Health Maintenance
What do ABCD and I mean
A = highly recommend and approve B = moderate to highly recommend C = individualised recommendation D = DO NOT RECOMMEND I = low certainty of net benefit/not enough data to make a recommendation, so we usually don't. If its offered make sure the patient knows that we don't have a ton of evidence on this.
•Weight loss to Prevent Obesity-Related Morbidity and Mortality in Adults: Behavioral interventions
Adults w/ a BMI ≥ 30, offer or refer to intensive, multicomponent behavioral interventions Example of primary prevention! try to get them to lose weight
F- fall prevention in community dwelling older adults
Age 65 or older at increased risk of falls, w/o osteoporosis or vitamin D deficiency: Recommend: exercise. Optional: Selectively offer multifactorial interventions to prevent falls (C) - PT, vision, gait assessment DO NOT RECOMMEND: Do not recommend Vitamin D supplementation to prevent falls (however, would be recommended for osteoporosis/osteopenia for bone health)
V - Vision screening
Ages 3-5 years old I statement for under 3, 65+ Medicare covers an eye exam during initial welcome to medicare visit
What are the 3 stages of prevention
1. Primary prevention = preventing it before it starts. identifying and managing risk factors for a disease Examples: patient on a statin before they have a stroke/MI, smoking cessation in someone who doesn't have COPD/lung cancer, flu shot, screening colonoscopy and removing pre-cancerous polyps 2. Secondary prevention: screening to identify diseases in the earliest stages, before the onset of symptoms Examples: checking blood pressure before they get sx of htn, diabetes, mammography, pap smear, technically a colonoscopy too 3. Tertiary prevention: prevent further progression, complications and disability in an established disease Examples: diabetes getting an annual retinal, foot (monofilament) tests, monitor urine for proteinurea
Vaccinations - both adult and children, we are responsible for the adult schedule
1.Influenza - annually 2.Tdap (tetanus, diphtheria, pertussis) or TD - booster Q 10 years. Also with each pregnancy and for every wound while pregnant. (must get Tdap first) 3. MMR: 1 or 2 doses - 19-64 y/o 4. Varicella - 2 doses 5. Zoster recombinant - 2 doses at 50 y/o 6. HPV: when younger up until age 45 7. Pneumococcal - then again at 65 8. Hep A, Hep B 9. Meningococcal 10. H flu (Hib) 11. COVID! "shingles, pneumococcal, flu, covid, tetanus"
O - obesity screen
Children and adolescents 6 years + --> BMI measurement --> THIS IS NOT REFERRING TO ADULTS •Offer comprehensive, intensive behavioral interventions to promote improvement in wt status If overweight or obese w/ additional CVD risk factors:Refer for intensive, multicomponent behavioral interventions
Testicular cancer screening
DO NOT RECOMMEND self or physical exam if having sx then yes, but remember these recommedations are for people without sx!!!
What makes an effective screening test? Disease, test itself, population
Disease: •high prevalence in the population •has a significant effect on quality or length of life •treatment methods are available •Asymptomatic period during which detection and tx significantly reduces morb/mort •Treatment in the asymptomatic phase yields a better result than tx delayed until symptoms appear AKA why we wouldn't screen for ALS •Screening test •Sensitive and specific •Acceptable to patients •Population Screened •High disease prevalence •Accessibility •Compliance with tests and necessary therapy
H - HIV prophylaxis (PREP)
Emtricitabine, Tenofovir -partner w/HIV -injection partner w/ HIV/sharing needles -Has used PEP multiple times
The comprehensive annual PE/AWV/WCC are an assessment of overall what? (physical exam, annual wellness visit, well child check)
Function! •Ability of the patient to function at optimal potential •It is measured by physical, emotional and cognitive functioning Best times to be doing prevention too
S - Statin for PRIMARY prevention of CV in adults
Recommend: Adults age 40-75y w/ no hx of CVD, 1 or more CVD risk factors, and calculated 10-year CVD event risk of 10% or greater --> Low to moderate dose Optional: Adults age 40-75y w/ no hx of CVD, 1 or more CVD risk factors and calculated 10-year CVD even risk of 7.5-10%: --> Low to moderate dose I statement: 76+ with no hx of CVD
D - Depression screening
Recommend: Adults aged ≥18y, Adolescents 12-18y and women who are pregnant or in peripartum periods: Screen with adequate systems in place to ensure accurate dx, tx and follow-up I Statement: <12 years old
C - •Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults w/ CV risk factors: Behavioral counseling
Recommend: Adults who are overweight or obese and have known CV risk factors, offer or refer to intensive behavioral counseling interventions to promote a healthful diet and physical activity Optional: Those w/o risk factors
D - prediabetes and type 2 diabetes screening
Recommend: Asymptomatic adults aged 35-70 y who are overweight or obese
H -Hep B screening
Recommend: pregnant women Adults & adolescents at risk At risk: - immigrated from high risk country -not vaccinated as infant -patients whose parents born in areas of high prevalence -HIV + patients -IVDU -household contacts/sex partners + for Hep B
