Preventive Care of Adults Ages 19 Years and Older

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1 PRACTICE GUIDELINES AND PRINCIPLES: Guidelines and principles are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines and principles should be followed in most cases. However, there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. PURPOSE: This guideline documents standards for preventive health services for adults. It is the expectation that primary care physicians will provide these services for their patients. These services can be completed as part of an age appropriate history and physical or during the course of routine office visits. These guidelines were developed for care of patients in the absence of symptoms or disease. While these guidelines will be applicable to asymptomatic patients under most circumstances, the clinician must consider whether special conditions require a different standard for a particular patient. This guideline does not replace the role of a comprehensive history and physical examination and it does not address the preventive health needs of pregnant women or individuals with chronic disorders, nor does it define benefits or reimbursement. KEY MESSAGES: Many cancer deaths can be prevented and the number of new cases can be reduced with early screening and treatment. Cancer screening should be suspended for persons of any age with a life expectancy of less than 5 years. Conversely, screening can be considered at any age with a life expectancy greater than 10 years. Premature mortality, morbidity, and disability due to both cancer and chronic illnesses can be prevented by promoting healthy behaviors and encouraging modification of risk factors (i.e. tobacco use, nutrition, and exercise.) Immunization is a very simple and effective way to prevent serious illness and death in adults, and is one of the safest and most cost-effective preventive measures available. A large, good-quality study found that risk factor assessment can identify individuals at substantially higher risk for HIV but still misses a significant proportion (20%- 26%) of HIV-positive clients who report no risk factors (since some patients may choose not to disclose high-risk behaviors, and others, especially women, may be unknowingly at risk from an infected partner). HIGH RISK POPULATIONS: All practitioners need to be aware that there are racial and ethnic disparities in the delivery of adult preventive health services. Minorities are more likely to be diagnosed with late-stage breast cancer and colorectal cancer compared with whites. African Americans and poorer patients have higher rates of avoidable hospital admissions (i.e., hospitalizations for health conditions that, in the presence of comprehensive primary care, rarely require hospitalization). Page 1

2 METRICS: There are a number of HEDIS (Health Plan Employer Data and Information Set) measures which reflect adult preventive care, including: Colorectal Cancer Screening the percentage of adults years of age who had appropriate screening for colorectal cancer. Advising Smokers to Quit the percentage of adults 18 years and older (current smokers or recent quitters) who were seen by practitioner, who received advice to quit smoking. REFERENCES: These guidelines are based primarily on recommendations from the United States Preventive Services Task Force (USPSTF). Scientific evidence indicates that these interventions are effective in improving health outcomes and can reduce the incidence of illness, disease and accidents. In cases where the USPSTF concluded that an intervention is clinically valuable, but did not recommend the screening interval, we have established a frequency based on expert opinion. The guidelines are also based on recommendations from The Advisory Committee on Immunization Practices Recommended Adult Immunization Schedule (October September 2007), The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) (2002), Consensus Opinion of the North American Menopause Society (2001) and the American Academy of Family Physicians Policy Recommendations for Periodic Health Examinations (1996). FOR DISTRIBUTION TO: Internists, Family Practice Physicians, General Practice Physicians, Pediatricians and Obstetrician/Gynecologists. ADVISORY COMMITTEE: Norman Lindenmuth, MD, Internal Medicine; Paul Frame, MD, Family Medicine; David Gandell, MD, Obstetrics and Gynecology; Joseph Finetti, MD, Family Medicine; Kathy Riegel, MPH, Wendy Knight, RN, MSN. LAST APPROVED BY: The Rochester Health Commission s Community-Wide Clinical Guidelines Steering Committee on April 16, Next scheduled update by April Approved By QMC: May 11, Page 3

3 STRENGTH OF RECOMMENDATIONS: The Rochester Community-wide Clinical Guidelines Steering Committee (SC) grades recommendations according to one of five classifications (A, B, C, D, I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms). A SC strongly recommends that clinicians provide [the service] to eligible patients. There is good evidence that [the service] improves important health outcomes to conclude that benefits substantially outweigh harms. B SC recommends that clinicians provide [this service] to eligible patients. There is at least fair evidence that [the service] improves important health outcomes to conclude that benefits outweigh harms. C SC makes no recommendation for or against routine provision of [the service]. There is at least fair evidence that [the service] can improve health outcomes to conclude that the balance of benefits and harms is too close to justify a general recommendation. D SC recommends against routinely providing [the service] to asymptomatic patients. There is at least fair evidence that [the service] is ineffective or that harms outweigh benefits. I SC concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that the [service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined. QUALITY OF EVIDENCE: The quality of the overall evidence for a service is on a 3-point scale (good, fair, poor). Good Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes. Fair Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the 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 their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes. Adapted from the USPSTF grading system. Approved Page 3

