Session 7: How Well Do You Know Your Disease Prevention Guidelines? Learning Objectives 1. Apply the latest screening recommendations for breast cancer, colorectal cancer, and genitourinary malignancies in your care of patients. 2. Outline the risks and benefits of daily aspirin therapy for primary prevention of cardiovascular events in a variety of patient populations.
Session 7 How Well Do You Know Your Disease Prevention Guidelines? Faculty Katherine E. Galluzzi, DO, CMD, FACOFP Dist. Professor and Chairperson Department of Geriatric Medicine Philadelphia College of Osteopathic Medicine Philadelphia, Pennsylvania Dr Katherine Galluzzi is chair of the Department of Geriatrics at the Philadelphia College of Osteopathic Medicine. Dr Galluzzi received her medical degree from the West Virginia School of Osteopathic Medicine in Lewisburg and completed a rotating internship and family medicine residency at Kennedy Memorial Hospitals University Medical Center in Stratford, New Jersey, and the University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine in Camden. She underwent clinical fellowship training in geriatrics at the University of Pennsylvania Center for the Study of Aging and completed a faculty development fellowship at Temple University School of Medicine. Dr Galluzzi holds a Certificate of Added Qualification in geriatrics and hospice and palliative medicine, and was recently recertified in family medicine. She is a certified medical director in long-term care through the American Medical Directors Association Certification Program and a certified diplomate of the American Board of Hospice and Palliative Medicine. Chair of the Council on Palliative Care Issues for the American Osteopathic Association, Dr Galluzzi is also a distinguished fellow of the American College of Osteopathic Family Physicians (ACOFP) and a fellow of the College of Physicians of Philadelphia. Dr. Galluzzi is an active member of ACOFP, the American Geriatric Society (AGS), and the American Academy of Hospice and Palliative Medicine (AAHPM), and was past president of the Pennsylvania Osteopathic Family Physicians Society (POFPS). Dr Galluzzi has authored articles focused on end-of-life care and the patient-centered approach to pain management in publications such as the Journal of the American Osteopathic Association. She is the recipient of many awards, including the Frederick J. Solomon Award of Merit from the Pennsylvania Society of ACOFP, the Barbara Bell Award from the Eastern Regional Geriatrics Society, and a distinguished fellowship award from ACOFP. Adriana Monferre, MD Academic Hospitalist Lankenau Medical Center Primary Care Physician Lankenau Clinical Care Center. Wynnewood, Pennsylvania Adriana Monferre, MD, is an academic hospitalist in the department of medicine at Lankenau Medical Center and clinical educator at the Lankenau Internal Medicine Clinical Care Center, both in Wynnewood, Pennsylvania. Dr Monferre graduated from the Temple University School of Medicine in 1994, where she received the Emanuel M. Weinberger award for achievement in nephrology. Dr Monferre completed a residency in internal medicine in 1997 and served as chief resident from 1997 to 1998, both at Temple University Hospital, becoming board certified in internal medicine in 1997. Dr Monferre was one of the first
internal medicine hospitalists at the Hospital of the University of Pennsylvania, also serving as instructor in the division of general internal medicine, University of Pennsylvania School of Medicine. She subsequently served as assistant professor of medicine and was the first director of the Hospitalist Medicine Group in the department of medicine, Temple University School of Medicine, later becoming the hospital s first section chief of hospitalist medicine. Dr Monferre has been involved in medical student and resident education throughout her career. She has also contributed her expertise to quality improvement activities through her service on committees on medication safety, student health, and performance improvement. Faculty Financial Disclosure Statements The presenting faculty reports the following: Dr Galluzzi has no financial relationships to disclose. Dr Monferre has no financial relationships to disclose.
