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The Practice of Preventative Medicine

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Title: The Practice of Preventative Medicine


1
The Practice of Preventative Medicine
  • What tests should we check on our patients and
    when should we check them?

2
Outline
  • What is preventative medicine and what is its
    importance
  • The definition of screening and how we decide
    what a good screening test is
  • Who do you look to for the current
    recommendations, and how do they formulate those
    recommendations
  • The tests/procedures and current recommendations

3
What is preventative medicine?
  • Disease prevention
  • Identification of disease at an early stage
  • Definition procedures/exams/interventions
    performed on patients without specific
    complaints, to identify and modify risk factors
    to avoid the onset of disease, or to find disease
    early in its course so that by intervening
    patients can remain well.
  • Synonyms health maintenance or the periodic
    health examination

4
What is the importance of reviewing this subject.
  • 1. It has been shown to be effective at many
    levels (ex. Community wide immunizations,
    colorectal cancer screening, cervical cancer
    screening, breast cancer screening, etc..)
  • 2. Your patients are going to ask you questions
    about why you are checking certain tests. (ex.
    Pap smear, mammograms)
  • 3. Cost considerations (if a test is not shown to
    be beneficial, then by checking it routinely we
    are wasting resources)

5
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6
3 levels of preventative medicine
  • 1. Primary prevention- prevents disease from
    occuring at all by removing its causes (ex. Use
    of folic acid to prevent neural tube defects,
    immunizations, counseling to adopt healthy
    lifestyles, mandating seat belt use, etc..)
  • 2. Secondary prevention- detects disease early
    when it is asymptomatic and when early treatment
    can stop it from progressing (ex. Pap smears,
    mammograms, FOBT, colonoscopy, etc..)
  • 3. Tertiary prevention-clinical activities that
    prevent further deterioration or reduce
    complications after a disease has declared itself
    ( ex. Starting BB after MI to decrease risk of
    death, initiation of ACE-I in diabetics to
    prevent nephropathy, etc.)

7
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8
Screening
  • The identification of unrecognized disease using
    various modalities (H/P, lab tests, Xray,
    procedures)
  • Sort out well appearing persons with a disease or
    risk factors for disease
  • Part of many primary and all secondary prevention
    measures
  • Screening tests are typically not diagnostic so
    the clinician must be willing to further
    investigate a test

9
How do we decide what to screen for?
  • 1. Must consider the burden of suffering caused
    by the condition (discomfort, disability, death)
  • 2. Must consider how good the screening test is
    in terms of sensitivity, specificity, cost, ease
    of use, safety, acceptability, risk of a false
    positive, labeling of pts with conditions.
  • 3. Then must consider in the case of primary
    prevention, how good is the intervention in
    preventing the disease, or in secondary
    prevention , how good are the treatments that are
    available for the disease (in terms of
    efficacy/compliance/early treatment as a benefit
    versus late treatment)

10
What does that mean?
  • Example Breast cancer screening
  • Primarily occurs in women gt50yrs
  • In women in their 20s the incidence is very low
    approx 1 in 100,000
  • For the women that get breast CA at that age
    there is a substantial morbidity and mortality,
    but given its rarity in that age group screening
    becomes impractical and would probably lead to
    more morbidity and usage of resources from
    further w/u of false positives (biopsies, further
    radiological tests, etc..)

11
The dreaded Statistics
  • A good screening test should have a high
    sensitivity to limit the false negatives and a
    high specificity to limit the false positives
    (these are affected by the prevalence of the
    disease in the population).
  • For many screening tests the gold standard from
    which sens/spec are determined is based on long
    term follow up with monitoring for occurrence of
    a disease following the screening test -detection
    method. The two problems with this are knowing
    the length of time needed to follow the patient
    to detect the disease, and the assumption that
    the abnormality detected would go on to cause
    disease if left alone (ex. Estimated that
    virtually all men gt90yr have foci of prostate
    CA). A second method to get around this is the
    incidence method which calculates sensitivity
    based on ratio of pts with a disease undergoing
    the screening test over that of the patients with
    the disease who dont have the test (1- pts with
    disease undergoing screening/ pts with disease
    who didnt have screening). This limits counting
    benign conditions found on screening but might
    decrease sensitivity by ignoring pts with
    malignancies with long lead times.