4 SCREENING AVERAGE RISK PROCEDURE WOMEN MEN Age Appropriate History and Physical Exam, Risk Assessment 1&2 Blood Pressure 3 At each preventive health visit. At least every 2 years (A). Age 65 and older - every 1-2 years. Height and Weight 4 Obesity Screening 5 Lipid Screening 6 Cervical Cancer Screening 7 Breast Cancer Screening 8 At each preventive health visit Screen for obesity (B). Use height and weight to calculate BMI. Age 20 and older- Screen every 5 years. Obtain a fasting lipid profile. Within 3 years of onset of sexual activity or age 21 (whichever comes first), at least every 3 years (A). Age 65 and older if previous testing is abnormal. Age screening mammography, with or without clinical breast examination (CBE), every 1-2 years (B). Colorectal Cancer Screening 9 Prostate Cancer 10 Depression Screening 11 Osteoporosis Screening 12 Age 50 and older (A).. Age 50 to 75- counsel patients on known harms and potential benefits of screening (I) with PSA and Digital Rectal Exam. Screen for depression (B) (assuming systems are in place to assure accurate diagnosis, effective treatment, and followup) Age 60 - Routine screening for women at increased risk for osteoporotic fractures (B). Age 65 and older - Routine screening for all women (B). HIV Screening Routine voluntary screening as a normal part of medical practice for patients up to those age 65. (Rochester Guideline Steering Committee recommends one time testing age 19 and older.) Visual Impairment 13 Hearing Impairment 14 Age 65 and older - encourage periodic eye exam by specialist. Age 65 and older - Periodically question about hearing. Counsel about availability of treatment when appropriate. letters refer to Rochester Community-Wide Clinical Guidelines Grading System, see page 2 for description. Approved April Next scheduled update April. Page 4

5 SCREENING AT RISK PROCEDURE WOMEN MEN Diabetes 15 Screen adults with hypertension or dyslipidemia (B). Abdominal Aortic Aneurysm 16 At age one time screening by ultrasonography for men who have ever smoked (B). STD Testing Based on Screen those at increased risk. (A,B) Risk (e.g. Chlamydia, HIV) Tuberculosis 21 Screen those at increased risk. (A). IMMUNIZATIONS PROCEDURE WOMEN MEN See attached Adult Immunization Table (CDC/ACIP). PROPHYLAXIS PROCEDURE WOMEN MEN Aspirin 22 Discuss ASA chemoprevention with adults who are at increased risk for CHD (A). COUNSELING PROCEDURE WOMEN MEN Folate 23 During childbearing years, encourage 0.4mg/day. Calcium 24 Assess dietary intake, encourage supplementation when appropriate. Tobacco Use 26 Screen for tobacco use and provide interventions (counseling, pharmacotherapy) for those who use tobacco products (A). Alcohol Misuse 27 Screen for alcohol misuse. Counsel those with risky/hazardous or harmful consumption (B). Injury Prevention 28 Counsel regarding accidental injury prevention including (as appropriate): lap/shoulder belt use, bicycle safety, motorcycle helmet use, smoke detectors, poison control center number, and driving while intoxicated. Sexual Health 29 Counsel regarding the risks for sexually transmitted diseases (STDs) and how to prevent them. Dental Health 30 Diet Counseling 31 Obesity Counseling 32 Advance Care Planning 33 Encourage oral hygiene and visit to dental care provider. For those with hyperlipidemia or other known risk factors for cardiovascular and diet-related chronic conditions - counsel (intensive) or refer regarding diet (B). Screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. (B) Age 18 and older - counsel all individuals regarding completion of advance directives. Page 5

