.pdf), and type 2 diabetes (done with the preclinic laboratory work). He does not meet the criteria to screen for syphilis (men who have sex with men, commercial sex workers, persons who exchange sex for drugs, and those in adult correctional facilities). Immunizations that are recommended include influenza vaccine annually, herpes zoster, and Tdap. Tdap and influenza vaccine are especially important if he is going to be in contact with his 3-week-old grandchild. You should mention that Tdap and influenza are also recommended for his wife for the same reason.

EXAMPLE 3, EARLY ADOLESCENT FEMALE A 12-year-old African American female visits the clinic with her mother because the mother felt it was time for herdaughter to have a checkup. The patient is seen at first with the mother and then alone. The patient is well, with no acute or chronic medical problems. She started having her menses 6 months previously and states she is not sexually active or considering it. She is active in sports, and her mother feeds her lots of fruits and vegetables and minimizes consumption of fast foods and sweetened drinks. The mother provides an immunization record that shows the patient has received all recommended childhood vaccines except for a single dose of varicella vaccine. The patient is 5 ft 4 in. tall and weighs 120 lb (75th percentile for both height and weight; BMI 20.6 kg/m2). Her mother is 45 years old and was diagnosed with breast cancer earlier in the year.

IMMUNIZATIONS One of the most effective forms of primary interventions available to family physicians is vaccines. The ACIP publishes updated immunization schedules annually. These include routinely recommended immunizations for infants, children, and adolescents (Figure 7-6), routinely recommended immunizations for adults starting at age 19 years (Figure 7-7), and catch-up recommendations for these two age groups (all can be found at www.cdc.gov/vaccines/ schedules/index.html). The catch-up schedules are useful in determining what vaccines to provide to someone who is not completely vaccinated with recommended vaccines at the time of the clinical encounter.

Family physicians should take every opportunity and use systematic approaches to ensure that patients are completely protected from vaccine-preventable diseases. This can involve assigning a clinical team member to be a vaccine advocate, implementing standing orders for nurses and others to administer vaccines, sending electronic reminders when vaccines are due, and taking advantage of each clinical encounter to provide recommended vaccines unless a valid contraindication exits (Community Preventive Services Task Force, Increasing Appropriate Immunizations)

The only sure way to prove that screening is effective is to perform a controlled clinical trial in which a large number of people are randomly assigned to one of two groups: screening and no screening. They then need to be followed over time to determine the age-adjusted cancer A-specific death rates (using the previous example). If screening is effective in preventing death from cancer A, the death rate in the screened group should be lower than the unscreened group. In addition, the overall death rate should be lower. If both conditions are not met, the screening test is of questionable value. Very few screening tests have been evaluated with such rigor, and we are often left with making decisions about effectiveness on lower quality observational studies. However, a recommendation can still be made without a controlled clinical trial if the observational evidence is strong enough. This requires that there be a large difference between those screened and unscreened, and that the difference is found consistently in multiple studies in which potential biases have been controlled for. Other factors that should be considered when assessing a screening test should include characteristics of the condition and the screening test. The condition should be serious (causing major mortality or morbidity) with a natural history that includes a lengthy asymptomatic period, and there should be an effective treatment for the condition or an intervention that prevents spread of the condition to others. The screening test should be readily available, relatively inexpensive, acceptable, and, above all, safe. This is because most of those being screened will not have the condition being screened for, and it is important not to cause them harm with screening.

In addition, the test should be accurate. Accuracy is measured by sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). These terms and how they are determined are illustrated in Figure 7-3. Sensitivity is the proportion of those with the condition who are detected by the test. Specificity is the proportion of those without the condition who are labeled as negative. Generally, as a test's sensitivity improves, specificity worsens and vice versa. PPV is the proportion of those with a positive test who actually have the condition, whereas NPV is the proportion of those who test negative who are condition free. While sensitivity and specificity are frequently reported as the most important statistic, from a physician and patient perspective, the predictive values are more critical. It is possible to have a test with a very good sensitivity and specificity but a poor PPV. This occurs when the prevalence of the condition in the screened population (the pretest probability) is low. With rare conditions, even with very accurate tests, a positive test is more likely to be a falsepositive than a true positive (i.e., it has a poor PPV). The effect of prevalence on PPV is illustrated in Table 7-1. This concept is very important for assessing screening tests because false-positives can cause harm. Another statistical concept one must understand to assess screening tests is the difference between relative risk reduction and absolute risk reduction. Using another hypothetical example, if a screening test and early treatment result in a 50% reduction in mortality, this looks pretty impressive. But what if the reduction in mortality is from a rate of 2 per 100,000 to 1 per 100,000? That is a relative reduction of 50% but an absolute reduction of only 1 per