12
Consider Simplicity and Cost
  • A good screening test should be relatively simple
    to perform (ex. BP) although that is not always
    the case (colonoscopy)
  • Cost of not only the test itself, but the cost of
    subsequent workups of positive results and the
    time missed from work for special visits to the
    physician must be considered

13
Acceptability, Labeling
  • Acceptability- Do the pt and physician find the
    test acceptable to perform (ex. Many asymptomatic
    pts refuse a colonoscopy, many women refuse
    pelvic exams)
  • Labeling- Psychologically a false positive result
    can be devastating for a pt. One study showed
    that almost 50 of women with false mammograms
    read as high suspicion suffered anxiety and
    worries that affected their daily lives (1).

14
Risk of False Positives
  • One study showed that on average internists
    selected 54 different tests during periodic
    health examinations (components of CBC, Chem 14
    etc.) (2).

15
Biases
  • Lead time bias- Period of time between detection
    of disease by screening versus when it would
    present with symptoms. If the period is very
    short then the screening test will not be very
    useful (ex. Lung cancer). If the lead time is
    long then the test might be useful (ex. Cervical
    CA).
  • Length time bias- more slow growing cancers are
    diagnosed during screening than during usual
    medical care when pts are more likely diagnosed
    with a rapid growing tumor causing symptoms, so
    screening may be catching more malignancies with
    a better prognosis and therefore might appear
    more beneficial than it truly is.

16
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17
Where do you look for the current recommendations?
  • The U.S. Preventative Services Task Force
    (USPSTF) was first convened by the U.S. Public
    Health Service in 1984 and its recommendations
    are considered the gold standard for clinical
    preventative services. They review the current
    available literature/information and make
    recommendations based on the available data.
  • They have released two print editions and
    portions of the 3rd edition are now available
    online.

18
The tests that I will review
  • H/P and Labs
  • HP
  • CBC
  • CHEM 8
  • LFTs
  • Fasting Lipids
  • TSH
  • PSA
  • UA
  • PAP Smear
  • HIV Serology
  • FOBT
  • Radiological/Procedural
  • Colonoscopy
  • Mammogram
  • EKG/Stress testing/Calcium scores
  • CXR
  • DEXA
  • Ankle/Brachial Index (PAD)
  • Carotid Doppler

19
How do they rate these tests?
  • First they rate the evidence
  • Prior to the 3rd edition
  • Grade I-at least one properly randomized
    controlled trial
  • Grade II-obtained from other controlled trials or
    analytic studies, or from multiple time series
    with dramatic results in uncontrolled
    experiments, has 3 subcategories based on the
    type of study
  • Grade III-Opinions of respected authorities based
    upon clinical experience, descriptive studies and
    case reports, or reports of expert committees.
  • With the 3rd edition they tried to simplify it
  • Good- consistent results obtained from well
    designed, well conducted studies in the
    representative population that directly assess
    effects on health outcomes
  • Fair- evidence sufficient to determine effects on
    health outcomes but the strength of evidence is
    limited by the number, quality, or consistency of
    individual studies, generalizability to routine
    practice, or indirect nature of the evidence on
    health outcomes.
  • Poor-evidence is insufficient to assess the
    effects on health outcomes because of limited
    number or power of studies, important flaws in
    design or concept of studies, gaps in the chain
    of evidence, or lack of information on important
    health outcomes.

20
Next they give a recommendation and grade the
recommendation based on that evidence
  • Prior to 3rd edition there were 5 grades
  • A-There is good evidence to support the
    recommendation for inclusion of the service for
    the periodic health evaluation.
  • B-There is fair evidence to support the
    recommendation for inclusion of the service for
    the periodic health evaluation.
  • C-There is insufficient evidence for or against
    the recommendation for inclusion of the service
    for the periodic health evaluation.
  • D-There is fair evidence to support the
    recommendation to exclude the service for the
    periodic health evaluation.
  • E-There is good evidence to support the
    recommendation to exclude the service for the
    periodic health evaluation.
  • For the 3rd edition USPSTF changed grading to
    include recommendations
  • A-USPSTF strongly recommends the clinician
    provide the service to eligible pts, because
    there is good evidence it was found to improve
    important health outcomes and concludes that
    benfits outweigh the harms
  • B-USPSTF recommends the clinician provide the
    service to eligible pts, because there is fair
    evidence it was found to improve important health
    outcomes and concludes that benfits outweigh the
    harms
  • C-USPSTF makes no recommendation for or against
    the service, because there is fair evidence it
    can improve health outcomes but balance of
    benfits and harms is too close for a general
    recommendation
  • D-USPSTF recommends against the service for
    asymptomatic pts, because there is fair evidence
    it is ineffective or that harms outweigh benefits
  • I-The evidence is insufficient to recommend for
    or against the service