Faculty Disclosures Session 7: 7:45 AM - 9:15 AM Dr Galluzzi has no financial relationships to disclose. Dr Monferre has no financial relationships to disclose. How Well Do You Know Your Disease Prevention Guidelines? Katherine E. Galluzzi, DO, CMD, FACOFP Dist. Adriana Monferre, MD Learning Objectives Pre-test Question 1 Apply the latest screening recommendations for breast cancer, colorectal cancer, and genitourinary malignancies in your care of patients Outline the risks and benefits of daily aspirin therapy for primary prevention of cardiovascular events in a variety of patient populations Which of the following is TRUE? 1. Clinical breast examination (CBE) yields a low percentage of false positives 2. Self-breast examination (SBE) has been shown to save lives 3. USPSTF recommends against SBE 4. All of the above Pre-test Question 2 Pre-test Question 3 The USPSTF recommends ASA prophylaxis for prevention of MI and stroke in high-risk populations when the benefits exceed the risks. Which of the following is/are true? 1. Use in men aged 45-79 years to prevent MI 2. Use in women aged 45-79 years to prevent MI and stroke 3. Use in women aged 55-79 years to prevent stroke 4. 1 and 2 only 5. 1 and 3 only According to the CDC, routine HIV screening is recommended in healthcare settings for: 1. Pregnant females only 2. Patients with high-risk behaviors and/or history of sexually transmitted infection only 3. All adolescents and adults 4. 1 and 2 only 1
Review recommendations, focusing on: US Preventive Services Task Force (USPSTF) Advisory Committee for Immunization Practices (ACIP) American College of Physicians (ACP) American Academy of Family Physicians (AAFP) Centers for Disease Control (CDC) National Cholesterol Education Program (NCEP) American Diabetes Association (ADA) American College of Obstetrics and Gynecology (ACOG) American Cancer Society (ACS) National Osteoporosis Foundation (NOF) American Geriatric Society (AGS) American College of Cardiology Foundation/American Heart Association (ACCF/AHA) American College of Gastroenterology (ACG) Issues and Controversies USPSTF guidelines will often open the discussion of the topics covered today Guidelines on same recommendation are issued at different times by different authorities and analyze different data, so recommendations may differ When controversial, additional guidelines of other recognized authorities will also be presented, and dates of various guidelines are provided to help with your decisions Bottom Line: your best clinical judgment must prevail USPSTF Grade Definitions USPSTF Grade Definitions (Cont.) Grade Definition Suggestions for Practice A The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service. B C 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. The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. Offer or provide this service. Offer or provide this service only if other considerations support the offering or providing the service in an individual patient. Grade Definition Suggestions for Practice 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. Discourage the use of this service. I statement 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. Read the clinical considerations section of USPSTF Recommendations. If the service is offered, patients should understand the uncertainty about the balance of benefits/harms. ADA Evidence Grading System for Clinical Recommendations (2011) Level of Evidence A B C Description Clear or supportive evidence from adequately powered well-conducted, generalizable, randomized controlled trials Compelling nonexperimental evidence Supportive evidence from well-conducted cohort studies or case-control study Supportive evidence from poorly controlled or uncontrolled studies Conflicting evidence with the weight of evidence supporting the recommendation George 58-year-old man will present for his physical tomorrow and ask to have prostate cancer screening. He has no prostate symptoms or family history of prostate cancer. Will you order a PSA? 1. Yes 2. No 3. Not enough information E Expert consensus or clinical experience ADA. Diabetes Care. 2011;34(suppl 1):S12. Table 1. 2