100,000. In this example, it is necessary to screen 100,000 people to save one life or, stated another way, the number needed to screen (NNS) is 100,000. When assessing a screening test, it is important to ask about all these variables: sensitivity, specificity, PPV, NPV, NNS, and number needed to harm (NNH). It also is necessary to compare the benefits from testing to the harms caused by testing. Benefits can include improved outcomes resulting from early detection as well as, with infectious diseases, prevention of spread to others. Harm can result from both false-positive and false-negative results, complications that can result from further testing when the test is positive, and complications from the treatment for the condition

It is increasingly appreciated that additional harm can occur from testing, called overdiagnosis. This occurs because not all disease detected by screening is destined to progress and cause morbidity and mortality. Sometimes the condition regresses or does not progress, or progresses so slowly that other conditions cause death first. An example of this is prostate cancer. Many prostate cancers detected by screening would never cause a man any problems. It would have gone unnoticed if the screening had not been performed. But almost all these men will undergo further diagnostic testing and then treatment, with significant resulting morbidity and even mortality caused by complications of these interventions. There is now an appreciation that overdiagnosis occurs as a result of cancer screening much more frequently than was previously known (Kalager et al., 2012

accurately diagnosing and treating diseases of public health importance, such as sexually transmitted infections, influenza, and tuberculosis; providing recommended treatment for family members and other contacts to infectious diseases or referring them to the public health department; reporting of infectious diseases, cancers, and other reportable conditions as required by state and local reporting requirements; enforcing infection control practices in the clinical setting; and providing advice to infectious patients on how to avoid spreading disease. Avoiding unnecessary or harmful testing and treatments should also be considered part of the prevention package offered by family physicians. Family physicians should be continually aware of the epidemiology of disease in their communities, which diseases are endemic, which ones are not, and which infectious diseases are occurring at increased rates as part of an epidemic or seasonal increase. Local and state health departments as well as the CDC provide routinely updated epidemiological information through a variety of communication outlets. This knowledge assists physicians in making more accurate clinical diagnoses and providing appropriate treatments. The CDC and state health departments provide recommendations on how to diagnose and treat infectious diseases such as sexually transmitted infections, influenza, tuberculosis, and many others. A list of the most commonly used recommendations and their location on the CDC website is contained in Table 7-15. Following these official guidelines assists in providing accurate surveillance data, helps control infectious disease outbreaks, and assists in preventing antibiotic resistance. When an infectious disease is discovered in a patient, the family physician should think about the implications of this for the family and the community. Family members may benefit from immunizations and/or chemoprevention depending on the disease. Some states allow treatment of sexually transmitted infections and other infectious diseases for contacts of patients, without directly examining the contact. This is called expedited partner therapy (EPT), and it not only benefits the contact but can also prevent reinfection of the patient. Examples of when EPT can be

Major Public Health Achievements of the Past Century ■ Vaccination ■ Motor-vehicle safety ■ Safer workplaces ■ Control of infectious diseases ■ Prevention of deaths from coronary heart disease and stroke through risk factor reduction ■ Safer and healthier foods ■ Maternal and child health programs ■ Family planning ■ Fluoridation of drinking water ■ Tobacco use prevention

strong evidence-based methodology that consists of systematic reviews of the evidence and tying recommendations to the strength of the evidence. A challenge for the CPSTF is that community-wide recommendations are rarely subjected to controlled clinical trials so that methods of assessing and ranking other forms of evidence are required. The methods used by the CPSTF are described on their website (www.thecommunityguide .org/index.html). The recommendations made are contained in the Guide to Community Preventive Services, often called The Community Guide, which is also available on the website. The Community Guide also provides evidence-based recommendations for increasing the use of preventive services in the clinical setting