21
History and Physical
  • No general recommendation for or against general
    H/P and the only thing it costs is time
  • Obviously a thorough H/P on initial consultation
    and then periodically is the best screening tool
    that we have since the majority of our diagnoses
    are made through H/P
  • Certain aspects that do have recommendations

22
Blood Pressure
  • For pts age 18 Grade A with good evidence for
    regular screening for HTN (at least every one to
    two years)

23
Clinical Breast Exam
  • Grade-I no study comparing CBE to no exam, and
    studies show that breast cancer mortality is
    similar in groups screened with mammography /-
    CBE, most organizations including the AMA
    recommend to begin yearly exams starting at age
    40 (if not earlier based on family history)

24
Digital Rectal Exam
  • Grade I Although DRE has some utility as a
    screening tool for prostate CA (although
    sensitivity is still quite low) it is
    inconclusive whether early detection improves
    outcomes and screening is associated with
    important harms (frequent false , anxiety,
    biopsies etc.). None of the major medical
    societies endorses universal or mass screening of
    any particular group, but they conclude that men
    most likely to benefit are age 50 (or younger if
    they have a strong family history) and have a
    life expectancy of gt10yrs.

25
CBC
  • No general recommendation on a complete blood
    count
  • For H/H- Grade C (2nd edition) with level I/II
    evidence which is inconclusive, so no rec. for or
    against general use as screening tool. For
    Pregnant women Grade A with level I/II evidence
    for screening

26
Chemistry Panel
  • No general recommendation on total chem panel
  • Glucose-
  • In general population-Grade I, not enough
    evidence available to recommend for or against
    screening
  • In patients with HTN or hyperlipidemia- Grade B
    with good evidence for annual screening since in
    pts with HTN and hyperlipidemia there is a higher
    level of DM II and that those pts benefit from
    more aggressive treatment of their
    HTN/hyperlipidemia

27
Liver Function Tests
  • No general recommendations to use as a screening
    tool
  • There are recommendation for Hep viral screening
  • Hep B surface antigen
  • In pregnant women at first prenatal visit- Grade
    A with good evidence for screening all pregnant
    women
  • In general asymptomatic pts- Grade D with no
    evidence of benefit and possible harms (cost,
    labeling, etc.)
  • In high risk pts- Grade C, no recommendation for
    or against, might be beneficial to identify pts
    that might benefit from vaccination
  • Hep C serology
  • In general population- Grade D, with no evidence
    of benefit and possible harms
  • In high risk pts- Grade I, In high risk pts
    screening would have higher yield and tx with
    current therapies appear beneficial but no data
    as to whether early tx improves mortality
    (although older therapies are suggestive that it
    does) so they were unable to give a general
    recommendation for or against, but other groups
    including the NIH/CDC do recommend screening high
    risk groups

28
Lipids
  • For Men age 35 and Women age 45- Grade A with
    good evidence for screening every 5 years
  • For men/women less than those ages with other
    risk factors for CAD- Grade B with good evidence
    for screening every 5 years
  • For men/women less than those ages without risk
    factors for CAD- Grade C with no good evidence
    for or against screening although potential
    benefit in this pt population is likely less

29
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30
TSH
  • In Asymptomatic pts- Grade I, no recommendation
    for or against regular screening since there is
    no substantial data showing benefit to treating
    subclinical screening detected thyroid disorder

31
PSA
  • Pts of any age- Grade I, no recommendation for or
    against use as a regular screening test for
    similar reasons to DRE. Must discuss
    risks/benefits of the test with pt and decide
    together whether to proceed.

