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Adult Preventive Health Care Guidelines

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Title: Adult Preventive Health Care Guidelines


1
Adult Preventive Health Care Guidelines
  • Debbie King FNP PNP

2
Introduction
  • Clinical preventive guidelines were developed to
    assist practitioners in making decisions about
    appropriate health care for specific clinical
    circumstances.
  • Are not fixed protocols
  • Intended for providers to consider
  • Not intended to replace professional medical
    judgment

3
Clinicians Handbook of Preventive Care
  • http//www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book
    hsarchivepartA4489
  • The criterion for inclusion of a preventive
    service in the Clinician's Handbook is a
    recommendation for its routine use in the care of
    asymptomatic persons by a major US authority such
    as a Federal health agency (eg, Centers for
    Disease Control and Prevention, National
    Institutes of Health), a non-Federal expert panel
    (eg, US Preventive Services Task Force), a
    national professional organization (eg, American
    Academy of Family Physicians, American Academy of
    Pediatrics), or a national voluntary health
    organization (eg, American Cancer Society,
    American Heart Association). Recommendations of
    the Canadian Task Force on the Periodic Health
    Examination have also been included.

4
Clinicians Handbook of Preventive Care
  • Because the Clinician's Handbook focuses on
    preventive care for the general population
    without special risk factors, the following types
    of preventive care have not been included
    tertiary prevention (treatment to prevent
    progression of known disease), prenatal and
    perinatal care, and preventive care for certain
    high-risk groups. Preventive services not
    recommended by at least one major authority have
    been excluded. However, the exclusion of a
    medical procedure does not suggest that it is
    ineffective in diagnosing and treating disease.
    The clinician should exercise judgement on a
    case-by-case basis with respect to preventive
    services not addressed in the Clinician's Handbook

5
The National Coordinating Committee on Clinical
Preventive Services
  • Ambulatory Pediatric Association
  • American Academy of Family Physicians
  • American Academy of Pediatrics
  • American Academy of Physician Assistants
  • American Association of Colleges of Nursing
  • American Association of Health Plans
  • American College of Obstetricians and
    Gynecologists
  • American College of Occupational and
    Environmental Medicine
  • American College of Physicians
  • American College of Preventive Medicine
  • American Hospital Association
  • American Medical Association
  • American Nurses Association
  • American Osteopathic Association
  • American Public Health Association
  • Association of Academic Health Centers
  • Association of American Medical Colleges
  • Association of Health Services Research
  • Association of Schools of Public Health
  • Association of State and Territorial Health
    Officials
  • Association of Teachers of Preventive Medicine
  • Blue Cross Blue Shield Association
  • Institute of Medicine
  • National Alliance of Nurse Practitioners
  • National Association of Community Health Centers
  • National Association of County and City Health
    Officials
  • North American Primary Care Research Group
  • Society of General Internal Medicine
  • Society for Public Health Education
  • Society of Teachers of Family Medicine

6
Federal Liaisons to the National Coordinating
Committee on Clinical Preventive Services
  • Department of Health and Human Services
  • Agency for Health Care Policy and Research
  • Centers for Disease Control and Prevention
  • Food and Drug Administration
  • Indian Health Service
  • Health Resources and Services Administration
  • Health Care Financing Administration
  • National Institutes of Health
  • Office of the Assistant Secretary for Planning
    and Evaluation
  • Substance Abuse Mental Health Services
    Administration
  • Department of Defense
  • Department of Transportation
  • US Coast Guard
  • Department of Veterans Affairs
  • Office of Personnel Management

7
Criteria for US Clinician handbook of Preventive
Services Inclusion
  • 1. The condition must have a significant effect
    on the quality and quantity of life
  • 2. Acceptable method of treatment must be
    available
  • 3. The condition must have an asymptomatic period
    during which detection and treatment
    significantly reduce morbidity and mortality
  • 4. treatment in the asymptomatic phase must yield
    a therapuetic result superior to that obtained by
    delaying treatment until symptoms appear
  • 5. Tests that are acceptable to patients must be
    available, at a reasonable cost, to detect the
    condition in the asymptomatic period and
  • The evidence of the condition must be sufficient
    to justify the cost of the screening

