Preventive Health

Based on the USPSTF 2014

Louella Patricia D. Carpio, MD

August 15, 2018

Objectives
• Describe the USPSTF recommendations
• Enumerate Grade A and B recommendations
• Highlight relevant diseases
• Apply the recommendations to a family
The US Preventive Task Force
• An independent panel of non-Federal experts in prevention and
evidence-based medicine
• Makes evidence-based recommendations based on clinical
preventive services, including screening, counseling, and preventive
medications
• Recommendations apply to:
• Services offered in primary care setting
• Adults and children with no signs and symptoms
Recommendation Grades
Grade Definition
A The USPSTF recommends the service. There is high certainty that the net benefit is
substantial
B The USPSTF recommends the service. There is high certainty that the net benefit is
moderate or there is moderate certainty that the net benefit is moderate to substantial
C The USPSTF recommends selectively offering or providing this service to individual
patients based on professional judgement and patient preferences. There is at least
moderate certainty that the net benefit is small.
D The USPSTF recommends against the service. There is moderate or high certainty that the
service has no net benefit or that the harms outweigh the benefits
I The USPSTF concludes that the current evidence is insufficient to assess the balance of
benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and
the balance of benefits and harms cannot be determined.
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Hypertension, DM Stabbing Liver disease

 Newborn
USPSTF with Grade A and B Recommendations

Screening Medication
• Congenital hypothyroidism • Gonococcal ophthalmia
• Hearing loss neonatorum
• Phenylketonuria
• Sickle Cell Disease
 Child/Adolescent
USPSTF with Grade A and B Recommendations
Screening
• Major Depressive Disorder
in Children and Adolescents
• Obesity in children aged 6
years and older
• Visual impairment in
children ages 1-5
Interventions
• Obesity: offer/ refer for
intensive counseling
• Tobacco use in children and
adolescents, primary care
interventions
Medication
• Iron supplementation*
 Pregnant
USPSTF with Grade A and B Recommendations

Screening Interventions
• Bacteruria • Breastfeeding counseling
• Gestational DM • Tobacco use
• Hepatitis B • Skin cancer counseling
• Hepatitis C*
• Iron deficiency anemia
• Syphilis infection Medication
• HIV • Iron supplementation*
• Alcohol misuse
 Women
USPSTF with Grade A and B Recommendations

Interventions
Screening
• Hepatitis C • Alcohol misuse counseling
• Alcohol misuse
• Falls in older adults
• BRCA-related CA • High blood pressure
• STI counseling
• Breast CA • HIV
• Skin CA counseling
• Cervical cancer • Intimate partner
• Tobacco use counseling and
• Chlamydial infection violence & elderly interventions
• Colorectal CA abuse
• Depression • Lipid disorders Medication
• Diabetes • Lung CA • Breast CA preventive medications
• Gonorrhea • Obesity • Falls in older adults
• Osteoporosis • Folic Acid supplementation
 Men
USPSTF with Grade A and B Recommendations

Screening Interventions
• Abdominal Aortic Aneurysm • Alcohol misuse behavioral
• Alcohol misuse counseling
• Colorectal CA • Falls in older adults (exercise/ PT)
• Depression • STI counseling
• Diabetes Mellitus • Skin cancer counseling
• Hepatitis C • Tobacco use counseling and
intervention
• High BP
• HIV screening Medication
• Lipid disorders • Aspirin for CVD prevention
• Lung CA • Falls in older adults (Vit D)
• Obesisty
Clinical Summaries of
Recommendations
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 Elderly Care
Cognitive Impairment Screening
Falls in Older Adults
 I No recommendation
Increasing age is the strongest known predictor
Other risk factors: cardiovascular disease, head
trauma, learning disabilities
Most widely used instrument: MMSE
✓ B Intervention consisting of exercise or physical
therapy and/or vitamin D supplementation to
prevent falls
Community-dwelling adults aged 65 years and
older who are at increased risk for falls
Risk: history of falls, history of mobility, and poor
performance on Get-Up and Go test
 Elderly Care
Hearing Loss in Older Adults
Impaired Visual Acuity
Menopausal Hormone Therapy
 I No recommendation
Increasing age is the strongest known predictor
Various screening tests: whispered voice test,
finger rub test
 I No recommendation
Increasing age is the strongest known predictor
Visual screening test (ie. Snellen)
 D Do not prescribe estrogen or combined estrogen
and progestin for prevention of chronic
conditions
Risk for serious adverse events such as stroke,
breast CA, dementia, gallbladder disease, DVT, PE
 Elderly Care
Osteoporosis Screening, Women
Osteoporosis Screening, Men
Vitamin D and Ca supplementation
to prevent fractures
✓ B Screen for osteoporosis
Women age ≥65 years without previous known
fractures or secondary causes of osteoporosis
Current diagnostic and treatment criteria rely on
DEXA of hip and lumbar spine
 I No recommendation
As many as 1 in 2 postmenopausal women and 1
in 5 older men are at risk for an osteoporosis
related fracture
 I No recommendation
Inadequate evidence to determine the effect of
combined Vit D and Ca supplementation on the
incidence of fractures in men and premenopausal
women
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2007 2009
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Hypertension, DM Stabbing Liver disease