32
UA
  • For Asymptomatic men/women (not pregnant)- Grade
    D with fair evidence that there is no benefit to
    routine screening
  • Pregnant women- Grade A, recommends routine
    UA/Culture at 12-15 wks to r/o asymptomatic
    bacteruria
  • As a screen for bladder CA- Grade D with fair
    evidence that screening is not beneficial due to
    the low prevelance of asymptomatic disease that
    progresses to clinically significant disease

33
PAP Smear/Pelvic
  • Women who are sexually active and have a cervix-
    Grade A with good evidence for beginning
    screening pap smears at least every 3 yrs within
    3yrs of onset of sexual activity or by age 21.
    There is no direct evidence that yearly screening
    is more effective, but several organizations have
    made recs. regarding yearly screening till 2 to 3
    normals followed by screening every 3 yrs, or
    yearly testing in pts with higher risk sexual
    activity, although there is no data to support
    either of these recs..
  • Women 65 with adequate normal pap smears
    recently and at not at high risk- Grade D with
    limited evidence for benefit with cont screening
    in this population
  • Women who had hysterectomy for benign disease-
    Grade D with fair evidence that there is little
    benefit to cont screening in the population
  • HPV testing- Grade I with poor evidence to
    determine the risks/benefits of HPV testing in
    conjunction with pap smear as a screening tool.
    Trials are ongoing looking at question, but
    currently no recommendation for or against its
    use.

34
HIV Serology
  • History is very important on deciding this issue
  • In non high risk groups- Grade C recommendation
    with fair evidence , no recommendation for or
    against screening
  • In high risk groups (IVDU, homosexual men)- Grade
    A with good evidence for periodic screening
  • For Pregnant women- Grade A with good evidence
    for routine screening

35
FOBT/Colonoscopy
  • Recommends screening for CRC in general with
    Grade A, good evidence that screening beginning
    at age 50 for average risk individuals is
    beneficial. They do not make direct
    recommendations on which screening modality to
    use although they suggest multiple possibilities
    including yearly FOBT flexible sigmoidoscopy
    every 5 yrs, or colonoscopy every 10 yrs
    (considered the gold standard) that vary in their
    cost, complications, availability,
    sensitivity/specificity etc..
  • For pts with a FH of colon CA before age 60 it is
    reasonable to begin screening at an earlier age

36
Mammogram
  • For women age 40- Grade B recommendation with
    fair evidence of benefit for screening with
    mammogram every 1-2 yrs with or without CBE/SBE

37
EKG/Stress testing/Calcium Scores
  • In pts at low risk for CHD events- Grade D
    recommendation with fair evidence that although
    testing will detect a small percentage of pts
    with disease, the harm from screening the
    population including unnecessary procedures/over
    treatment/labeling outweigh any benefits
  • In pts at increased risk for CHD- Grade I with
    insufficient evidence to recommend for or against
    screening in this population. It is unclear in a
    asymptomatic pt in this population whether these
    tests add more information than risk
    stratification based on conventional CHD risk
    factors, and whether the benefits outweigh the
    harms. (the AHA suggests stress testing might be
    beneficial for diabetic pts if they are going to
    start a vigorous exercise program).

38
CXR
  • To screen for Lung CA- Grade I with insufficient
    evidence to recommend for or against routine
    screening (there is no good study designed to
    look at screening versus not screening, but
    observational studies suggest that CXR screening
    does not decrease mortality from lung CA which
    makes since because by the time it is visible on
    a CXR it has usually metastasized on a cellular
    level and we have essentially no effective
    treatment options for metastatic disease).

39
DEXA (Dual-energy x-ray absorptiometry )
  • Women age 65 or women between 60-64 who are at
    increased risk (low wt, postmenopausal not on
    estrogen replacement)- Grade B recommendation
    with good evidence that screening is beneficial
    in these groups of women. There is no specific
    recommendation on the screening interval, but it
    is thought that 2 yrs might be needed to see a
    substantial difference in BMD.
  • Women age 60-64 who are not at increased risk or
    women younger than 60- Grade C with fair evidence
    that it would prevent a small number of fractures
    but the benefits and harms were similar so no
    recommendation for or against screening in this
    population
  • Women/Men on long term corticosteroids- Not
    specifically reviewed. A summary statement by
    the Amer College of Rheum in 2001 recommended
    that for Pt on Prednisone 5mg daily for time of
    3months that they be screened annually to
    biannually (and tx preventatively)(3).
  • Screening in Men- has not been reviewed to date