USPSTF Prostate Cancer Screening Guidelines (2012) PSA-Based Screening for Prostate Cancer Possible benefit of screening: Recommends against prostate-specific antigen (PSA) based screening for prostate cancer. Grade D Recommendation. Reducing 10 year risk of prostate cancer 10 year risk of dying of prostate CA with no screening Men, n 5 in 1000 10 year risk of dying of prostate CA with screening 4-5 in 1000 Number who do not die of prostate CA because of screening 0-1 in 1000 Moyer V A. Ann Intern Med. doi:10.1059/0003-4819-157-2-201207170-00459 Moyer V A. Ann Intern Med. doi:10.1059/0003-4819-157-2-201207170-00459 PSA-Based Screening for Prostate Cancer Harms of screening: Men, n PSA-Based Screening for Prostate Cancer Harms of screening (continued): Men, n At least 1 false positive PSA result Most positive results lead to biopsy Of men having biopsy, ~33% have bothersome symptoms including pain, fever, bleeding, infection and temporary urinary difficulties; 1% will be hospitalized 100-120 in 1000 Prostate CA diagnosis Complications of treatment of those screened Develop serious CV events Develop DVT or PE Develop erectile dysfunction Develop urinary incontinence Die due to treatment 110 in 1000 2 in 1000 1 in 1000 29 in 1000 18 in 1000 <1 in 1000 Moyer V A. Ann Intern Med. doi:10.1059/0003-4819-157-2-201207170-00459 Moyer V A. Ann Intern Med. doi:10.1059/0003-4819-157-2-201207170-00459 Other Prostate Cancer Guidelines American Cancer Society (2010): Asymptomatic men with >10-year life expectancy can be screened at age 50 (PSA +/- DRE) after informed decision about uncertainties, risks, and potential benefits Black men or men with FH should receive information at age 45 American Urological Association (2009): Recommend baseline PSA testing (and DRE) be offered to men as young as age 40 with life expectancies of > 10 years after discussion of testing's benefits and risks October, 2011: Submitted response letter to USPSTF after its guidelines were released, disagreeing with its draft recommendations; they are currently updating their guideline Wolf AM, et al. CA Cancer J Clin. 2010; 60:70-98. http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf http://www.auanet.org/content/health-policy/government-relations-and-advocacy/in-the-news/aua-response-to-uspstf.cfm Question A yearly digital rectal exam (DRE) and office fecal occult blood testing (FOBT) are acceptable colon cancer screening modalities. 1. True 2. False 3
USPSTF Screening for Colorectal Cancer (CRC): Summary of Recommendation (2008) Recommends screening using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. Risks and benefits of these screening methods vary. Grade: A Recommendation. Recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in individual patients. Grade: C Recommendation. USPSTF Screening for Colorectal Cancer (CRC): Summary of Recommendation (2008) Recommends against screening for colorectal cancer in adults > age 85 years. Grade: D Recommendation. Concludes that evidence is insufficient to assess benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. Grade: I Statement. http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm Accessed 1/4/09 http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm Accessed 1/4/09 USPSTF Screening for Colorectal Cancer (CRC): Summary of Recommendation (2008) Base screening choice on patient preferences, medical contraindications, adherence, and available resources for testing and follow-up Discuss benefits and potential harms of options Acceptable methods of screening: Annual FOBT x 3 or fecal immunochemical test (FIT) Sigmoidoscopy every 5 years with 3 high-sensitivity home FOBT every 3 years Colonoscopy at 10-year intervals DRE PLUS IN-OFFICE FOBT IS NOT ACCEPTABLE SCREENING http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm Accessed 1/4/09 American College of Gastroenterology Colorectal Cancer Screening Recommendations (2009) Cancer prevention tests are preferred over detection tests Preferred CRC prevention test is colonoscopy every 10 years beginning at age 50 years for non-african Americans Screening for African American patients should begin at age 45 years because of the high incidence of CRC and certain cancerous lesions in this population FIT is the preferred cancer detection test Am J Gastroenterol. 