Paying for Preventive Services The Patient Protection and Affordable Care Act (PPACA), Public Law 111-148, passed on March 23, 2010, established that a set of preventive health services shall be included without cost sharing by group health plans and health insurers offering group or individual health insurance. These services include: ■ Those recommended with an A or B rating by the USPSTF. ■ Immunizations that are recommended by the ACIP. ■ Preventive services for infants, children, and adolescents that are included in guidelines supported by the Health Resources and Services Administration (HRSA), which in effect are those described in the Bright Futures initiative of the AAP. ■ Additional services for women as provided for by guidelines supported by the HRSA. The HRSA contracted the task of developing this list to the IOM (2011b). The intent of this provision in the PPACA is to provide an incentive to Americans to obtain evidence-based (or at least evidence-informed) preventive services to promote health and prevent disease. While on the surface it appears to provide an array of free preventive services, family physicians and patients need to appreciate that unanticipated expenses can occur from these services. As an example

Preventive interventions should be supported by high-level evidence of effectiveness and safety. ■ Of all organizations and committees that make prevention recommendations, the U.S. Preventive Services Task Force (USPSTF) uses the most robust, evidence-based methodology. ■ Other groups that make recommendations pertinent to prevention in the primary care and community setting are the Advisory Committee on Immunization Practices (ACIP) and the Community Preventive Services Task Force, both supported by the Centers for Disease Control and Prevention (CDC). ■ Screening tests should be assessed for accuracy, safety, and effectiveness. Effectiveness means that screening results in an outcome that is better than occurs when the condition presents naturally and that the benefit gained exceeds harms caused. ■ Screening tests can appear effective when they are not because of lead time and length biases. ■ In low-prevalence conditions, even with accurate tests, the positive predictive value of the test will be low. ■ One of the harms that can arise from screening is overdiagnosis, finding and treating disease, with the associated harms from diagnosis and treatment, when the condition would have resolved on its own or never progressed. ■ Some behaviors that lead to bad health can be modified by brief interventions in a clinical encounter, others need more intensive interventions. ■ A four-step approach of considering risk assessment, risk reduction, screening, and immunizations can assist family physicians in remembering to address prevention with each patient. ■ Reducing "risks" for specific diseases found in observational studies should be tested in controlled clinical trials to see if risk reduction lowers the incidence of the disease. ■ Tools available for risk reduction include behavior modification and chemoprevention.

Physicians should offer to patients screening tests that have an A or B recommendation from the USPSTF. ■ Physicians should offer and encourage patients to accept immunizations recommended by the ACIP. ■ Preventive services offering the most benefit and those most acceptable to the patient should be prioritized. ■ Smoking is the leading cause of preventable mortality and morbidity. Any patient who smokes should be encouraged to cease smoking and be offered nicotine replacement, medications, and support group referral. ■ Accurately diagnosing and treating diseases of public health importance, such as sexually transmitted infections, influenza, and tuberculosis, helps control these diseases and prevent drug resistance. ■ Family physicians can minimize the effects of communicable diseases in the community by providing recommended treatment for family members and other contacts of those with infectious diseases either with expedited partner therapy or by referring them to the public health department. ■ Infection control practices should be enforced in the clinical setting. ■ Physicians should report infectious diseases, cancers, and other reportable conditions as required by state and local reporting requirements. ■ Clinic staff should be vaccinated as recommended by the CDC. ■ Avoiding unnecessary or harmful testing and treatments and their associated harms should be considered part of the preventive practices of family physicians. ■ Genomic and genetic testing holds promise for enhancing clinical prevention, but only a few tests have been proven effective at this time, and genetic risk profiling for chronic disease risk has not proven to be beneficial. ■ Making prevention interventions routine, as part of the clinical system, helps to ensure a high level of performance.