I - intimate partner violence screening
Recommend: women of reproductive age HITS,EHITS,HARK, PVS --> refer for intervention if screen positive I statement for older or vulnerable adults (no good screening tool right now)
H - Hypertension screen
Recommend: •Adults ≥ 18y w/o known HTN: (A) •≥40y and at increased risk: annually •18-39y w/ normal BP and no risk factors: q3-5y Modifiable risk factors include unhealthy diets (excessive salt consumption, a diet high in saturated fat and trans fats, low intake of fruits and vegetables), physical inactivity, consumption of tobacco and alcohol, and being overweight or obese. I statement: children and adolescents HTN = >140/90
D - Dental caries - medication/screen
Recommend: •Screening birth through 5 years: (B) •Rx fluoride supplementation starting at age 6 mo for children whose water supply is deficient (B) •Apply fluoride varnish to primary teeth of all infants and children starting at age of primary tooth eruption (B)
Skin cancer prevention - 2018
Recommend: •Young adults, adolescents, children and parents of young children- counsel on minimizing exposure to UV radiation for persons aged 6 mo to 24 y w/ fair skin types to reduce risk of skin cancer (B) Optional: Adults >24y w/ fair skin types: counseling as above I statement: asymptomatic adults
D - unhealthy drug use
Recommended for 18 + I statement: adolescents
A - Unhealthy alcohol use screening and behavioral counseling interventions
Recommended for: Adults 18 and older including pregnant women: Screen and provide brief behavioral counseling interventions I Statement: Under the age of 18 We use the AUDIT-C questionnaire - 3 questions with 5 answer choices. max score of 12, lowest of 0 Men - 4+ = positive Women - 3+ = positive
C- Colorectal cancer screening
Recommended for: Adults aged 45-75 •Adults 45-49y: screen starting at age 45 (B) •Adults aged 50-75y: screen starting at age 50 (A) Istatement: Adults aged 76-85y: individual decision
A - Aspirin use to prevent CVD & Colorectal cancer
Recommended for: Adults aged 50-59y w/ a ≥ 10% 10-y CVD risk: initiate low dose ASA Optional for: Adults aged 60-69y w/ a ≥ 10% 10-y CVD risk: individual decision (C) I Statement: •Adults <50y: no recommendation (I) •Adults aged 70y or older: no recommendation (I) However, new draft is saying 40-59 at high risk is optional and over 60 should not take
A - AAA screening
Recommended for: Men aged 65-75y who have ever smoked - 1 time screening Optional for: Men aged 65-75 y who have never smoked Do not recommend for: Women who have never smoked and have no FH of AAA I Statement: Women aged 65-75 who have ever smoked or have FH of AAA (I)
B - breast cancer screening with mammography
Recommended for: Women aged 50-74y: Screen every 2 years Genetic counseling and testing recommended for women w/ personal or FH of breast, ovarian, tubal or peritoneal cancer or an ancestor w/ BRCA ½ gene mutation Optional for: •Women aged 40-49y I Statement: Women 75y and older: no recommendation *BSE and provider exam: insufficient evidence for use in those w/o increased risk
B - breast cancer medication use
Recommended for: •Women aged ≥35y at increased risk for breast cancer, offer risk-reducing medications Do not recommend for: Women aged ≥ 35y not at increased risk for breast cancer, do not offer risk reducing medications
O - osteoporosis to prevent fractures screening
Recommended: -Women over 65 -Post menopausal women <65, at increased risk Screen with bone density screening and treat based on risk Osteopenia: weight bearing exercise, proper calcium, vitamin D Osteoporosis: look into bisphosphonates I statement: for men
What is the USPSTF?
The US Preventive Services Task Force Created in 1984 •Convened by federal Agency for Healthcare Research and Quality (AHRQ) in 1998 •Independent, volunteer panel of national experts in: 1.preventive medicine 2. evidence-based medicine 3. primary care specialists in: - family med -peds -internal med -geriatrics -behavioral med -obgyn -etc 16 volunteer members that go through peer reviewed literature every year
Who do the USPSTF recommendations apply to?
•Apply only to people who have no signs or symptoms of the specific disease or condition under evaluation Primary or secondary prevention!
STI screen/counsel: Syphilis/c
•Asymptomatic, non-pregnant adults and adolescents at increased risk - MSM -HIV -hx of incarceration/commercial sex work •Pregnant women *behavioral prevention counseling for all We test with RPR followed by VDRL (more confirmatory test) if patient tests positive for any of these then need to address and properly tx
T -Tobacco smoking cessation in adults (>18) and pregnancy women, behavioral and pharmacotherapy interventions
•Behavioral and pharmacotherapy interventions in adults who are not pregnant •Behavioral interventions in pregnant women I statement: pharm intervention while pregnant (can't use nicotine replacement or Chantix)
What is health promotion
•Identifying ways to improve overall well being •Requires collaboration with the patient •Requires encouraging the patient to take necessary steps This requires buy in from the patient - motivational interviewing!