2009;104:739-750. ACP Guidance Statements for Colorectal Cancer Screening (CRC) (2012) Guidance Statement 1: Perform individualized assessment of risk for CRC in all adults Guidance Statement 2: Screen average-risk adults starting at age 50 and high-risk adults starting at 40 or 10 years younger than age at which the youngest affected relative was diagnosed with CRC Guidance Statement 3: Use stool-based test, flexible sigmoidoscopy, or optical colonoscopy as screening in patients at average risk. Use optical colonoscopy as screening in those at high risk. Select test based on the test s benefits and harms, availability and patient preferences Guidance Statement 4: Stop screening in those >75 or with life expectancy <10 years Question The USPSTF recommends routine mammography every 2 years starting at age 40. 1. True 2. False Qaseem A, et al. Ann Intern Med. 2012;156:378-386. 4
USPSTF Breast Cancer Screening: Summary of Recommendations (2009) Recommends biennial screening mammography for women aged 50 to 74 years. Grade: B Recommendation. Decision to start regular, biennial screening mammography before age 50 should be individual one and take patient context into account, including patient's values regarding specific benefits and harms. Grade: C Recommendation. Concludes current evidence insufficient to assess additional benefits and harms of screening mammography in women > 75 years. Grade: I Statement. US Preventive Services Task Force. Ann Intern Med. 2009;151:716-726. Other Breast Cancer Screening Recommendations ACOG 2011: recommends screening mammography every year starting at age 40 ACS 2003: Women at average risk should begin annual mammography at age 40 AAFP 2009: Mirrors USPSTF recommendation BOTTOM LINE: Despite USPSTF recommendations, Medicare/Medicaid/private insurance all continue to cover breast cancer screening starting at age 40 http://www.acog.org/from_home/publications/press_releases/nr07-20-11-2.cfm Smith RA, et al. CA Cancer J Clin. 2003; 53:141-169. http://www.aafp.org/online/en/home/clinical/exam/a-e.html Clinical Breast Examination (CBE) May identify 4.5-10.7% of breast cancers that mammography misses Clinician proficiency impacts effectiveness 1 High rate false positives 2 Recommendations vary ACS and ACOG 2011 recommend one every 3 years for average risk women ages 20-30; annually for women > 40 3 USPSTF 2010: current evidence insufficient to assess additional benefits and harms of CBE beyond screening mammography in women > 40. Grade: I Statement. 1.McDonald S, Saslow D, Alciati MH. CA Cancer J Clin. 2004;54:345-61. 2. Elmore JG et al. N Engl J Med 1998; 338:1089-1096. 3. Smith RA, Cokkinides V, Eyre HJ. CA Cancer J Clin. 2005;55:31-44. Breast Self-Examination (BSE) Recommendations vary ACS and others: teach woman the procedure and provide to them as an option 1 USPSTF 2010 recommends against teaching BSE. Grade: D Recommendation Not shown to have an effect on breast CA mortality rate 3 1. Smith RA, et al. CA Cancer J Clin. 2005;55:31-44. 2. US Preventive Services Task Force. Screening for Breast Cancer: Recommendations and Rationale. 2002 3. Kosters JP, et al. Cochrane Database of Systematic Reviews. 2003;3:CD003373. Anna 52-year-old diabetic. No history of GI bleed or NSAID intolerance. Do you start her on ASA prophylaxis to prevent an MI? 1. Yes 2. No 3. Not sure USPSTF: Aspirin for the Primary Prevention of CV Events (2009) Use ASA for men aged 45 to 79 years when potential benefit due to MI reduction outweighs potential harm due to increase in GI hemorrhage. Grade: A Recommendation. Use of ASA for women aged 55 to 79 years when potential benefit of reduction in ischemic strokes outweighs the potential harm of increase in GI hemorrhage. Grade: A Recommendation. US Preventive Services Task Force. Ann Intern Med. 2009;150:396-404. 5
USPSTF: Aspirin for the Primary Prevention of CV Events (2009) Current evidence is insufficient to assess balance of benefits and harms of ASA for CV disease prevention in men and women >80 years. Grade: I Statement. Recommends against the use of ASA for stroke prevention in women <55 years and for MI prevention in men <45 years. Grade: D Recommendation. USPSTF: Aspirin for the Primary Prevention of CV Events (2009) Doses used in primary prevention trials ranged from 75 mg/d to 500 mg/d Women s Health Study used 100 mg every other day may be reason why no effect seen in reducing combined outcome of CVD events or MIs Consistent evidence shows ASA use increases risk for GI bleeding events ASA use increases risk for