useful include chlamydia and trichomonas infections. Family physicians who live in states where EPT is not legal and those who are not comfortable providing EPT should either recommend the exposed contact see a physician for assessment and treatment or refer the patient to the local health department. A current catalogue of the legal status of EPT by state can be found at the CDC Expedited Partner Therapy web page (www.cdc.gov/std/ ept/default.htm/). Much of the public health surveillance system depends on reports that come from clinical settings. Hospitals, physicians, and other providers are required to report to the local health department occurrences of specific infectious diseases. In some locations, new diagnoses of cancers are also required. Family physicians should be aware of what the reporting requirements are in the locale of their practice. These requirements usually specify that individual cases should be reported; however, in some instances, the requirement applies only to suspected outbreaks or multiple cases. Anytime family physicians detect an infectious disease that is out of the ordinary, with potential to spread in the community, they should consult with a public health department, either local or state. Most of the required reports request information about the patient that includes name, address of residence, and phone number. If this information is required, it is exempt from the requirements of the Health Insurance Portability and Accountability Act (HIPAA), and the patient's consent to report is not required. The public health department uses this information for a variety of purposes, including detailed surveillance, contact notification, and implementation of preventive measures. A clinical setting can be the source of spread of infectious disease in the community. Sick, infectious patients visit physician offices and clinics, and measures need to be taken to insure that spread of disease does not occur in these settings, to other patients as well as to physicians and staff. Measures that can be taken fall into five categories: policies on respiratory hygiene, policies on hand hygiene, immunization of staff, triage policies, and use of personal protective equipment (PPE). Policies on all these areas should be in place and enforced. A checklist of what the CDC considers minimum expectations for the prevention of infections in the outpatient setting can be found at its

Policies for Respiratory Hygiene in Health Care Settings ■ Signs at entrances asking patients to inform office staff if they have symptoms of a respiratory infection ■ Signs describing expectations regarding respiratory hygiene and demonstrating the correct way to cover the mouth and nose with a tissue when coughing or sneezing; proper disposal of tissue and hand cleansing after contact with respiratory secretions ■ Offering masks to those who are coughing and not practicing respiratory hygiene ■ Providing readily available tissues and hand sanitizer and no-touch receptacles for tissue disposal

Risk factor assessment shows that injuries from a motor vehicle crash are the most likely cause of death in this age group. A more detailed family history is important to see if she has a high-risk family history for breast cancer. You can request that the mother gather this information to present at a future visit. Risk reduction should include counseling about tobacco avoidance. Skin cancer behavioral counseling is recommended only for those with fair skin color, not African Americans and others with dark skin. Recommended screening includes tests for depression, which can be performed using one of the tools on the USPSTF website, and obesity (done)

Recommended immunizations include Tdap, meningococcal conjugate vaccine (MCV4), human papillomavirus (HPV) first dose of a three-dose schedule, varicella dose 2 (catch up), and annual influenza vaccine. Bright Future recommendations for this age group include measuring blood pressure, checking vision, performing a psychosocial and behavioral assessment, and providing anticipatory guidance focused on substance abuse and safety. The USPSTF states that the evidence is insufficient to recommend for or against these interventions

Assessing Physician Counseling Changing patients' behavior is difficult. An in-depth discussion on effective counseling and behavioral modification methods is in Chapter 8. While there are many behaviors that place a person at risk for current and future adverse health, not all of them are conducive to being modified by counseling in a clinical encounter. Since family physicians do not have time to counsel regarding all potential risky behaviors, it is important to focus on the ones that have the greatest effect on health and for which evidence of the effectiveness of counseling exists. The USPSTF provides guidance on this topic but frequently finds that evidence is insufficient to judge whether physician advice and counseling actually change behavior. This does not mean that a family physician should not provide counseling when insufficient evidence exists, but they should be aware that evidence is lacking about the effectiveness of counseling in that situation and that time might be better spent on interventions supported by stronger evidence