 Adults
Aspirin for Prevention of CVD
NSAIDS or Aspirin for
Prevention of Colorectal CA
✓ A Encourage aspirin use when potential CVD
benefit outweighs potential harm
Men age 45-79 years
Women age 55-79 years
Consider NSAID use and history of GI ulcers
Estimate the 10-year CVD risk
 D Do not use aspirin or NSAID
Aspirin and NSAIDs, taken in higher doses, reduce
incidence of adenomatous polyps
Aspirin increases GI bleeding and hemorrhagic
stroke; NSAIDS increase incidence of GI bleeding
and renal impairment
Harm outweighs benefits
 Adults
Colorectal CA ✓ A Screen with high sensitivity FOBT, sigmoidoscopy,
or colonoscopy
Adults age 50 to 75 years

Annual screening with FOBT

Sigmoidoscopy every 5 years, with FOBT every 3
years
Screening colonoscopy every 10 years

Diabetes Mellitus ✓ B Screen for type 2 diabetes mellitus

Asymptomatic adults with sustained blood
pressure greater than 135/80 mmHg
 Adults
High BP in adults ✓ A Screening for High BP in adults
Screening every 2 years with BP <120/80
Screening every year with SBP 120-139 or DBP 80-
90

Lipid disorders in adults ✓ A Screen for lipid disorders

Men age 35 years and older
Women age 45 years and older who are at
increased risk for CHD
 Adults
Lung CA ✓ B Screen annually for lung CA with low-dose CT
Asymptomatic adults aged 55-80 years who have a
30 pack-year smoking history and currently smoke
or have quit smoking within the past 15 years

Obesity in adults ✓ A Screening for Obesity

Patients with a BMI of 30 kg/m2 or higher should
be offered or referred to intensive,
multicomponent behavioral interventions
 Adults
Peripheral Arterial Disease
Tobacco Use in Adults
 I No Recommendation
Important risk factors for PAD: older age, diabetes,
smoking, hypertension, high cholesterol level,
obesity, and physical inactivity
PAOD is more common in men than in women
ABI is the most commonly used test
SBP(ankle)/SBP(brachial artery)
✓ A Ask about tobacco use. Provide tobacco cessation
interventions to those who use tobacco products
5A framework provides a useful counseling
strategy
 Adults
Depression in Adults ✓ B Screen when staff-assisted depression care
supports are in place to assure accurate
diagnosis, effective treatment and follow-up
Men age 45-79 years
Women age 55-79 years

No recommendation
Suicide Risk  I Strongest risk factors for attempted suicide include
mood disorders or other mental disorders,
comorbid substance abuse disorders, history of
deliberate self-harm, and a history of suicide
attempts

Suicidal ideation with a specific plan of action is

associated with a significant risk for attempted
suicide
Adults
NOT RECOMMENDED (D)
• Carotid Artery Stenosis,
Screening
• COPD using spirometry
• Coronary heart disease with ECG
• Genital Herpes
INSUFFICIENT EVIDENCE (I)
• Bladder CA screening
• CKD screening
• Coronary Heart Disease (Risk
assessment, Non-traditional RF)
• Glaucoma screening
• Screening for Oral CA
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2007 2009
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Hypertension, DM Stabbing Liver disease

 Adult Men
Abdominal Aortic Aneurysm ✓ B Screen once for AAA with ultrasonography
Major risk factors: male sex, a history of ever
smoking (100 cigarettes in a lifetime)

Do not use PSA-based screening for prostate CA

Prostate CA  D PSA-based screening results in considerable
overdiagnosis

Do not screen
Testicular CA  D There is inadequate evidence that screening
asymptomatic patients by means of self-
examination or clinician examination has greater
yield or accuracy for detecting testicular cancer at
more curable stages.
>90% of diagnosed cases of testicular CA will be
cured
 73 65
I Fermin, 74

II
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Fidel,51 ? 50 ? Remy
1994 43
III

2007 2009
Emily Anna Jeremy
20 18 13

Hypertension, DM Stabbing Liver disease

 Adult Women
Breast CA ✓ B Screen every 2 years
Applies to women aged ≥ 40 years who are not at
an increased risk by a known genetic mutation

Evidence indicates that biennial screening is

optimal

Screen
Cervical CA ✓ A Screen with cytology every 3 years (women ages 21-
65) or co-test (cytology/ HPV testing) every 5 years
(women ages 30-65)
 Adult Women
Intimate partner violence and ✓
Screen women for intimate partner violence
B (IPV), and provide or refer women who screen
elderly abuse positive to intervention services.