hemorrhagic strokes in men; risk for hemorrhagic strokes in women not significantly increased Overall benefit in reducing CVD events with ASA dependent on baseline CVD risk and risk for GI bleeding US Preventive Services Task Force. Ann Intern Med. 2009;150:396-404. US Preventive Services Task Force. Ann Intern Med.2009;150:396-404. USPSTF: Aspirin for the Primary Prevention of CV Events (2009) Shared decision making strongly encouraged with persons whose risk is close to (either above or below) these estimates of 10-year risk levels As potential CV disease reduction benefit increases above harms, the recommendation to take aspirin should become stronger Men Women Age 10-year CHD Risk Age 10-year Stroke Risk 45-59 years 4% 55-59 years 3% 60-69 years 9% 60-69 years 8% 70-79 years 12% 70-79 years 11% Risk Assessment for Stroke in Women Risk factors for stroke include age, HTN, DM, smoking, history of CV disease, atrial fibrillation, and LVH Tools for estimation of stroke risk such as the stroke risk calculator are available at: www.reynoldsriskscore.org/ or www.westernstroke.org/personalstrokerisk1.xls US Preventive Services Task Force. Ann Intern Med. 2009;150:396-404. US Preventive Services Task Force. Ann Intern Med. 2009;150:396-404. ADA ASA Recommendations (2012) Net benefit of ASA in primary prevention in those without CV events is controversial even for patients with DM Should not be recommended for CVD prevention for adults with diabetes at low CVD risk, since potential adverse effects from bleeding likely offset potential benefits (C) ADA ASA Recommendations (2012) Consider ASA therapy (75 162 mg/day) (C) As a primary prevention strategy in those with type 1 or type 2 DM at increased CV risk (10-year risk >10%) Includes most men >50 years of age or women >60 years of age who have > 1 additional major risk factor(s) Family history of CVD Hypertension Smoking Dyslipidemia Albuminuria Diabetes Care. 2012;35 (suppl 1):S11-63. Diabetes Care. 2012;35 (suppl 1):S11-63. 6
Question In your practice, do you routinely do cholesterol screening in asymptomatic adults under age 35? 1. Yes 2. No National Cholesterol Education Program (NCEP) Guidelines (2001) In adults with no symptoms, cholesterol screening should take place every 5 years starting at age 20 Patients with heart disease or abnormal lipid levels should be screened every 1 to 2 years Those on medication to lower cholesterol should be screened every 6 weeks until lipid goals are met, and every 4 to 6 months thereafter ADA recommends all adults receive complete lipid panel every year JAMA. 2001;285(19) 2486-2497. USPSTF Screening Recommendations for Lipid Disorders (2008) SCREENING MEN Strongly recommends screening men aged 35 and older for lipid disorders. Grade: A Recommendation. Recommends screening men aged 20 to 35 for lipid disorders if they are at for coronary heart disease. Grade: B Recommendation. USPSTF Screening Recommendations for Lipid Disorders (2008) SCREENING WOMEN AT INCREASED RISK Strongly recommends screening women aged > 45 if they are at for CHD Grade: A Recommendation. Recommends screening women 20 to 45 if they are at for CHD Grade: B Recommendation. http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm. Accessed 1/3/12 http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm USPSTF Screening Recommendations for Lipid Disorders (2008) SCREENING YOUNG MEN AND ALL WOMEN NOT AT INCREASED RISK Makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for CHD Grade: C Recommendation. Question According to the American Diabetes Association (ADA), diabetes screening for someone with normal BMI and no CV risk should begin at: 1. Age 30 2. Age 45 3. Age 60 4. There are no recommendations to screen individuals with no risk factors http://www.uspreventiveservicestaskforce.org/uspstf/uspschol.htm 7