8
Prevention
  • Primary
  • Seat belt use
  • Secondary
  • Lead screening
  • Tertiary
  • Treatment for any condition

9
Recommending Bodies
  • US Preventive Services Task Force
  • Composed of 16 health care practitioners, from a
    variety of speciality
  • Recommends preventive care to eligible patients
    and benefits outweigh harm
  • Recommends to provide service that improves
    important health outcomes and benefits outweigh
    harm
  • Makes no recommendation for or against routine
    provision of care, if the service benefit verses
    harm is too close to call
  • Bibliography www.ahrq.gov/clinic/pocketgd/gcps1.h
    tm

10
Recommending Bodies- Cont
  • US Preventive Services Task Force-cont
  • Recommends against routinely providing service
    to asymptomatic patients if the service will be
    ineffective or harm does outweigh benefits
  • Concludes that the evidence is insufficient to
    recommend for or against routinely providing the
    service if balance of benefits and harms cannot
    be determined

11
Recommending Bodies
  • American Academy of Family Physicians
  • Bibliography Sources
  • (AAFP). Summary of recommendations for clinical
    preventive services. Revision 6.2. Leawood (KS)
    American Academy of Family Physicians (AAFP)
    2006 Aug. 15 p.
  • ADAPTATION
  • The starting point for the recommendations is the
    rigorous analysis of scientific knowledge
    available as presented by the United States
    Preventive Services Task Force (USPSTF) in their
    Guide to Clinical Preventive Services, 2nd
    Edition and ongoing releases of evidence reports
    and recommendations from the 3rd Edition.

12
American Family Site
  • Recommendations for clinical preventive services.
    PDA tool. Leawood (KS) American Academy of
    Family Physicians (AAFP) 2006 Aug. Electronic
    copies Available from the American Academy of
    Family Physicians (AAFP) Web site.
  • Recommended adult immunization schedule. United
    States, October 2006 - September 2007. 3 p.
    Electronic copies Available in Portable Document
    Format (PDF) from the American Academy of Family
    Physicians (AAFP) Web site.

13
KEY
  • KEY American Academy of Family Physicians
    AAFP
  • US Preventive Services Task ForceUSPSTF
  • Frequency periodically, use clinicians judgment
    as to frequency

14
Primary Care Is There Enough Time for
Prevention? Kimberly S. H. Yarnall, MD, Kathryn
I. Pollak, PhD, Truls Østbye, MD, PhD, Katrina M.
Krause, MA and J. Lloyd Michener, MD
  • Results. To fully satisfy the USPSTF
    recommendations, 1773 hours of a physicians
    annual time, or 7.4 hours per working day, is
    needed for the provision of preventive services.
  • Conclusions. Time constraints limit the ability
    of physicians to comply with preventive services
    recommendations.
  • Correspondence Requests for reprints should be
    sent to Kimberly S. H. Yarnall, MD, Box 3886,
    Duke University Medical Center, Durham, NC 27710
    (e-mail yarna001_at_mc.duke.edu ).

15
Access to US Preventive Services Task Force
recommendations from your I Touch
  • Go to uCentral
  • Then to 5-Minute Clinical consult
  • Then to Appendix 1 US Preventive Services Task
    Force Recommendation
  • Then to Grade Definitions after May 2007 and
    review this section
  • Then back to appendix and begin to use based on
    age

16
Screening Services for High Risk Patients
  • TB (PPD)
  • AAFP- Strongly recommends for close contacts to
    persons with TB, healthcare works, immigrants,
    HIV , alcoholics, IV drug users, residents of
    long term care facilities, underserved low income
    people
  • USPSTF- recommends screening for TB for
    asymptomatic high-risk persons

17
Screening Services for High Risk Patients
  • HIV
  • AAFP- strongly recommends screening in men who
    had sex with men after 1975, past or current IV
    drug users, persons who exchange sex for money or
    drugs and their partners, those with current or
    past sex partners who were IV drug users,
    bisexual or HIV positive persons seeking
    treatment for STD
  • USPSTF-strongly recommends that clinicians screen
    for human immunodeficiency virus all adolescents
    and adults at increased risk for HIV infection,
    and pregnant women