6 SCREENING - USUAL RISK: ANNOTATIONS 1 Age Appropriate History and Physical Exam: There are no studies comparing the efficacy of various schedules for preventive care visits. The intervals suggested below are based on a combination of various medical opinions and the frequency required by certain preventive services: years: Every 5 years years: Every 3 years years: Every 2 years 60 years and over: Every 1-2 years 2 Risk Assessment: When conducting periodic health exams, consider leading causes of mortality and morbidity for the age group along with individual risk factors. 3 Blood Pressure: Normotensive adults should receive blood pressure measurements at least every 2 years if their last diastolic and systolic blood pressure readings were below 85 and 140 mm Hg, respectively (A). USPSTF Because prevalence rises with age, measurements are recommended every 1-2 years for those 65 and older. Expert Opinion. 4 Height and Weight: Height and weight should be measured at each preventive health examination. USPSTF Obesity Screening: Screen all adults for obesity (B). Body mass index (BMI), calculated as weight in kilograms divided by height in meters squared is reliable and valid for identifying adults at increased risk for mortality and morbidity due to overweight and obesity. 6 Lipid Screening Routine cholesterol testing should begin in young adulthood ( 20 years of age). At a minimum, the USPSTF recommends that screening for lipid disorders include total cholesterol and HDL C. (B) USPSTF Lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides) is the preferred initial test. In young adults, above-optimal LDL cholesterol levels deserve clinical attention through therapeutic lifestyle changes. The value of routine drug treatment for hyperlipidemia under the age of 35 has not been established. The Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III, or ATP III) 2002, 7 Cervical Cancer Screening: Screen for cervical cancer in women who have been sexually active and have a cervix. Screening with cervical cytology (Pap smears) reduces incidence of and mortality from cervical cancer. Indirect evidence suggests most of the benefit can be obtained by beginning screening within 3 years of onset of sexual activity or age 21 (whichever comes first) and screening at least every 3 years (A). Routine screening is not recommended for women who have had a total hysterectomy for benign disease and for women older than age 65 who have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer (D). USPSTF Use of monolayer technology is preferred given the sensitivity, specificity, and cost-effectiveness of this technology. Expert opinion and literature review. 02/05 8 Breast Cancer Screening: Screening mammography, with or without clinical breast examination (CBE), is recommended every 1-2 years for women aged 40 and older (B). Evidence for benefit is also generalizable to women aged 70 and older (who face a higher absolute risk for breast cancer) if their life expectancy is not

7 compromised by comorbid disease. Evidence is insufficient to recommend for or against routine CBE alone to screen for breast cancer, or to recommend for or against teaching or performing routine breast self-examination (I). USPSTF Colorectal Cancer Screening: Screen men and women 50 years of age or older for colorectal cancer (A). Several screening methods are effective in reducing mortality from colorectal cancer. Screening studies have been restricted to patients younger than 80. Potential options include home FOBT, flexible sigmoidoscopy, the combination of home FOBT and flexible sigmoidoscopy, colonoscopy, and double-contrast barium enema. Each option has advantages and disadvantages that may vary for individual patients and practice settings. The choice of specific screening strategy should be based on patient preferences, medical contraindications, patient adherence, and available resources for testing and follow-up. Clinicians should talk to patients about the benefits and potential harms associated with each option before selecting a screening strategy. Neither digital rectal examination (DRE) nor the testing of a single stool specimen obtained during DRE is recommended as an adequate screening strategy for colorectal cancer. USPSTF Prostate Cancer Screening: The evidence is insufficient to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE) (I). Given the uncertainties and controversy surrounding prostate cancer screening, clinicians should not order the PSA test without first discussing with the patient the known harms and potential benefits of screening. Harms include false-positive and false negative results, unnecessary anxiety and biopsies, and potential complications of treatment of some cancers that may never have affected a patient's health. Men should be informed of the gaps in the evidence, and they should be assisted in considering their personal preferences and risk profile before deciding whether to be tested. USPSTF Depression Screening: Screening adults for depression is recommended in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up (B). Benefits from screening are unlikely to be recognized unless such systems are functioning well. Many formal screening tools are available (e.g., the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire [GHQ], Center for Epidemiologic Study Depression Scale [CES-D]). Asking the two simple questions about mood and anhedonia as recommended by the PHQ -2. ("Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?") may be as effective as using longer instruments. Treatment may include antidepressants or specific psychotherapy approaches (e.g., cognitive behavioral therapy or brief psychological counseling), alone or in combination. USPSTF (Refer to guideline Identification and Treatment of Major Depression in Primary Care for Adults Age 18 and Older for available treatment options and follow-up care.) 12 Osteoporosis Screening: Women aged 65 and older should be screened routinely for osteoporosis (B). Routine screening should begin at age 60 for women at increased risk for osteoporotic fractures (B). The risk for osteoporosis and fracture increases with age and other factors. Bone density measurements accurately predict the risk for fractures in the short-term, and treating asymptomatic women with osteoporosis reduces their risk for fracture. The exact risk factors that should trigger screening in this age group are difficult to specify based on evidence. Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density. Low weight and no current use of estrogen therapy are incorporated with age into the 3-item Osteoporosis Risk Assessment Instrument (ORAI). There is less evidence to support the use of other individual risk factors (for example, smoking, weight loss, family history, decreased physical activity, alcohol or caffeine