ADA Recommendations: Testing for Diabetes in Asymptomatic Adults (2011 Update) Without risk factors, DM testing should begin at age 45 If results normal, repeat testing at least every 3 years Consider more frequent testing depending on initial results and risk status Can use A1C, FPG, or 2-h 75-g OGTT ADA Recommendations: Testing for Diabetes in Asymptomatic Adults (2011 Update) Consider testing overweight/obese adults with one or more additional risk factors In those without risk factors, begin testing at age 45 years (B) If tests are normal Repeat testing at least at 3-year intervals (E) Use A1C, FPG, or 2-h 75-g OGTT (B) In those with for future diabetes Identify and, if appropriate, treat other CVD risk factors (B) ADA. Testing in Asymptomatic Patients. Diabetes Care. 2011;34(suppl 1):S14. Table 4. ADA. II. Testing in Asymptomatic Patients. Diabetes Care. 2011;34(suppl 1):S13-S14. ADA Recommendations: Testing for Diabetes in Asymptomatic Adults (2012 Update) Should be considered in all adults who are overweight (BMI 25 kg/m 2 *) and have additional risk factors: Physical inactivity First-degree relative with diabetes High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) Women who delivered a baby weighing >9 lb or were diagnosed with GDM Hypertension ( 140/90 mmhg or on therapy for hypertension) HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l) Women with polycystic ovarian syndrome (PCOS) A1C 5.7%, IGT, or IFG on previous testing Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) History of CVD *At-risk BMI may be lower in some ethnic groups. Diabetes Care. 2012;35 (suppl 1):S11-63. 4 USPSTF Diabetes Screening Recommendations (2008) Recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Grade: B Recommendation. Concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower. Grade: I Statement. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm. Accessed 1/3/12 Question In addition to flu and pneumococcal vaccinations, do you routinely vaccinate your diabetes patients against hepatitis B? 1. Yes 2. No ACIP Recommendations for Hepatitis B Vaccination for DM (December 2011) Hepatitis B vaccination should be administered to unvaccinated adults with DM who are aged 19 through 59 years. Recommendation category A. Hepatitis B vaccination may be administered at the discretion of the treating clinician to unvaccinated adults with DM who are aged 60 years. Recommendation category B. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a4.htm. Accessed 1/6/12 8
Rationale/Recommendations for Hepatitis B Vaccination in Persons with DM Shared use of blood-contaminated equipment increases risk for exposure to blood borne pathogens Complete the series as soon as feasible after DM diagnosis No serologic tests or additional vaccination needed if patient received complete series in past Decisions to vaccinate DM patients 60 should weigh risks from increased need for assisted blood-glucose monitoring in LTC facilities, likelihood chronic sequelae if infected vs. declining immunologic responses to vaccines with aging There is no maximum interval between doses that makes the series ineffective Jim 67-year-old former 1.5 ppd smoker x 40 years with treated HTN presents for his physical. Which of the following tests is/are indicated? 1. Ultrasound of his carotids 2. Ultrasound of his abdominal aorta 3. Both 4. Neither http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a4.htm. Accessed 1/6/12 USPSTF Abdominal Aortic Aneurysm Screening: Summary of Recommendations (2005) Recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked. Grade: B Recommendation. Makes no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked. Grade: C Recommendation. Recommends against routine screening for AAA in women. Grade: D Recommendation. USPSTF Screening for Carotid Artery Stenosis: Summary of Recommendation (2007) Recommends against screening for asymptomatic carotid artery stenosis (CAS) in the general adult population. Grade: D Recommendation. First published in: Ann Intern Med. 2005;142:198-202. http://www.ahrq.gov/clinic/uspstf05/aaascr/aaars.htm First published in: Ann Intern Med. 2007;147:854-859. http://www.ahrq.gov/clinic/uspstf/uspsacas.htm Question Which patient should be offered HIV testing during a routine physical? 1. A 20-year-old college student living at home; no known STDs 2. A 48-year-old widow with 2 teenage children; no known STDs 3. Both 4. Neither Screening for HIV in Health Care Settings: Guidance Statement From the American College of Physicians (ACP) and HIV Medicine Association (2009) Guidance Statement 1: ACP recommends that clinicians adopt routine screening for HIV and encourage patients to be tested. Guidance Statement 2: ACP recommends that clinicians determine the need for repeat screening on an individual basis. Qaseem A, et al. Ann Intern Med. 2009;150:125-131. 9
