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Review of Current Preventive Medicine Guidelines

Alisa Holland, PGY-2 1/11/11. Review of Current Preventive Medicine Guidelines. USPSTF Grade Definitions. A – Strongly Recommended Benefits outweigh harms. Good evidence of improvement in health outcomes. B – Recommended

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Review of Current Preventive Medicine Guidelines

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  1. Alisa Holland, PGY-2 1/11/11 Review of Current Preventive Medicine Guidelines

  2. USPSTF Grade Definitions • A – Strongly Recommended • Benefits outweigh harms. Good evidence of improvement in health outcomes. • B – Recommended • Benefits outweigh harms. Fair evidence of improvement in health outcomes. • C – No Recommendation • Fair evidence of improvement in health outcomes. Benefits and harms are too close to recommend intervention. • D – Not Recommended • Risks outweigh harms or fair evidence to suggest that intervention is ineffective. • I – Insufficient Evidence to Recommend • Cannot determine balance of benefits and harms.

  3. Cancer • Breast • Cervical • Colorectal

  4. Breast Cancer Recommendations(USPSTF) • Last Update: December 2009 • Screening mammogram every other year from ages 50 to 74 (Grade B) • Recommends against teaching breast self-exam (Grade D) • Insufficient evidence to recommend performing clinical breast exam after age 40 if patient receives a screening mammogram • Insufficient evidence to assess benefits and harms of digital mammogram and breast MRI

  5. Breast Cancer Recommendations(USPSTF) • Refer women with family history of BRCA1 and BRCA2 mutations for genetic counseling and BRCA testing (Grade B). • Recommends against referring women for BRCA testing who have no family history of BRCA mutations (Grade D) • Recommends against routine use of tamoxifen or raloxifene for chemoprevention in low or average risk patients (Grade D) • Discuss chemoprevention with patients at high risk for breast cancer and low risk for therapy side effects (Grade B).

  6. USPSTF Evidence • Screening every other year on average has 81% of the benefit of annual screening. • 50% fewer false positive results • Screening annually reduces mortality from breast cancer by additional 3%. • SBE and CBE are shown not to reduce mortality and result in increase of benign biopsy results. • Chemoprevention with tamoxifen in high risk women showed a significant reduction in invasive and non-invasive breast cancers (BCPT trial).

  7. Breast Cancer Recommendation(ACS) • Screening mammogram every year starting at age 40 and continuing as long as the patient is in good health. • SBE is an option for women starting in their 20s. • CBE should be performed every 3 years between ages 20-39. Annual CBEs starting at age 40 years. • Women with high risk of breast cancer should have mammogram and MRI every year.

  8. Cervical Cancer Recommendations(USPSTF) • Released: January 2003 • Screen patients who are sexually active and who have a cervix (Grade A). • Recommends against screening women over age 65 who have a history of normal pap smears (10 years per ACS guidelines) and are not high risk (Grade D) • Recommends against routine pap smears in patients who have had a total hysterectomy for benign reasons (Grade D) • Insufficient evidence to recommend computerized screening and HPV testing as primary screening tests.

  9. Cervical Cancer Recommendations(ACS) • Begin screening within three years of onset of sexual activity or age 21 and screen at least every three years. • Lengthen screening interval starting no sooner than age 30 if patient has had 2-3 consecutive normal results. Continue annual screening if patient has risk factors such as cervical neoplasia, HPV, STDs, or high risk sexual behavior.

  10. Colorectal Cancer Recommendations(USPSTF) • Released: October 2008 • Screen using FOBT, sigmoidoscopy, or colonoscopy between ages 50 and 75 (Grade A). • Recommends against screening between ages 76 and 85 (Grade C) • Recommends against screening after age 85 (Grade D) • Insufficient evidence to assess benefits and harms of CT colonography or fecal DNA testing for screening purposes

  11. Colorectal Cancer Recommendations(USPSTF) • Recommended screening intervals: • FOBT annually • Sigmoidoscopy every 5 years with FOBT every 3 years • Screening colonoscopy every 10 years

  12. Colorectal Cancer Recommendations(ACS) • Options for screening include: • Flexible sigmoidoscopy every 5 years • Colonoscopy every 10 years • Double-contrast barium enema every 5 years • CT colonography every 5 years • FOBT annually • Fecal immunochemical test (FIT) annually • Stool DNA (sDNA) test, unknown interval

  13. USPSTF No Screen List • Bladder cancer • Lung cancer • Oral cancers • Ovarian cancer • Pancreatic cancer • Testicular cancer • Prostate cancer* • Skin cancer

  14. Heart and Vascular Disease • AAA • Aspirin use • Hypertension • Lipids • Tobacco use

  15. Abdominal Aortic Aneurysm(USPSTF) • Released: February 2005 • One time screening using abdominal ultrasound for men between the ages of 65 and 75 with a history of tobacco use (Grade B) • Recommends against routine screening in women (Grade D) • Abdominal palpation not recommended for screening given poor accuracy

  16. Aspirin Use(USPSTF) • Released: March 2009 • Use in men aged 45 to 79 if benefit from reduction of MI outweighs potential harm of GI hemorrhage (Grade A). • Use in women 55 to 79 if benefit from reduction in ischemic strokes outweighs potential harm of GI hemorrhage (Grade A). • Insufficient evidence to recommend use in patients aged 80 years and over. • Recommends against routine use for MI prevention in men under age 45 and for stroke prevention in women under age 55 (Grade D).