Putting Prevention into Practice There are many barriers to practicing preventive medicine in a family medicine clinical setting. These include time pressures, inadequate reimbursement, and lack of interest from the patient. These barriers can be overcome with a systematic and organized approach to prevention that is part of each patient encounter. A complete set of preventive

born just 3 weeks ago. Both parents are still alive at ages 89 and 90 years. He does not exercise regularly. He had a tetanus shot an uncertain number of years ago and has never had a flu shot. His current height is 5 ft 10 in. and weight is 250 lb (BMI 35.9 kg/m2). His blood pressure in the clinic is 130/75 mm Hg (using a large cuff) and he reports a similar reading when he checks it at home. His fasting labs, obtained a week before the clinic visit, demonstrate normal renal functions, a cholesterol level of 155 mg/ dL, an HDL cholesterol level of 35 mg/dL, and glucose level of 95 mg/dL. His risks include obesity, hypertension (controlled on medication), and hypercholesterolemia (also being treated with medication but not optimally controlled). Using the NHLBI cardiovascular disease (CVD) risk calculator (http:// cvdrisk.nhlbi.nih.gov/calculator.asp), his risk of a myocardial infarction in the next 10 years is 12%.

Risk reduction could include obesity intensive educational interventions. To be effective in assisting him to lose weight, this will need to consist of setting weight loss goals, improving diet and increasing physical activity, addressing barriers to change, self-weight monitoring regularly, and setting strategies to maintain lifestyle changes. Today you can ask him to go online and assess his diet and obtain advice on how to improve his diet at the DHHS website (www.healthfinder.gov/HealthTopics/ Category/health-conditions-and-diseases/diabetes/eat -healthy). A plan for regular follow-up and monitoring should be established. Recommended chemoprevention includes continued treatment for hypertension and hypercholesterolemia to reduce risks of cardiovascular disease. If he has no history of bleeding disorders, he might benefit from daily lowdose aspirin, and this can be discussed. At age 61, with a 12% risk of a heart attack, daily aspirin will prevent about four heart attacks per 100 men over 10 years (see www .uspreventiveservicestaskforce.org/uspstf09/aspirincvd/ aspcvdrsf2.htm

Chemoprevention can be utilized as either a primary or tertiary prevention intervention. Those in Table 7-8 are primary interventions that are recommended by the USPSTF. Table 7-9 includes examples of other uses of medications for prevention in specific circumstances. These include those that are used commonly, such as medications to control high blood pressure and hypercholesterolemia, which can prevent cardiovascular disease, and medications to improve hyperglycemia in those with diabetes, which can prevent the microvascular complications of this chronic condition. Others are less common and need to be kept in mind when patients present after an event that places them at risk for a recurrence or have had an exposure to an infectious agent

SCREENING Secondary prevention, or screening for early detection of asymptomatic disease, is an important component of clinical prevention. As described previously, the USPSTF and the AAFP list screening tests that family physicians should offer to patients. The USPSTF offers a user-friendly electronic version of their recommendations called the Electronic Preventive Services Selector (ePSS). It can be downloaded to all types of electronic devices and used to search for recommended screening tests by age and gender (see http:// epss.ahrq.gov/PDA/index.jsp). If the screening test is recommended only for certain risk groups, there is an attached tool to assist in measuring risk.

a description of the natural history of the condition, the types of interventions available, and the level of evidence that exists on their effectiveness and harms, as well as how the task force recommendation either agrees with or differs from those of other organizations. All USPSTF recommendations are found on their website (www .uspreventiveservicestaskforce.org/recommendations .htm). The process used by the USPSTF is scientifically robust and is considered the gold standard for assessing evidence and making recommendations. The result, however, often leads to recommendations that are at odds with other organizations and advocacy groups, which tend to adopt new technologies before they are fully tested for effectiveness or safety. In addition, because of a reluctance to make a recommendation without strong evidence, the wording of USPSTF recommendations is often vague about the frequency of testing or screening, because the relative effectiveness of different screening frequencies has not been assessed

THE CENTERS FOR DISEASE CONTROL AND PREVENTION ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES The Advisory Committee on Immunization Practices (ACIP) was created in 1964 to provide expert external advice and guidance to the director of the Centers for Disease Control and Prevention (CDC) and the Secretary of the U.S. Department of Health and Human Services (DHHS) on use of vaccines. The ACIP is an official federal advisory committee and is governed by the Federal Advisory Committee Act, which has strict requirements for public notification of meetings, allowing for public comment, and publication of minutes. The ACIP recently adopted a new system for developing evidence-based recommendations that is based on a modification of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach (Guyatt et al., 2011). Key factors considered in the development of their recommendations include the balance of benefits and harms, type of evidence, values and preferences of the people affected, and health economic analyses. There are two categories of recommendations: category A (either for or against) applies to all persons in an age- or risk-factorbased group, while category B is a recommendation that is not meant to be universal but recognizes that a vaccination may be found to be appropriate for an individual within the context of a clinician-patient encounter. Evidence tables are used to summarize the benefits and harms and the strengths and limitations of the body of evidence. This new process brings the ACIP more in line with contemporary evidencebased processes (Ahmed et al., 2011).