8 use, or low calcium and vitamin D intake) as a basis for identifying high-risk women younger than 65. At any given age, African-American women on average have higher bone mineral density (BMD) than white women and are thus less likely to benefit from screening. USPSTF Visual Impairment: Vision screening has been recommended for elderly adults based on high prevalence of under corrected impairments, the accuracy of screening tests, the effectiveness of eye glasses, and the willingness of older adults to follow through with additional screening and the purchase of eye glasses. 14 Hearing Impairment: Screening for older adults is recommended through periodically questioning them about their hearing, counseling them about the availability of hearing aid devices, and making referrals for abnormalities when appropriate. USPSTF SCREENING - AT RISK: 15 Diabetes: The evidence is insufficient to recommend for or against routinely screening asymptomatic adults for type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose (I). Screening is recommended for type 2 diabetes in adults with hypertension or hyperlipidemia (B). The ADA recommends the fasting plasma glucose (FPG) for screening over other options. USPSTF Abdominal Aortic Aneurysm: One-time screening by ultrasonography is recommended in men aged 65 to 75 who have ever smoked [*at least 100 cigarettes in person s lifetime] (B). There is no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked (C). The USPSTF recommends against routine screening for AAA in women (D). One-time screening to detect an AAA using ultrasonography is sufficient. There is negligible health benefit in re-screening those who have normal aortic diameter on initial screening. USPSTF Chlamydia: Routinely screen all sexually active women aged 25 years and younger and other asymptomatic women at increased risk for infection. (A) Age is the most important risk marker. Other patient characteristics associated with a higher prevalence of infection include being unmarried, African-American race, having a prior history of sexually transmitted disease (STD), having new or multiple sexual partners, having cervical ectopy, and using barrier contraceptives inconsistently. Partners of infected individuals should be tested and treated if infected or treated presumptively. USPSTF HIV: Currently a consensus is lacking on HIV screening and testing. Recommendations are therefore listed by the CDC, NYSDOH, USPSTF and Rochester Guideline Steering Committee (RGSC): To encourage HIV testing more broadly, NYSDOH, consistent with the Centers for Disease Control and Prevention (CDC) Advancing HIV Prevention Initiative, urges HIV testing to be recommended as a routine part of medical care and other services. The CDC recommends that in all health-care settings, screening for HIV infection should be performed routinely for all patients until the age of 65 (MMWR, Sept. 22, 2006/vol.55/No. RR-14). However, the USPSTF 2005, states that there is insufficient evidence to recommend for or against routine HIV screening in persons without identified risk factors (C). USPSTF s specific recommendations are counseling and testing for HIV should be offered to all persons at increased risk for infection (A).

