Prevention and Wellness Care in General Medicine: What’s the Evidence?

1. Prevention and Wellness Care in General Medicine: What’s the Evidence? Donna E. Sweet, MD, AAHIVS, MACP Professor of Medicine The University of Kansas School of Medicine - Wichita

2. What In the World Do you Do??… What do you choose to address??

3. Preventive ServicesRecommended by theUSPSTF

9. All recommendation are linked to a letter grade that reflects:1) The magnitude of net benefit 2) The strength and certainty of the evidence supporting the provision of a specific preventive service. Recommendations of the U.S. Preventive Services Task Force

10. Magnitude/Certainty of Net Benefit and Letter Grades A & B: Recommend use C: Optional recommendation for use D: Recommend against use I: No recommendation; insufficient evidence

11. In my opinion… Top Issues

12. Lipids

13. Lipid Screening USPSTF: Summary of Recommendations 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 increased risk for coronary heart disease. Grade: “B” Recommendation.

14. Lipid Screening USPSTF: Summary of Recommendations Screening Women at Increased Risk: • Strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.  Grade: “A” Recommendation. • Recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Grade: “B” Recommendation.

15. Lipid Screening USPSTF: Summary of Recommendations Screening Young Men and All Women Not at Increased Risk: • The USPSTF 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 coronary heart disease. Grade: “C” Recommendation.

16. Lipid Screening Increased Risk Defined For this purpose, Increased Risk is defined as those with a presence of any of the following factors: • Diabetes. • Previous personal history of CHD or non-coronary atherosclerosis (e.g., abdominal aortic aneurysm, peripheral artery disease, carotid artery stenosis). • A family history of cardiovascular disease before age 50 in male relatives or age 60 in female relatives. • Tobacco use. • Hypertension. • Obesity (BMI >30).

17. NCEP ATPIII, AHA, and ADA: Recommended Lipid Goals * Non-HDL-C = Total cholesterol – HDL-C. • National Cholesterol Education Program. NIH Publication No. 02-5215; September 2002. • Mosca L et al. Circulation. 2007. • American Diabetes Association. Diabetes Care. 2008;30:S4-S41. • Grundy SM et al. Circulation. 2004;110:227-239.

18. Hypertension

19. Hypertension in the U.S. • Responsible fore 35% of all CV events (MI/CVA) • 49% of all episodes of heart failure • 34% of all premature deaths • Those with hypertension have 2-4 X more risk for stroke, MI, heart failure and PVD than those without hypertension

20. HTN • HTN Can be effectively detected through office measurement of BP • Treatment of elevated BP reduces CV events • Magnitude of risk reduction depends on the degree of HTN and presence of other CV risk factors • Studies find no important adverse effects in those screened and labeled as Hypertensive

21. Hypertension Screening USPSTF: Summary of Recommendations The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults aged 18 and older. Grade: “A” Recommendation. http://www.ahrq.gov/clinic/pocketgd09/pocketgd09.pdf

22. Hypertension Screening How Often to Measure? • Measure every 2 years if normal • Measure every 1 year if borderline blood pressure

23. Hypertension Screening Clinical Considerations • Clinicians should consider the patient’s overall cardiovascular risk profile when making treatment decisions including: • smoking • diabetes • abnormal blood lipid • values • age • sex • sedentary lifestyle • obesity http://www.ahrq.gov/clinic/pocketgd09/pocketgd09.pdf

24. Treatment Does Reduce BP and the Incidence of CV Events The degrees of risk reduction depends on patients levels and duration of elevation, their other risks for CVD and the choice of anti-hypertensive treatment

25. Hypertension Screening Is It Done? • Recent NHANES III (National Health and Nutrition Exam Survey) shows: • 31% of HTN Americans are unaware they have HTN • 17% are aware but not in treatment • 29% are treated, but not controlled

26. Diabetes Screening

27. Ann Intern Med 2008;148:846-854.

28. The USPSTF found convincing evidence that available screening tests accurately detect type 2 diabetes during an early, asymptomatic phase. Detection: Ann Intern Med 2008;148:846-854.