Screening for HIV in Health Care Settings: Guidance Statement From the American College of Physicians (ACP) and HIV Medicine Association (2009) Reasons for screening endorsement: 10-25% of people who test HIV-positive report no highrisk behaviors Almost half of newly diagnosed patients are identified late in their illness, when they might not reap full benefit from antiretroviral treatment People unaware of their infection status transmit > 20,000 infections per year Because of this ongoing transmission, screening is costeffective even in low-risk communities Qaseem A, et al. Ann Intern Med. 2009;150:125-131. HIV Guidelines From Other Organizations USPSTF/AAFP 2007: Strongly recommends HIV screening in all adolescents and adults at for HIV infection. Grade: A Recommendation. No recommendation to screen if not at elevated risk. Grade: C Recommendation. CDC 2006: Screening should be performed routinely for all adolescents and adults patients should be notified that testing will be performed and may decline (opt-out screening) All those with TB, those seeking Rx for STD, and all pregnant patients should be screened Qaseem A, et al. Ann Intern Med. 2009;150:125-131. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm CDC Recommendation: Screen Baby Boomers for Hepatitis C Recommends one time testing of those born between 1945 and 1965 Rationale: >15,000 deaths yearly, mostly from this age group; numbers projected to increase significantly 1 in 30 boomers infected; most don t know it Screening and treatment will save lives Available therapies can cure ~ 75%, preventing cirrhosis/cancer Question A 22-year-old asymptomatic woman presents for her routine OB/GYN visit. In addition to a Pap smear, what screening do you perform? 1. Chlamydia screening 2. Gonorrhea screening 3. Both 4. Neither http://www.cdc.gov/nchhstp/newsroom/2012/hcv-testing-recs-pressrelease.html. Accessed 9/21/12 STI Screening Recommendations for Men and Nonpregnant Women STI USPSTF CDC AAFP ACOG Chlamydia Screen women Screen women Screen women Screen younger than 25 years and others at 25 years and younger and others at 25 years and younger and others at women 25 years and younger and others at Gonorrhea Syphilis Screen women younger than 25 years and others at Screen women and men at Screen women at increased risk Screen women exposed to syphilis Screen women younger than 25 years and others at Screen persons at http://www.uspreventiveservicestaskforce.org/uspstf08/methods/stinfections.htm. accessed 1/3/12 Weinbaum CM, et al. MMWR Recomm Rep. 2008;57(RR-8):1-20. http://www.ahrq.gov/downloads/pub/prevent/pdfser/hepcser.pdf. http://www.aafp.org/afp/2008/0315/p819.html Screen adolescents and others at Screen women at STI Screening Recommendations for Men and Nonpregnant Women (Cont.) STI USPSTF CDC AAFP ACOG Hepatitis B Hepatitis C Do not screen general population Screen and provide vaccination for persons at Do not Screen all screen persons born general between 1945 to population; 1965 (Aug 2012) insufficient evidence to recommend for or against screening persons at Do not screen general population Do not screen general population; insufficient evidence to recommend for or against screening persons at No specific recommendation Screen women at 10
Question 33-year-old woman returns for her yearly physical. She had a negative PAP smear last year and has no history of STIs or cervical dysplasia. Do you do a Pap smear, an HPV test, both or neither? 1. Pap only 2. HPV only 3. Both 4. Neither USPSTF Screening for Cervical Cancer: Summary of Recommendations (2012) Screen women age 21-65 yr with cytology (Pap smear) Q 3 yr or, for women age 30-65 who want to lengthen screening interval, screen with cytology + HPV Q 5 yr. A recommendation. Recommends against screening women < 21 years D recommendation. Recommends against screening in women > 65 yr who have had adequate prior screening and are not otherwise at high risk. D recommendation. Recommends against screening in women who have had hysterectomy with removal of the cervix and who do not have a Hx of high-grade precancerous lesion or cervical cancer D recommendation. Recommends against screening for cervical cancer with HPV testing, alone or in combination with cytology, in women < 30 yr D recommendation. http://www.annals.org/content/early/2012/03/14/0003-4819-156-12-201206190-00424.full. Accessed 3/15/12 ACS/ASCCP/ASCP Cervical Cancer Screening Guidelines (2012) No woman should be screened every year <21 years: Cytology not recommended, even if sexually active 21-29 years: recommend screening w/ cytology alone every 3 yrs 30-65 years: cytology alone every 3 yrs OR cytology and HPV test every 5 yrs 65+ years: consider stopping Question A 46-year-old male who presents to establish care. He hasn t been to a doctor for many years, and has no significant PMH. He denies chest pain, SOB and is a non-smoker. Which routine tests are indicated? 