18
Screening Services for High Risk Patients
  • STDS
  • AAFP- recommends counseling adolescents and
    adults regarding the risks for STDs and how to
    prevent them
  • USPSTF strongly recommends that clinicians screen
    persons at increased risk for syphilis infection

19
Basic Adult Prevention Guidelines
  • Coronary Artery Disease/MI- all adults
  • AAFP-strongly recommends counseling adults at
    increased risk, regarding the benefits and risks
    of aspirin prophylaxis, AND- recommends against
    routine screening with resting ECG, exercise
    treadmill, or electron-beam computerized
    tomography scanning for coronary calcium or
    severe coronary artery stenosis or the prediction
    of CHD events in adults at low risk for CHD events

20
Basic Adult Prevention Guidelines
  • Coronary Artery Disease/MI- all adults
  • AAFP-found insufficient evidence to recommend for
    or against- routine screening with resting ECG,
    exercise treadmill, or electron-beam computerized
    tomography scanning for coronary calcium or
    severe coronary artery stenosis or the prediction
    of CHD events in adults at increased risk for CHD
    events

21
Basic Adult Prevention Guidelines
  • Coronary Artery Disease/MI
  • The USPSTF recommends against routine screening
    with resting electrocardiography, exercise
    treadmill test, or electron-bean computerized
    tomography scanning for coronary calcium for
    either the presence of severe coronary artery
    stenosis or the prediction of coronary heart
    disease events in adults at low risk for CHD
    events

22
Basic Adult Prevention Guidelines
  • Abdominal Aortic Aneurysm-Men 65-75 who ever
    smoked
  • SUPSTF- recommends one time screening by
    ultrasonography

23
Basic Adult Prevention Guidelines
  • Diabetes-- all adults-
  • AAFP- recommends screening for DM II in adults
    with hypertension and hyperlipidemia. This
    insufficient evidence to recommend for or against
    screening adults who are at low risk for coronary
    vascular disease
  • USPSTF- concludes that the evidence is
    insufficient to recommend for or against
    routinely screening asymptomatic adults for DMII,
    impaired glucose tolerance or impaired fasting
    glucose

24
Basic Adult Prevention Guidelines
  • Menopause/Osteoporosis Hormone Replacement TX--
    All Women-
  • AAFP-strongly recommends counseling all
    perimenopausal women regarding the individualized
    short and long-term benefits and risks of
    postmenopausal hormone replacement therapy
  • USPSTF recommends against the routine use of
    combined estrogen progestin for the prevention of
    chronic conditions in postmenopausal women,
    recommends osteoporosis screening in women over
    65 and women 60 and older at increased risk

25
Basic Adult Prevention Guidelines
  • Testicular CA adolescent and adult males
  • AAFP strongly recommends against routine
    screening for testicular cancer in asymptotic
    males
  • USPSTF recommends against routine screening for
    testicular cancer in asymptomatic males

26
Basic Adult Prevention Guidelines
  • Thyroid Cancer Screening All adults
  • USPSTF concludes the evidence is insufficient to
    recommend for or against routine screening for
    thyroid disease

27
More Thyroid Screening Recommendations
  • II. The American Academy of Clinical
    Endocrinologists recommends screening symptomatic
    women and women gt 40yo with family h/o thyroid
    disease
  • III. Not recc'd in asymptomatic individuals by
    USPSTF, ACOG, AAFP 2005
  • The USPSTF found fair evidence that the thyroid
    stimulating hormone (TSH) test can detect
    subclinical thyroid disease in people without
    symptoms of thyroid dysfunction, but poor
    evidence that treatment improves clinically
    important outcomes in adults with screen-detected
    thyroid disease. Although the yield of screening
    is greater in certain high-risk groups (e.g.,
    postpartum women, people with Down syndrome, and
    the elderly), the USPSTF found poor evidence that
    screening these groups leads to clinically
    important benefits. There is the potential for
    harm caused by false positive screening tests
    however, the magnitude of harm is not known.
    There is good evidence that over-treatment with
    levothyroxine occurs in a substantial proportion
    of patients, but the long-term harmful effects of
    over-treatment are not known. As a result, the
    USPSTF could not determine the balance of
    benefits and harms of screening asymptomatic
    adults for thyroid disease