29. Diabetes ScreeningUSPSTF: Summary of Recommendations Summary of Recommendations: • The USPSTF 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. • The USPSTF 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. Ann Intern Med 2008;148:846-854.

30. Screening for Type 2 Diabetes Mellitus: Update of 2003 Systematic Evidence Review for the U.S. Preventive Services Task Force • Conclusion: • Persons with hypertension probably benefit from screening, because blood pressure targets for persons with diabetes are lower than those for persons without diabetes. • Intensive lifestyle and pharmacotherapeutic interventions reduce the progression of prediabetes to diabetes, • Few data examine the effect of these interventions on long-term health outcomes. Evidence Syntheses, No. 61. Investigators: Susan L Norris, MD, MPH, Devan Kansagara, MD, Christina Bougatsos, BS, Peggy Nygren, MA, and Rongwei Fu, PhD. Oregon Evidence-based Practice Center Rockville (MD): Agency for Healthcare Research and Quality (US); June 2008. PMID: 20722158. Publication No.: 08-05116-EF-1

31. Osteoporosis in Postmenopausal Women

32. USPSTF: Osteoporosis Screening Guidelines Summary of Recommendations • The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures. Grade: B Recommendation. • The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures.Grade: C Recommendation.

33. Osteoporosis Guidelines

34. Osteoporosis Guidelines

35. Summary • Osteoporosis screening and treatment is evidence-based in older adults (women > men) • DEXA is best validated tool • Multiple medications are effective • Current choice should be individualized • Many questions remain-based on current literature • Risk factors and risk groups • Frequency of measurement • Duration of treatment

36. HIV Testing

37. CDC Recommends Routine HIV Testing… Sept. 21, 2006 – The CDC recommends routine screening for persons aged 13-64 years and pregnant women and retesting at least annually for all persons likely to be at high risk for HIV

38. USPSTF HIV Guidelines All adolescents and adults at increased risk for HIV infection.  Rating: 'A' All pregnant women for HIV.   Rating:  'A' Routine screening adolescents and Adults who are not at increased risk for HIV infection.   Rating:  'C'

39. Awareness of HIV Status among Persons with HIV, United States At the end of 2006, an estimated: • 1,106,400 persons in the United States were living with HIV infection • (95% confidence interval 1,056,400 - 1,156,400) • 21% of those are undiagnosed. • 56,300 people were newly infected with HIV in 2006 (the most recent year that data are available) http://www.cdc.gov/hiv/topics/surveillance/basic.htm#hivaidsage

40. Late HIV Testing, 1996-2005 281,421 received diagnosis of HIV • 38.3% had ADIS diagnosis within 1 year of HIV diagnosis • 6.7% between 1-3 years 45% with AIDS Diagnosis in <3 years

41. Those Most Likely to Test Late Include… • Heterosexuals • Those with a low-perceived risk of HIV • People aged 18-29 • African-Americans and Latinos

42. Mortality and HAART Use Over Time HIV Outpatient Study, CDC, 1994-2003 14 0.9 0.8 12 0.7 10 0.6 Patients on HAART 8 Deaths per 100 PY 0.5 Patients on HAART Deaths per 100 PY 0.4 6 0.3 4 0.2 2 0.1 0 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 Year

43. PACTG 076 & USPHS ZDV Recs CDC HIV screening Recs ~95% reduction

44. Testing Changes Behavior

45. Testing Changes Behavior

46. Written Consent is No Longer Required in the VA for HIV Testing Diagnosis of HIV testing in VA requires that a patient be provided with written educational materials and give specific verbal informed consent to HIV testing. The patient's verbal consent should be documented in the patient's electronic health record. (August 2009)

47. Summary of Review of Evidence • HIV meets the criteria for screening, and effective treatment is available • Many patients with HIV visit healthcare providers but their infection goes undetected • People decrease their risk behaviors when they find out they are infected with HIV • HIV screening in healthcare settings is cost-effective • Opt-out screening increases testing rates

48. Cancer Screening

49. What We Tell Our Patients…

50. Breast Cancer Screening