9 A person is considered high risk for HIV infection (and thus offered HIV testing) if she/he reports 1 or more individual risk factors or receives health care in a high-prevalence or high risk setting. Risk factors include: those seeking treatment for sexually transmitted diseases; men who have had sex with men after 1975; past or present injection drug users; persons who exchange sex for money or drugs and their sex partners; women and men whose past or present sex partners were HIV-infected; bisexuals; or injection drug users and persons with a history of transfusion between 1978 and Clinicians should assess risk factors for HIV infection in all patients by obtaining a careful sexual history and inquiring about drug use. USPSTF Due to lack of evidence and consensus around routine screening, and after a review of epidemiology of HIV in Monroe County, the RGSC recommends one time testing age 19 and older. (note: this is a one time recommendation for 2007) 19 Syphilis: Screening persons at increased risk for syphilis infection and pregnant women is strongly recommended (A). Persons at increased risk because of high-risk sexual activities include commercial sex workers, persons who exchange sex for drugs, those with other sexually transmitted diseases (STDs) including HIV, and contacts of persons with active syphilis. USPSTF Gonorrhea: Routine screening of men or women is not recommended in the general population of low-risk adults (D) Routine screening for gonorrhea is recommended for asymptomatic women at high risk of infection (B). Women and men under age 25 are the highest risk for infection. High-risk groups include commercial sex workers (prostitutes), persons with a history of repeated episodes of gonorrhea, and young women (under age 25) with two or more sex partners in the last year. (C). USPSTF Tuberculosis (PPD): Screening for tuberculous infection by tuberculin skin testing is recommended for all persons at increased risk of developing tuberculosis (TB) (A). Asymptomatic persons at increased risk include persons infected with HIV, close contacts of persons with known or suspected TB (including health care workers), persons with medical risk factors associated with TB, immigrants from countries with high TB prevalence (e.g., most countries in Africa, Asia, and Latin America), medically underserved low-income populations (including high-risk racial or ethnic minority populations), alcoholics, injection drug users, and residents of long-term care facilities (e.g., correctional institutions, mental institutions, nursing homes). PROPHYLAXIS: 22 Aspirin: Discuss aspirin chemoprevention with adults who are at increased risk for coronary heart disease (CHD) (A). Men older than 40 years, postmenopausal women, and younger people with risk factors for coronary heart disease (e.g., hypertension, diabetes, or smoking) are at increased risk. Discussions with patients should address both the potential benefits and harms of aspirin therapy. Risk assessment should include asking about the presence and severity of the following risk factors: age, sex, diabetes, elevated total cholesterol levels, low levels of high-density lipoprotein (HDL) cholesterol, elevated blood pressure, family history (in younger adults), and smoking. USPSTF COUNSELING: 23 Folate: Daily multivitamins with folic acid to reduce the risk of neural tube defects are recommended for all women who are planning or capable of pregnancy. USPSTF 1996.

10 24 Calcium: Estimates of adequate intakes of calcium, vitamin D, and magnesium for peri-and postmenopausal women are based on evidence relating to osteoporosis prevention. At least 1,200 mg/day calcium is required for most women. A dietary intake of IU of vitamin D is recommended, either through sun exposure or through dietary intake. There is no current evidence to support magnesium supplementation for most peri-and postmenopausal women who ingest a balanced diet. Consensus Opinion of The North American Menopause Society Tobacco Use: Screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products (B). Brief smoking cessation interventions, including screening, brief behavioral counseling (less than 3 minutes), and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit smoking and remain abstinent after 1 year. USPSTF Alcohol Misuse: Screening and behavioral counseling interventions* to reduce alcohol misuse are recommended (B). Screening in primary care settings can accurately identify patients whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence, but place them at risk for increased morbidity and mortality. Brief behavioral counseling interventions with follow-up produce small to moderate reductions in alcohol consumption that are sustained over 6- to 12-month periods or longer. Alcohol misuse includes "risky/hazardous" and "harmful" drinking that places individuals at risk for future problems. "Risky" or "hazardous" drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. "Harmful drinking" describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet criteria for dependence. [*Effective interventions to reduce alcohol misuse include an initial counseling session of about 15 minutes, feedback, advice, and goal-setting, with further assistance and follow-up.] USPSTF Injury Prevention: The AAFP Summary of Policy Recommendations for Periodic Health Examinations (RPHE), Last revised August Sexual Health: The AAFP Summary of Policy Recommendations for Periodic Health Examinations (RPHE), Last revised August Dental Health: Counseling patients to visit a dental care provider on a regular basis, floss daily, brush their teeth daily with a fluoride-containing toothpaste, and appropriately use fluoride for caries prevention and chemotherapeutic mouth rinses for plaque prevention is recommended. USPSTF Diet Counseling: Medium- to high-intensity * counseling interventions can produce medium-to-large changes in average daily intake of core components of a healthy diet (including saturated fat, fiber, fruit, and vegetables) among adult patients at increased risk for diet-related chronic disease (B). [* greater than two contacts of 30 minutes or more.] Major diseases in which diet plays a role include coronary heart disease, some types of cancer, stroke, hypertension, obesity, osteoporosis, and non-insulin-dependent diabetes mellitus. Evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients (I). USPSTF 2003.

11 32 Obesity Counseling: The most effective interventions combine nutrition education and diet and exercise counseling with behavioral strategies to help patients acquire the skills and supports needed to change eating patterns and to become physically active. It is advisable to refer high risk obese patients to programs that offer intensive counseling and behavioral interventions for optimal weight loss. USPSTF Advance Care Planning: Advance Care Planning is a process that requires conversation and results in the completion of an Advance Care Directive. An Advance Care Directive allows patient preferences and goals to drive care and to guide shared medical decision making in the event the patient is unable to communicate. Studies have demonstrated that physician counseling markedly increases the completion rate of Advance Care Directives.