28
Basic Adult Prevention Guidelines
  • Skin Cancer screeningAll adults
  • USPSTF concludes that the evidence is
    insufficient to recommend for or against routine
    screening for skin cancer using a total body skin
    examination fro the early detection of cutaneous
    melanoma, basal cell cancer, or squamous cell
    skin cancer

29
Basic Adult Prevention Guidelines
  • Dementia elderly adults
  • USPSTF concludes that the evidence is
    insufficient to recommend for or against routine
    screening for dementia in older adults
  • Depression all adults
  • AAFP recommends screening adults for depression
  • USPSTF recommends screening adults for depression
    in clinical practices that have systems in place
    to assure accurate diagnosis, effective treatment
    and follow-up

30
Basic Adult Prevention Guidelines
  • Obesity-all adults
  • AAFP recommends that clinicians screen all adult
    patients for obesity and offer intensive
    counseling and behavioral interventions for a
    least three months to promote sustained weight
    loss for obese adults. The recommendation is to
    measure height and weight periodically for all
    patients
  • USPSTF recommends that clinicians screen all
    adult patients for obesity and off intensive
    counseling and behavioral interventions to
    promote sustained weight loss for obese adults

31
Basic Adult Prevention Guidelines
  • Vision Screening with Snellen Chart-65 years and
    older
  • AAFP recommends screening for visual difficulties
    in elderly adults by performing Snellen acuity
    testing
  • USPSTF recommends screening diminished visual
    acuity with the Snellen visual chart for elderly
    only.

32
Basic Adult Prevention Guidelines
  • Glaucoma-all adults
  • USPSTF-Insufficient evidence to recommend routine
    screening

33
Basic Adult Prevention Guidelines
  • Hearing screening-elderly adults
  • AAFP-recommends screening for hearing
    difficulties by questioning elderly adults about
    hearing impairment and counsel regarding the
    availability of treatment when appropriate-periodi
    cally question them about hearing, counsel them
    about the availability of hearing aids, make
    appropriate referrals

34
Basic Adult Prevention Guidelines
  • Hearing screening-elderly adults- cont
  • USPSTF-insufficient evidence to recommend for or
    against routinely screening asymptotic
    adolescents and working-age adults for hearing
    impairment. Recommendations against such
    screening except for those exposed to excessive
    occupational noise levels, may be made on other
    grounds

35
Basic Adult Prevention Guidelines
  • Oral Cancer Screening-all adults
  • USPSTF- insufficient evidence to recommend
    routine screening of asymptomatic persons for
    oral cancer by PCP

36
Basic Adult Prevention Guidelines
  • Pap Smear and Pelvic Exam any age if sexually
    active, otherwise 18 or older
  • AAFP- strongly recommends that a pap be completed
    at least every 3 years to screen for cervical
    cancer for women who have ever had sex and have a
    cervix
  • USPSTF-strongly recommends screening for cervical
    cancer in women who have been sexually active and
    have a cervix

37
ACOG new guidelines
  • Jul 21, 2010 - Pap smears in women under 21 do
    more harm than good, new guidelines from the
    American College of Obstetricians and
    Gynecologists (ACOG) say.
  • In most cases such tests reveal only human
    papillomavirus (HPV) infections, which rarely
    lead to cervical cancer in women under 21
  • Adolescents with compromised immunity should not
    wait until 21 to be screened.
  • Although this group makes up less than one
    percent of adolescents, they are much more
    vulnerable to cancer from HPV.

38
American College of Obstetricians and
Gynecologists (ACOG).
  • As of Dec. 2009 ACOG recommends Less Frequent
    Screening
  • The revised recommendations now call for cervical
    screening once every 2 years vs annually for most
    women younger than 30 years and once every 3
    years for most women 30 years and older.