THE AMERICAN ACADEMY OF PEDIATRICS AND BRIGHT FUTURES The AAP endorses a set of periodic visits and clinical guidelines for children starting at birth and continuing to age 21 years. This set of recommendations is called Bright Futures and can be found on the AAP website http://www .aap.org/en-us/professional-resources/practice-support/ Pages/PeriodicitySchedule.aspx. There is a set of recommended screening tests, developmental assessments, immunizations, and anticipatory guidance recommended for each visit. Due to a scarcity of research on the effectiveness of preventive services in infants and children, many of these recommendations are not based on high-quality evidence. The AAP acknowledges this by calling these recommendations "evidence informed." The AAFP has not endorsed the Bright Futures guidelines. They are, however, the basis for Medicaid preventive services for children and some quality-improvement programs use them as performance measures of quality in child preventive care.

THE COMMUNITY PREVENTIVE SERVICES TASK FORCE The Community Preventive Services Task Force (CPSTF) was formed in 1996 and consists of 15 members appointed by the director of the CDC. They are tasked to make recommendations and develop guidance on which community-based health promotion and disease-prevention interventions work and which do not work, based on available scientific evidence. The CDC provides the CPSTF with technical and administrative support. This task force uses a

existing evidence on the issue with clearly defined inclusion and exclusion criteria; a clear and accepted method of assessing each study and for summarizing and ranking all of the evidence; and several reviewers doing the assessment, using defined methods of resolving differences of opinion. High-quality guidelines also involve a panel of experts with an array of skills, including how to assess the medical literature; conflict of interest policies that minimize and manage potential as well as real conflicts of interest; a methodology that assigns a strength of recommendation that reflects the best available evidence behind it; a limited number of clearly worded, unambiguous recommendations; an emphasis on patient-oriented outcomes, as well as options that allow for patient preferences; a consideration of potential harms as well as benefits; tools that assist with implementation, if they are available; and plans for periodic updating. As described in the IOM report (2011a), many guidelines and recommendations currently do not meet these standards. This places family physicians in an awkward position, as poor-quality guidelines produced by specialty societies and special interest groups can be perceived as the gold standard because they come from the specialists who are seen as the experts in a particular topic. Some specialty societies produce high-quality guidelines, others do not. Specialist-dominated panels can be conflicted (setting out to defend current practices and justify payments), often do not consider potential harms, frequently are not prevention oriented, and may lack the members with the skills needed to assess the medical literature. This has resulted in the American Academy of Family Physicians (AAFP) developing its own prevention recommendations. These can be found on the AAFP website (www.aafp.org/patient-care/ clinical-recommendations/cps.html

THE UNITED STATES PREVENTIVE SERVICES TASK FORCE The U.S. Preventive Services Task Force (USPSTF) was first created in 1984 as an independent panel of experts to provide guidance to physicians on the use of clinical preventive services. In 1998, it was placed under the sponsorship of the Agency for Healthcare Research and Quality (AHRQ), while maintaining its independent status, and provided with support to conduct scientific evidence reviews of a broad array of clinical preventive services and develop recommendations. The topics the task force addresses include screening tests, counseling, and preventive medications. The USPSTF uses a rigorous and strict methodology of considering evidence and making recommendations after balancing documented benefits and harms (USPSTF, 2014). The task force does not consider the costs of the services being assessed or cost-benefit analyses. The interventions evaluated are often already in common use and frequently recommended by specialty and advocacy organizations before they have been thoroughly assessed for effectiveness and safety. The USPSTF recommendations are separated into four categories: Level A recommendations are reserved for interventions with a clear predominance of benefits over harms backed by high-quality evidence. If evidence is not as robust, or the benefit/harm differential not as great but still in favor of benefits, a B recommendation is given. When benefits and harms are balanced, or overall benefit is minimal, it is assigned a C. Level D (a recommendation against) is assigned when no benefit exists or harms exceed benefits. If insufficient evidence exists to judge the balance of benefits and harms, the USPSTF is not compelled to make a practice recommendation and will assign it an I. Each recommendation made by the task force is accompanied by