What are the goals of the USPSTF?
•Review peer-reviewed literature to assess evidence-based interventions •Make graded recommendations about preventive services including the following: 1.screening tests 2.counseling services 3.preventive medications
T - Prevention and Cessation of Tobacco Use in Children and adolescents <18y: Primary Care Interventions (education/counseling)
•School-aged children and adolescents who have not started to use tobacco (B) (to prevent initiation of tobacco use)
What is health maintenance
•Systematic program or plan to do the following: 1. Prevent illness 2.Maintain maximum function 3. promote health Physical, mental, and emotional health!
STI screen:Chlamydia/Gonorrhea
-Sexually active female < or equal to 24 -At increased risk of infection >24 NOT RECOMMENDED: for men (men are more likely to have sx!)
What to do with PHQ9 score
1-4 = none, do nothing 5-9 = mild, watchful wait and repeat at f/u 10-14 = moderate: tx plan, consider counseling, f/up and/or meds 15-19: moderately severe: immediate meds and/or psychotherapy 20-27: immediate meds and if severe impairment or poor response expedited referral
Options for colon cancer screening
1. High-sensitivity guaiac fecal occult blood test (HsgFOBT) or fecal immunochemical test (FIT) every year 2. Stool DNA-FIT every 1-3 years (ex. Cologuard). Kit mailed to your house 3. CT colonography every 5 years 4. Flex sigmoidoscopy every 5 years 5. Flex sigmoidoscopy every 10 years + annual FIT 6. Colonoscopy screening every 10 years = most sensitive and specific Note: if any of the above are positive, will refer for a colonoscopy
G -Gestational diabetes screen
Asymptomatic pregnant persons at 24 weeks of gestation or after
O - ovarian cancer screening
NOT RECOMMENDED in asymptomatic women
How is a recommendation graded as ABCD or I?
How many studies were done, how large are studies, how consistent were results, other factors that might help assess certainty of studies. They look at strength of evidence and also the balance of benefits and harms - needs to equal a net benefit
T - thyroid dysfunction screen
I statement for nonpregnant, asymptomatic adults however, all pregnant women will get screened at onset of pregnancy to check for hypothyroidism
Skin cancer screening
I statement adults and seniors
M - menopausal HRT (hormone replacement therapy) for primary prevention of chronic disease
NOT RECOMMENDED We can use it for vasomotor sx of menopause (hot flashes), but not to prevent chronic disease
Do USPSTF take into consideration the costs of services?
No! This could be a limitation
STI: screen for HSV
Not recommended
P - prostate cancer screening
OPTIONAL: men 55-69 y/o Risks: ex of enlarged prostate, older, african american, family hx of prostate cancer NOT RECOMMENDED 70+ Screen with a PSA level and digital rectal exam
What types of services do the recommendations address?
Only services offered in the primary care setting or services referred by a primary care provider
Ways to screen for depression
PHQ2 --> if this is positive (anything over 0 -go to the 9). this is out of 6 points max PHQ 9 - max score of 27. Considered mild depression at 5. technically 10 questions, one asks how difficult it makes your day to day activities
G - Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Preventive Medication:
Provide prophylactic erythromycin topical ointment to prevent gonococcal ophthalmia neonatorum for all newborns
C - Cervical cancer screening
Recommend for: •Women aged 21-29y: screen w/ cytology alone q 3 years (A) •Women aged 30-65y: screen w/ cytology alone q 3 years, hrHPV testing alone q5y or every 5 years with co-testing (A) Do NOT Recommend: Women <21y, >65y w/ adequate prior screening and not at high risk; and women who are s/p hysterectomy (removal of cervix) w/o hx of CIN 2 or 3 or cervical cancer: do not screen for cervical cancer
L - Lung cancer screen
Recommend: •Asymptomatic adults aged 50-80 y who have a 20 pack-year smoking hx and currently smoke or have quit w/in the past 15 years- annual screen w/ LDCT •Discontinue when the patient has not smoked x 15 years or develops condition where life expectancy is limited or unwilling to have curative lung surgery Screen with a low dose CT --> make sure the person is willing to do this annually, otherwise might not be worth it
H - Hep C screen
Recommend: •One-time Screen in adults aged 18-79 years •Periodic Screen <18 and >79 if high risk
H - HIV screening
Recommend: - Pregnant women -Ages 15-65 - Younger and older at risk
F - folic acid for prevention of neural tube defects
Women who are planning or capable of pregnancy: take a daily supplement containing 0.4-0.8mg of folic acid 1 month before and 2-3 months into pregnancy
T - Latent TB screen
asymptomatic ADULTS at increased risk - HIV/AIDS -smoke -malnutrition -diabetes -severe kidney disease -healthcare worker