40
Ankle/Brachial Index
  • In Asymptomatic Individuals- Grade D with fair
    evidence that pts in this category would not
    benefit from screening/treatment

41
Carotid Doppler
  • In Asymptomatic Individuals- Grade I with
    insufficient evidence for screening with carotid
    doppler in this population

42
Summary What you should definitely do
  • Men
  • Annual HP starting at age 18 including BP
    measurement
  • Fasting Lipids every 5 yrs starting at age 35 for
    average risk pts and younger if pt has
    significant risk factors
  • CRC screening starting at age 50 with either
    annual FOBT with flex sig every 5 yrs or
    colonoscopy every 10 yrs. If Pt has FH of early
    CRC then it is acceptable to begin screening at a
    younger age (dictated by their history)
  • If pt has HTN or Hyperlipidemia then check annual
    fasting glucose
  • HIV Serology annually in high risk populations
  • Women
  • Annual HP starting at age 18 including BP
    measurement
  • Fasting Lipids every 5 yrs starting at age 45
    for average risk pts and younger if pt has
    significant risk factors
  • CRC screening starting at age 50 with either
    annual FOBT with flex sig every 5 yrs or
    colonoscopy every 10 yrs. If Pt has FH of early
    CRC then it is acceptable to begin screening at a
    younger age (dictated by their history)
  • If pt has HTN or Hyperlipidemia then check annual
    fasting glucose
  • HIV Serology annually in high risk populations
  • Pap Smear every 1-3 yrs (no good evidence to
    support one way over another) starting within 3
    yrs of initiation of sexual activity or by age
    21.
  • Mammogram annually starting at age 40
  • DEXA biannually starting at age 65 for normal
    risk pts or age 60 for higher risk pts
  • H/H, Glucose, Hep B sur Ag, UA/Culture, and HIV
    serology all recommended in pregnant women

43
Screening tests that the evidence is inconclusive
or not available
  • Men
  • DRE /- PSA annually starting at age 50 in men
    with a 10 yr life expectancy
  • Annual fasting glucose in pts without risk
    factors
  • Lipids in pt less than 35 yrs old without CAD
    risk factors
  • TSH
  • HIV screening in low risk individuals
  • Hep B/C screening in high risk individuals
  • CXR in long term smokers to screen for lung CA
  • DEXA (no recommendation to date)
  • EKG /- Stress testing for asymptomatic pts with
    multiple risk factors for CAD (including DM)
  • Women
  • Annual fasting glucose in pts without risk
    factors
  • Lipids in pt less than 45 yrs old without CAD
    risk factors
  • TSH
  • HIV screening in low risk individuals
  • Hep B/C screening in high risk individuals
  • CXR in long term smokers to screen for lung CA
  • DEXA in pts less than 60 yrs old
  • EKG /- Stress testing for asymptomatic pts with
    multiple risk factors for CAD (including DM)
  • HPV testing in addition to PAP Smear

44
Tests Not recommended for screening
  • CBC/CHEM8/LFTs
  • ABI
  • PAP/Pelvic for pts who had hysterectomy secondary
    to benign disease, or for women 65yrs or older
    who have had negative pap smears on regular
    routine screening
  • Carotid Dopplers
  • Hep B/C serologies
  • UA (for bladder CA or other etiologies)

45
Bibliography
  • 1. Lerman, C, Trock, B, Rimer, BK, et al.
    Psychological and behavioral implications of
    abnormal mammograms. Ann Intern Med 1991
    114657.
  • 2. Romm, FJ, Fletcher, SW, Hulka, BS. The
    periodic health examination Comparison of
    recommendations and internists' performance.
    South Med J 1981 74265.
  • 3. Recommendations for the prevention and
    treatment of glucocorticoid-induced osteoporosis
    2001 update. American College of Rheumatology Ad
    Hoc Committee on Glucocorticoid-Induced
    Osteoporosis. Arthritis Rheum 2001
    Jul44(7)1496-503. 54 references
  • 4. www.ahrq.gov/clinic/prevnew.htm.
  • 5. www.uptodate.com, Preventive services
    recommendations for periodic health evaluation,
    F. Daniel Duffy, MD
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