Do not screen for ovarian cancer

Ovarian CA  D Annual screening with transvaginal ultrasonography
and serum CA-125 testing in women does not
decrease ovarian cancer mortality. Screening for
ovarian cancer can lead to important harms,
including major surgical interventions in women
who do not have cancer. Therefore, the harms of
screening for ovarian cancer outweigh the benefits.
 Adult Women
Intimate partner violence and ✓
Screen women for intimate partner violence
B (IPV), and provide or refer women who screen
elderly abuse positive to intervention services.

Do not screen for ovarian cancer

Ovarian CA  D Annual screening with transvaginal ultrasonography
and serum CA-125 testing in women does not
decrease ovarian cancer mortality. Screening for
ovarian cancer can lead to important harms,
including major surgical interventions in women
who do not have cancer. Therefore, the harms of
screening for ovarian cancer outweigh the benefits.
 Adult Women
Chlamydia ✓ A Screen if sexually active.
24 years and younger, and those 25 years and
older at increased risk

Screening test: NAAT

Screen
Gonorrhea ✓ B Sexually active women, including those who are
pregnant, who are at increased risk for infection
 73 65
I Fermin, 74

II
7
Fidel,51 ? 50 ? Remy
1994 43
III

2007 2009
Emily Anna Jeremy
20 18 13

Hypertension, DM Stabbing Liver disease

 Pregnant
USPSTF with Grade A and B Recommendations

Screening Interventions
• Bacteruria • Breastfeeding counseling
• Gestational DM • Tobacco use
• Hepatitis B • Skin cancer counseling
• Hepatitis C*
• Iron deficiency anemia
• Syphilis infection Medication
• HIV • Iron supplementation*
• Alcohol misuse
 Pregnancy: Recommended Screening Schedule
USPSTF with Grade A and B Recommendations

Schedule
Bacteruria 12-16 weeks
Gestational DM After 24 weeks
Hepatitis B First prenatal visit
IDA -
Syphilis First prenatal visit
HIV -
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2007 2009
Emily Anna Jeremy
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Hypertension, DM Stabbing Liver disease

 Child/ Adolescents
Screening for visual
impairment in children ages 1-
5 Screening tests: visual acuity tests, stereoacuity
Speech and Language Delay
✓ B Provide vision screening
24 years and younger, and those 25 years and
older at increased risk
test, cover-uncover test, Hirschberg light reflex
test, Autorefraction, Photoscreening
No Recommendation
 I Most consistently reported risk factors: family
history of speech and language delay, male sex, and
perinatal factors, such as prematurity and low birth-
weight.
 Child/ Adolescents
Obesity in children and
adolescents
Tobacco Use in Children and
Adolescents
✓ B Screen children aged 6 years and older for
obesity. Offer or refer for intensive counseling
and behavioral interventions.
Overweight = age- and gender-specific BMI at
≥85th to 94th percentile
Obesity = age- and gender-specific BMI at ≥95th
percentile
Provide intervention to prevent initiation of
✓ B tobacco use
 Child/ Adolescents
Major Depressive Disorder in
Children and Adolescents
✓ B Screen when systems for diagnosis, treatment,
and followup are in place.
Risk factors for MDD: parental depression, having
comorbid mental health or chronic medical
conditions, and having experienced a major
negative life event
The following screening tests have been shown to
do well in teens in primary care settings:
• Patient Health Questionnaire for Adolescents
(PHQ-A).
• Beck Depression Inventory-Primary Care
Version (BDI-PC).
Child/ Adolescents
INSUFFICIENT EVIDENCE (I)
• Illicit and Prescription Drug use in Children and Adolescents
• IDA Screening
• Lipid disorders in children
 ALL groups
Behavioral counseling
interventions for a healthful
diet and exercise
HIV Infection
 C Clinicians may choose to selectively counsel
patients rather than incorporate counseling into
the care of all adults in the general population
Screen for HIV
✓ A Adolescents and adults aged 15 to 65 years,
younger adolescents and older adults at increased
risk for infection, and pregnant women
 ALL groups
STIs ✓ B Offer high intensity counseling
All sexually active adolescents
Adults at increased risk for STIs

Provide counseling about minimizing exposure to

Skin Cancer, Behavioral ✓ B UV to reduce risk for skin CA
Counseling Adolescents and adults aged 15 to 65 years,
younger adolescents and older adults at increased
risk for infection, and pregnant women

No recommendation
Skin Cancer, Screening  I Skin cancer risks: family history of skin cancer,
considerable history of sun exposure and sunburn.
Groups at increased risk for melanoma:
Fair-skinned men and women over the age of 65
years, atypical moles, with more than 50 moles.
Questions?