  17. Hypertension and Hyperlipidemia(USPSTF) • Released: December 2007 (HTN) and June 2008 (HLD) • Screen for HTN in patients aged 18 and older (Grade A). • Screen men age 35 and older for HLD (Grade A). • Screen men aged 20 to 35 for HLD if they are at increased risk for CHD (Grade B). • Screen women age 45 and older for HLD if they are at increased risk for CHD (Grade A). • Screen women aged 20 to 45 if they are at increased risk for CHD (Grade B).

  18. Tobacco Use Recommendations(USPSTF) • Released: April 2009 • Ask all adults about tobacco use and provide cessation interventions (Grade A). • Ask all pregnant women about tobacco use and provide tailored cessation counseling (Grade A).

  19. Tobacco Use Counseling Guidelines • “5-A” framework: • Ask about tobacco use • Advise to quit with a clear personalized message • Assess willingness to quit • Assist in quitting • Arrange for follow-up and support • Use multiple counseling sessions and telephone quit lines (1-877-YES-QUIT).

  20. USPSTF No Screen List • Coronary Artery Stenosis • Coronary Heart Disease* • Peripheral Artery Disease*

  21. Infectious Disease • Chlamydia • Gonorrhea • Hepatitis B • HIV • STD counseling • Syphilis • TB

  22. Chlamydia Recommendations(USPSTF) • Released: June 2007 • Screen all sexually active women age 24 and younger and women over age of 24 if they are at increased risk (Grade A). • Screen all pregnant women under age 24 and pregnant women over age 24 if they are at increased risk (Grade B). • Recommends against screening women age 25 or older if they are not at increased risk (Grade D) • Insufficient evidence to recommend screening men

  23. Chlamydia Recommendations(CDC) • Screen all sexually active women under age 25. • Screen older women with risk factors. • Consider screening sexually active young men in populations with high incidences of infection.

  24. Gonorrhea Recommendations(USPSTF/CDC) • Released: May 2005 • Screen all sexually active women at increased risk (Grade B). • Recommends against screening women and men at low risk for infection (Grade D) • Insufficient evidence to recommend screening men at increased risk for infection • Insufficient evidence to recommend screening pregnant women at low risk

  25. Hepatitis B Recommendations(USPSTF) • Released: February 2004 • Screen pregnant women at their first prenatal visit (Grade A). • Recommends against screening asymptomatic patients routinely (Grade D)

  26. Hepatitis B Recommendations(CDC) • Populations recommended for testing: • Patients born in Eastern Europe, Asia, Africa, Middle East, and Pacific Islands • MSM • IVDU • Patients receiving cytotoxic or immunosuppressive therapy • Patients with persistently elevated AST/ALT • Hemodialysis patients • Pregnant women

  27. HIV Recommendations(USPSTF) • Released: July 2005 • Screen all adults at increased risk for infection (Grade A). • Screen all pregnant women (Grade A). • No recommendation for screening adults not at increased risk (Grade C)

  28. HIV Recommendations(CDC) • Screen all patients aged 13 to 64. • Screen patients at high risk for infection annually. • Screen all pregnant women at their first prenatal visit. Re-screen in third trimester in areas with high rates of HIV.

  29. STD Counseling Recommendations(USPSTF/CDC) • Released: October 2008 • Use high-intensity counseling to prevent STDs for all adults at increased risk for STDs (Grade B). • Insufficient evidence to recommend counseling to adults not sexually active or at low risk for infection

  30. Syphilis Recommendations(USPSTF/CDC) • Released: July 2004 • Screen patients at increased risk for infection (Grade A). • Screen all pregnant women (Grade A). • Recommends against screening patients not at increased risk for infection (Grade D).