tbBle 90-92

USPSTF recommends for infants, children, and adolescents. It is equally important not to provide screening tests that are not effective and/or are harmful, such as those given a D rating by the USPSTF (Table 7-12). These tables describing USPSTF recommendations were developed at the time of the writing of this chapter and reflect the USPSTF recommendations as of that time. Keeping up to date on screening recommendations is challenging. The USPSTF makes a new recommendation or updates an old recommendation about once a month. Physicians can sign up for periodic updates at the USPSTF website (www.uspreventiveservicestaskforce .org/announcements.htm).

RISK REDUCTION Once a patient's short and long-term health risks are known, the family physician can concentrate on reducing these risks. Time and effort is best spent on risk reduction that evidence demonstrates will result in improved outcomes. There are two major tools for reducing patients' risks for disease—behavioral change counseling and chemoprevention. Both can be applied as primary or tertiary prevention. Information on how to provide effective behavioral change counseling is provided in Chapter 8. Because the leading causes of death are chronic diseases affected by

behavior, with the harmful effects building up over a number of years, convincing younger adults to change unhealthy behaviors is challenging as is altering habits that have been practiced for long periods. We should keep in mind, however, that if behavior change is achieved in only a small percentage of patients, this can add up, on a population level, if all physicians applied the most effective counseling and behavior modification methods. Some behaviors can be changed by brief counseling that can be provided in a clinical encounter. Table 7-6 lists those that are recommended by the USPSTF. Other behaviors are more difficult to change and require more intensive and multicomponent interventions. Table 7-7 lists behaviors in this category and the more intensive interventions needed to change them that are recommended by the USPSTF. In these instances the family physician can provide more intensive counseling themselves or defer to other health care professionals who have more time and training in this area.

while colonoscopy screening for colorectal cancer every 10 years should be available without patient cost sharing (it is a level A recommendation by the USPSTF), a polypectomy performed during the procedure and follow-up testing are not covered by this PPACA provision and can result in significant out-of-pocket expenses. Assessing Screening Tests Many physicians and much of the public believe that screening and finding disease early is always beneficial. Many single-issue advocacy groups view screening as a key element in the control of their condition of concern. Family physicians simply do not have time to screen for every condition advocated, and should not screen for all of them, even if they did have time. Screening should only be conducted when the outcome of screening (finding the condition early and treating it) provides an outcome that is superior to waiting for the condition to become symptomatic. Additionally, the benefits provided by the screening test should outweigh any harms it causes. Assessing the effectiveness of screening tests is not easy. Let us take an imaginary example. If screening for a cancer, labeled cancer of organ A, is detected by screening and then treated, life expectancy is 8 years. If the disease is detected by the presence of symptoms and then treated, life expectancy is 2 years. Does this prove that screening is effective? Many will answer that it does, including many practicing physicians (Wegwarth et al., 2012), but it does not. There are two biases in observational studies of this type that can affect the results: lead time bias and length bias (Figure 7-2). Lead time bias means that the disease is detected earlier, but the outcome is not changed. The point of death is not moved back; the disease was simply detected earlier making it seem that life expectancy is improved. Length bias comes from the fact that screening is more likely to find less aggressive disease. Cancers can have more aggressive and less aggressive forms. Aggressive forms leave little time from onset to symptoms to be detected by screening. Less aggressive forms exist in an asymptomatic state for an extended period and are more likely to be detected by screening, again leading to perceived increase in life expectancy.

