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Individual Health vs. Public Health

Individual Health vs. Public Health. If you’re the 1/1000, it’s a 100% for you. What absolute level of risk will society/an individual tolerate?. Population-based approach should account for safety, cost, availability. Medicare 1998 - 2001. Average Risk. FOBT Annually

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Individual Health vs. Public Health

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  1. Individual Health vs. Public Health • If you’re the 1/1000, it’s a 100% for you • What absolute level of risk will society/an individual tolerate? • Population-based approach should account for safety, cost, availability

  2. Medicare 1998 - 2001 Average Risk • FOBT Annually • Flex Sig q 4 yrs Screening Colonoscopy q 10 yrs High Risk • 1st degree relative w/adenoma or CA • FAP, HNPCC • Personal hx adenoma or CA or IBD Colonoscopy q 2 yrs Uncertainty in 50-64 age group

  3. Prevalence of FOBT/Sigmoidoscopy - 1997 AGE  50 FOBT - 1 YearFS/Procto - 5 Years Total M F Total M F 19.8 18.4 21.0 30.6 35.2 26.8 Behavioral Risk Factor Surveillance System Ries L, Cancer 2000;88:2398

  4. Provider Endorsement/Education • Risk Appropriate Screening • Public Acceptance • Cost/Efficiency • Help Physicians

  5. Provider Endorsement/Education • Risk Appropriate Screening • PublicAcceptance • Cost/Efficiency • Help Physicians

  6. Sigmoidoscopy Use in 1o Care Physicians in Allegheny County • Surveyed 400 physicians - 70% response rate • Median age 44; most full time clinicians Training: 44% rigid; 28% flexible Proficiency: 32% rigid; 22% flexible 49% equipment available Regularly refers or schedules pts: 34% Of those: 50%  5 pts/month Schoen RE, Weissfeld JL, Kuller LH; Preventive Medicine 1995

  7. Sigmoidoscopy Use in 1o Care Physicians in Allegheny County - Attitudes • 83% sigmoidoscopy impt • 88% agree with ACS rec’s Factors that influence decision to recommend: Cost - 62% Low prob finding a lesion - 52% Patient discomfort - 48%

  8. ACES:Physician Knowledge of Reimbursement for Screening FSG (N=95) - 1999

  9. Provider Endorsement Medical services are not baseball stadiums: “Build it and they will come” does NOT Apply

  10. Altering Physician Behavior - CRC Screening • Media Effect • Liability

  11. Pittsburgh Post-GazetteMay 20, 2000

  12. Provider Endorsement/Education • Risk Appropriate Screening • Public Acceptance • Cost/Efficiency • Help Physicians

  13. Satisfaction with Flexible Sigmoidoscopy (N=1221) General% Strongly Agree Very Satisfied with care 97.6 Pain/Discomfort (Didn’t) have a lot of pain 96.2 More comfortable than expected 68.5 (Didn’t) cause me great discomfort 78.1 Enthusiasm Willing to have another 93.1 Sigmoidoscopy will benefit my health 91.1 Strongly recommend to friends 74.9 Schoen. Arch Intl Med 2000;160:1790

  14. Provider Endorsement/Education • Risk Appropriate Screening • Public Acceptance • Cost/Efficient Delivery • Help Physicians

  15. NP’s and Sigmoidoscopy Back to Back FSG, N = 249 Schoenfeld. Gastro 1999;117:312 Per Polyp GI NP P Missed Adenomas Missed Adenomas  1 cm 21% (3/14) 0/4 20% (6/30) 2/10 .91 Per Patient .12 .43 12% 3% 6% 2% No polyp FS #1, Polyp FS #2 No adenoma FS #1, Adenoma FS #2

  16. Adherence with T3 Flexible Sigmoidoscopy 10,164 Available T3 Visit 8,804 (86.4%) Completed T3 FSG 1,360 Did not complete T3 FSG 688 Had T3 Visit 672 No T3 Visit Weissfeld. Cancer 2002 (in press)

  17. Sigmoidoscopy & Mammography • Need training for proficiency • Need Consistent Experience to Maintain Proficiency • Need Current Technology • Infection Control • High Through-Put • Standardize Reporting/Terminology • Follow outcome

  18. Provider Endorsement/Education • Risk Appropriate Screening • Public Acceptance • Cost/Efficiency • Help Physicians

  19. Systems Approach to Prevention • GAPS Goal setting regarding preventive care Assessment of existing routines Planning to modify existing routines Starting and maintaining improved preventive care system • PPP • Put Prevention Into Practice (AHRQ) Deitrich. Arch Family Med 1994;3:126

  20. Goals • Help physicians assess risk • Help physicians recommend action • Create visible, high quality, high volume, efficient delivery • Affordable • Accessible

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