1. HIV only 2. Fasting blood glucose only 3. Fasting blood glucose, ECG 4. Fasting blood glucose, lipid panel, HIV 5. Fasting blood glucose, lipid panel, HIV, and ECG Saslow D, et al. CA Cancer J Clin. 2012;pm id#: 22422631 USPSTF Screening for CHD with ECG Ethel Recommends against screening with resting or exercise electrocardiography (ECG) for prediction of coronary heart disease (CHD) events in asymptomatic adults at low risk for CHD events. Grade: D Recommendation. Concludes current evidence is insufficient to assess balance of benefits and harms of screening with resting or exercise ECG for prediction of CHD events in asymptomatic adults at intermediate or high risk for CHD events. Grade: I Statement. 79-year-old woman presents to establish care Hx and meds: DM on glyburide 5 mg BID Hypertension on HCTZ 12.5 mg daily Insomnia on amitriptyline 25 mg HS Osteoarthritis on diclofenac 75 mg BID http://www.uspreventiveservicestaskforce.org/uspstf/uspsacad.htm. Accessed August 4,2012 11
Question According to the revised Beers Criteria for potentially inappropriate medication, which is APPROPRIATE for this age group? 1. Glyburide 2. HCTZ 3. Amitriptyline 4. Diclofenac 5. Glyburide and HCTZ only 6. None of the above Updated Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults Avoiding use of inappropriate drugs is an effective, costsaving strategy to reduce PIMs. Beer s evidence-based criteria are divided into 3 categories: First category: PIMs and classes to avoid in older adults Anticholinergics Sedating antihistamines Alpha blockers Mineral oil Digoxin > 0.125 mg/d, regardless of level The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012. Updated Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults Second category: PIMs and classes to avoid in older adults with certain diseases/ syndromes that the drugs can exacerbate NSAIDs or COX-2 inhibitors in CHF Estrogen with urinary incontinence Alpha blockers in women Inhaled anticholinergics in men Updated Beers Criteria for Potentially Inappropriate Medication (PIM) Use in Older Adults Third category: Drugs to be used with caution in older adults Antipsychotics Vasodilators ASA in persons aged > 80 years The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. J Am Geriatr Soc. 2012. Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Updated Beers Criteria and Pocket Card available on the American Geriatric Society website: http://www.americangeriatrics.org/health_care_profess ionals/clinical_practice/clinical_guidelines_recommend ations/2012 Summary Many conditions can be prevented or identified early through routine primary care screening Disease prevention guidelines are frequently updated as new data emerge Clinicians should keep abreast of the latest evidencebased guidelines in order to provide preventive services to adult patients 12
Post-test Question 1 Post-test Question 2 Which of the following is TRUE? 1. Clinical breast examination (CBE) yields a low percentage of false positives 2. Self-breast examination (SBE) has been shown to save lives 3. USPSTF recommends against SBE 4. All of the above The USPSTF recommends ASA prophylaxis for prevention of MI and stroke in high-risk populations when the benefits exceed the risks. Which of the following is/are true? 1. Use in men aged 45-79 years to prevent MI 2. Use in women aged 45-79 years to prevent MI and stroke 3. Use in women aged 55-79 years to prevent stroke 4. 1 and 2 only 5. 1 and 3 only Post-test Question 3 According to the CDC, routine HIV screening is recommended in health care settings for: 1. Pregnant females only 2. Patients with high risk behaviors and/or history of sexually transmitted infection only 3. All adolescents and adults 4. 1 and 2 only Questions? 13