39
Other Pap guidelines
  • ACOG American College of Obstetrics and
    Gynecology
  • ACOG Start 3y after sexual activity starts or
    21yo, whichever comes first,
  • ACOG now say women younger than 30 should undergo
    cervical cancer screening once every two years
    instead of an annual exam. And those age 30 and
    older can be screened once every three years.
  • ACS American Cancer Society
  • ACS 2003  Q1y (if using conventional cytology)
    or Q2y (if using liquid-based cytology) or Q3y
    (if gt 30yo and has had 3 consecutive normals).
    Start 3y after sexually active or age 21, stop _at_
    age 70 if have had 3 negative paps in a row and
    no abnormals in the prior 10y except don't ever
    stop in pts with h/o cervical Ca or in-utero
    exposure to DES or who are immunocompromised

40
Basic Adult Prevention Guidelines
  • Fecal Blood Occult Sigmoidoscopy and DRE/PSA or
    Colonoscopy and DRE/PSA for men and women over 50
  • AAFP- strongly recommends that clinicians screen
    men and women age 50 and older for colorectal
    cancer
  • USPSTF strongly recommends that clinicians screen
    men and women age 50 and older for colorectal
    cancer

41
Basic Adult Prevention Guidelines
  • BP screen 18 and older
  • AAFP- periodically, use clinicians judgment as
    to frequency
  • USPSTF- strongly recommends that clinicians
    screen adults age 18 and older for high blood
    pressure

42
Basic Adult Prevention Guidelines
  • Cholesterol Screening- Men 35-65 and women 45-65
  • American Heart Association- for above ages, using
    a total cholesterol level, is considered
    appropriate but not mandatory. It may be
    considered 5-10 years sooner with a family
    history, or the person has two other
    characteristics that place the person at
    increased risk of CHD

43
Basic Adult Prevention Guidelines
  • Clinical Breast exam and mammogram
  • 20-39, and 40 and over, and 50 and older
  • AAFP recommends women age 40 and older be
    screened for breast cancer with mammography every
    1-2 years after counseling by their family
    physician regarding the potential risks and
    benefits of the procedure
  • USPSTF advise against regular mammography
    screening for women 40-49 years of age, provide
    mammograms only every other year for women
    between 50 and 74, and stop all breast cancer
    screening in women over 74.

44
Other recommendations by the USPSTF
  • Screen for alcohol misuse- for men, women and
    pregnant females
  • Recommend aspirin for the primary prevention of
    cardiovascular events for adults at increased
    risk for CHD
  • Recommend bacteriuria screening for pregnant
    women
  • Recommend Hepatitis B screening for pregnant
    women
  • Screen for tobacco use and tobacco caused
    disease, counseling to prevent or cessation
    interventions for those who use tobacco, for men
    and women
  • Counseling
  • Calcium for women- 1000mg for 18-39, 1200-1500mg
    for 40
  • Folic acid women planning to get pregnant-
    0.4mg/day

45
Well Care- recommendations by the USPSTF
  • Comprehensive exam a complete history and
    physical to include a multi-system examination,
    system history review, family and social history
    and assessment of pertinent risk factors.
  • Vital signs and BP screenings as well as a
    clinical breast exam for women.
  • Risk factor screening includes family violence,
    substance abuse, and HIV
  • Nutrition and physical activity assessment also
    should be included

46
THURSDAY, Nov. 19 2009 (Health Day News) --
Screening for cancer and other preventive health
measures can prolong lives, but only 25 percent
of adults aged 50 to 64 in the United States are
getting these recommended screenings, a new
report shows. Prepared by the U.S. Centers for
Disease Control and Prevention, AARP and the
American Medical Association, the report also
lays out ways to improve the health of these
adults by increasing the breadth of preventive
services. "This is really looking at untapped
opportunities to improve the health of adults,"
said report co-author Lynda A. Anderson, director
of the CDC's Healthy Aging Program. "It really
talks about broadening the use of these
potentially lifesaving preventive
services." Areas of special attention in the
report include influenza vaccine, cholesterol
screening, colorectal cancer screening and for
women, breast and cervical cancer screening. Also
included are screenings for other behaviors that
could hurt health such as binge drinking.
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