flow chart 85

Examples of Putting the Four-Step Approach into Practice EXAMPLE 1, YOUNG ADULT MALE A 28-year-old male visits the clinic in October with a complaint of abdominal pain. The pain occurs after nights when he parties with friends, consuming 6 to 7 alcohol-containing drinks. He drinks some alcohol almost every day. He admits to occasionally driving home after these parties, but feels like he is not impaired, although he was cited for driving under the influence several months ago. He also admits to being in bar fights once or twice the past year. He smokes less than one pack of cigarettes per day and started at the age of 17 years and states he would like to quit. He denies any use of illicit drugs except occasionally smoking marijuana. He is an only child and both parents are alive with no health problems. There is no known history of cancer or early heart disease in his family. He currently takes no medications and has no chronic health problems. He has sex only with women, has had eight partners in the past year, and uses condoms irregularly. He works as an insurance adjuster in an office, exercises three to four times a week at the gym, lifting weights. He eats mostly fast food for convenience. He believes he has had all childhood vaccines but is not sure. His last tetanus shot was at age 22 years after a laceration. He is 5 ft 11 in tall and weighs 180 lb (body mass

table 94

Healthcare-associated Infections web page (www.cdc. gov/HAI/settings/outpatient/checklist/outpatient-care -checklist.html). Respiratory hygiene means covering the nose and mouth with a disposable tissue when coughing and sneezing. This should be an expectation for patients and staff. Measures that can be taken to encourage and enforce respiratory hygiene are listed in Table 7-16. Health care personnel should wash or sanitize their hands after every patient encounter. Patients should be instructed to use frequent hand washing when sick. Hand sanitizer should be readily available in clinical areas and waiting rooms. Office design and triage policy can assist in physically and temporally separating sick, infectious patients from others. Potentially infectious patients can be placed in a separate waiting area and/or asked to come in during specified time periods. However, if respiratory and hand washing policies are adhered to, having those with common respiratory infections use common waiting areas and examination rooms is acceptable. Other infectious diseases require more stringent measures. Fever accompanied by rash is particularly problematic. Measles, rubella, and varicella can all present this way and are highly infectious. Those presenting with rash and fever can be placed into a designated "rash room" and kept confined there until the diagnosis is clarified. If a highly infectious disease is suspected or confirmed, the room should not be used for other patient encounters for a time period as determined by the public health department. Physicians and other health care personnel are at increased risk of exposure to infectious diseases and should take measures to protect themselves and thereby also protect their patients and families. All health care personnel should be vaccinated according to CDC recommendations (Table 7-17). Having unvaccinated personnel in a clinical setting causes a risk to them, their families, and patients. They are also a liability risk to the practice. PPE should be used any time an exposure to a potentially infectious body fluid occurs. Details on the proper use of PPE are on the CDC web page, Healthcare-associated Infections (www.cdc .gov/HAI/prevent/ppe.html). When a family physician detects an infectious disease in a patient, advice should be given on how to prevent the spread of the disease to the patient's family, friends, and the community. A list of advice that can be provided is in Table 7-18. As noted earlier, the last important role for family physicians in practicing optimal preventive medicine is to avoid

table 99

Office Systems as an Aid to Prevention In a busy clinical setting, prevention can easily be relegated to the back bench. It takes effort to adhere to recommendations for counseling, chemoprevention, screening, and vaccines. Reporting of infectious diseases to the health department can be overlooked. Making prevention interventions routine, as part of the clinical system, helps ensure a high level of performance. Examples of systemization that can occur include electronic health record reminders to providers of recommended preventive services for each patient; flagging of infectious diseases that need to be reported; standing orders for immunizations; alerts when targets such as blood pressure and blood glucose levels are exceeded; and automatically generated reminders for patients that can be sent using electronic media. Other system-wide interventions with good evidence of effectiveness include group education sessions for diabetes selfmanagement and increasing breast cancer screening;

team-based approaches to assist patients in managing chronic conditions such as high blood pressure, diabetes, and high cholesterol; and periodic assessment and feedback to providers on performance on prevention measures (Community Preventive Services Task Force, Cardiovascular Disease Prevention, Diabetes Prevention and Control, and Obesity Prevention and Control). Individual team members can be charged with specific responsibilities such as assessing each patient's vaccine status or ensuring that hand sanitizers and tissues are readily available. Immunization schedule wall charts can be posted in waiting areas and examination rooms, and prevention-oriented patient education materials can be placed so they are easily seen and obtained. The key is making all aspects of prevention a priority and finding ways to make it happen