  31. TB Recommendations • USPSTF Recs Released: 1996 – defers to CDC for screening recommendations. • CDC Recommends testing patients who: • Have been in contact with a person with known or suspected TB • Are immunosuppressed • Are from Latin America, Caribbean, Africa, Asia, Eastern Europe, or Russia • Live in an area of high TB prevalence • IVDU

  32. USPSTF No Screen List • Bacteriuria* • Hepatitis C • HSV

  33. Mental Health and Substance Abuse Recommendations(USPSTF) • Depression • Released: December 2009 • Screen when support is in place to assure diagnosis, treatment, and follow-up (Grade B). • Recommends against screening when support is not in place (Grade C) • 2 Question mood assessment: mood and anhedonia • Alcohol Abuse • Released: April 2004 • Screen and counsel adults and pregnant women to reduce alcohol misuse (Grade B). • CAGE

  34. Tobacco/Alcohol/Drug Use Tool • 5 “R”s • Relevance • Risks • Rewards • Roadblocks • Repeat

  35. USPSTF No Screen List • Dementia • Illegal drug use • Suicidality

  36. Metabolic, Nutritional, and Endocrinology • Diabetes Mellitus • Diet • Obesity • Physical Activity • Iron Deficiency Anemia • Osteoporosis

  37. Diabetes Mellitus Recommendations(USPSTF) • Released: June 2008 • Screen adults with blood pressure greater than 135/80 mmHg (Grade B). • Insufficient evidence to recommend screening in patients with BPs less than 135/80 mmHg

  38. Diabetes Mellitus Recommendations(ADA) • Screen patients of any age every three years if they are overweight and who have at least one risk factor for DM. • Screen patients without risk factors starting at age 45 and repeat every three years. • Risk factors: • Physical inactivity • Family history (first degree) • High-risk race • Women delivering babies > 9 lbs. or diagnosed with GDM • HTN • HLD • PCOS

  39. Nutrition Recommendations(USPSTF) • Diet • Released: January 2003 • Counsel patients with HLD and other risk factors for heart disease or other diet related disease (Grade B). • Insufficient evidence to recommend routine diet counseling • Obesity • Released: December 2003 • Screen all patients and counsel to promote sustained weight loss

  40. Physical Activity (AHA) • Aerobic activity • Moderate: 30 minutes per day for five days per week • Vigorous: 20 minutes per day for three days per week • Muscle strengthening exercises • 2 days per week

  41. Iron Deficiency Anemia Recommendations(USPSTF) • Released: May 2006 • Screen pregnant women (Grade B). • Insufficient evidence to recommend use of iron supplementation in non-anemic pregnant women.

  42. Osteoporosis Recommendations(USPSTF) • Released: September 2002 • Screen women aged 65 and older routinely or starting at age 60 with increased risk factors for fractures (Grade B). • No recommendation for or against postmenopausal women under age 60 (Grade C).

  43. Osteoporosis Recommendations • Use older age and non hormone use after menopause to help determine screening population. • Screen women over 65 every 2 years. • Screen women under 65 every 5 years.

  44. USPSTF No Screen List • Hemochromatosis • Thyroid Disease • Glaucoma • COPD

  45. Immunizations • Influenza • Pneumococcal • Td/Tdap • Hepatitis B • Hepatitis A • HPV • MMR • Varicella • Meningococcal • Zoster

  46. Influenza Vaccine Recommendations(CDC) • Updated: 2010 • IM vaccine contains killed virus • Nasal spray vaccine contains live attenuated virus • Use in healthy patients ages 2-49 • Not for use in pregnant patients • Give to all patients over 6 months of age annually starting in September. • Patients over age 65 can receive standard dose vaccine or Fluzone High-Dose (higher percentage of antigen per virus strain). • Do not give to patients allergic to eggs.

  47. Pneumococcal (PPSV23) Vaccine Recommendations(CDC) • Indications for administration to patients under 65: • Revaccinate once after five years or at age 65 • Vaccinate all patients at age 65 years.

  48. Tetanus/Tetanus, Diptheria, and Pertussis (Tdap) Recommendations(CDC) • Update tetanus vaccine status every 10 years. • Revaccinate if patient has major or dirty wound and five years have elapsed since last vaccine. • Replace tetanus booster with Tdap for one occurrence to lower burden of pertussis among adults and decrease exposure to infants. • Vaccinate healthcare professionals with Tdap as soon as 2 years after previous Td booster for additional pertussis protection.

  49. Hepatitis B Vaccine Recommendations(CDC) • In areas of high HBV incidence, vaccinate all patients with Hepatitis B vaccine who have not had complete series • 3 IM doses of Hep B vaccine at 0, 1, and 6 months • Combined Hep A-Hep B vaccine (Twinrix) available for any adult with risk factors for both viruses.

  50. Hepatitis A Vaccine Recommendations(CDC) • Hepatitis A administered as two series schedule at 0 and 6 months. • Indications for Hepatitis A vaccination: • Patients traveling to areas with high or intermediate endemicity of Hepatitis A • MSM • Chronic liver disease • Drug use (IV and non-IV) • Occupational exposure • Patients with clotting factor disorders

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