Define shared decision making (or informed decision making) and describe the goals for the patient according to the USPSTF.
patient and clinician exchange information both contribute to the decision-making process, conclude about a plan of action
Goals
- Understand the risk/seriousness of the illness to be prevented
- Understand the preventive services, including the harms, benefits, alternative options, and uncertainties
- Benefit vs harm (for individual)
- Make decision based on comfort level
Discuss the benefits of the shared decision-making model and further how this may help to improve patient outcomes.
- Higher satisfaction
- less conflict in making decisions
- Autonomy (pt)
- Trust
- Increase adherence to care plans
- Realistic understanding about the harms and benefits of preventive care
- Improve patient outcomes: early detection and intervention, assess at risk populations
Indicate the barriers to shared decision making and discuss ways in which the clinician may attempt to overcome these barriers.
- Pt cant understand complex medical = patient education
- Doc not sure about evidence for benefit = evidence-based clinic protocols
- Limited time = (nurses) decision aids for review while awaiting the clinician
- Lack of reimbursement = screening fairs or non-profit organizations
Explain the rationale for offering or not offering screening laboratory tests.
- Pt want/deserve info
- Our responsibility to offer only if theres reasonable probability of more benefit than harm
Low value services
- Unacceptably high harm
- Modest/no benefit (min/no clinical benefit, small number could benefit)
- Uncertain benefit (not enough evidence, unfocused target)
Harms of preventive service
- Harm unacceptably high (HRT = out of favor, PCR = over treatment)
- Over dx/over tx
Blood Glucose
Patient Population
- All adults 40-70 (overweight or obese)
- Higher risk for developing diabetes (early screen)
Family Hx
Personal hx of gestational diabetes or polycystic ovary syndrome
Recommendation
- Overweight or obese or have risk factors→ should be routinely offered as part of periodic health screening
- Normal test = Intervals of every 3 years
Types of Screening tests
Fasting Plasma Glucose (FPG) test
Total Cholesterol and Lipid Profiles
Patient Population
- Adults aged 40 to 75 years
- 21 to 39 years, clincians use clinical judgement
Recommendations
- All adults 20 years and older should have fasting lipid profile At least every 5 years as part of assessment of CVD risk
- Shorter intervals in those closer to CVD risk
- Longer intervals with no increased CVD risk ppl
Types of Screening tests
Fasting lipid profile: total cholesterol, LDL-C (bad fat)
Human Immunodeficiency Virus
Patient Population
- Adolescents and adults 15-65 years (sexually active)
- Those in high risk settings
(STI clinics, Correctional facilities, Homeless shelters)
- Universal screening to all pregnant women in 1st trimester
- Rapid screening for women in labor with unknown HIV status
Recommendations
- Annually, counseling = pretest and posttest, STI prevention
- Increased risk
MSM after 1975
M/F having sex with multiple partners, unprotected
past/present injection drug users
Prostitue
Partners with HIV infected, IV drug users, bisexual
Persons being treated for STIs
History of blood transfusion between 1978 and 1985
Types of screening test
- ELISA screening
- Followed by Western Blot for confirmation
Syphilis
Patient Population
- MSM, or engage in high-risk sexual behaviors = every 3 months screening
- Prostitue
- Persons who exchange sex for drugs
- Adults in correctional facilities
Recommendations
- All asymptomatic high-risk adolescents and non-pregnant adults
- MSM or persons living with HIV
- All pregnant women-first prenatal visit
- 3rd trimester and at birth for high risk women
Types of screening tests
- Venereal disease research laboratory (VDRL) or rapid plasma reagin (RPR) for screening
- Antibody absorption assay (FTA-ABS) or Treponema pallidum particle agglutination (TP-PA) for confirmation
Prostate Cancer Screening With Prostate-Specific Antigen
Patient Population and Recommendations
- Average-risk men 50-70 years with at least a 10-year life expectancy
- High-risk men between 40-70 years (AA or men with first-degree relative with prostate cancer high risk at age 40)
Types of screening tests
- Prostate-specific antigen (PSA) and digital rectal examination (DRE)
Have to do both screens
- Confirmation by prostate biopsy
Risk versus benefits
Pap Smears
Patient population
- women aged 21 to 65yrs (intact cervix)
- Age 30-65 who have HPV testing along with cytology every 5 years
Recommendations
- High risk for HPV and cervical dysplasia = annual screening
(Documented HPV infections, hx of abnormal pap smears, early onset of intercourse, large number of sexual partners, cigarette smoking)
- Low risk for cervical cancer every 2-3 years
- Women with adequate screening and normal smears can stop at 65
Types of screening tests
- Inspect cervix and external os for ulcerations, nodules, masses, bleeding, leukoplakia, or discharge
- Complete pap test = collection of specimens from the endocervical canal and the ectocervix
- Reports the presence of cellular atypia, dysplasia, or carcinoma
Screening for Gonorrhea and Chlamydia
Patient population
- All sexually active women 24 years and younger, women at high risk, pregnant women
Recommendations
- Screening of nonpregnant women- annually
- Screening of pregnant women in first trimester, followed by repeat screening in third trimester for those at high risk
- Men- adolescent and young adult males who have sex with males who engage in high-risk sexual behaviors or settings.
Types of screening tests
- Culture, nucleic acid amplification tests, and nucleic acid hybridization tests
- Endocervical canal specimen or urine specimen/urethral swab in women and urethral swabs/urine specimen in men
- Based on pt sexual behaviors can also swab: posterior nasopharynx and tonsillar arches, anal samples
Colorectal Cancer Screening
Patient population
- All adults 50 to 75 years of age
Types of screening tests
- Fecal occult blood test (FOBT) every year
- Flexible Sigmoidoscopy every 5 years
- Combination of 1. And 2.
- Colonoscopy every 10 years
More often for pts: with first degree family hx of CRC, or hereditary polyposis syndromes
- Double-contrast barium enema every 5 years
Rarely used for screening
Fecal Occult Blood Testing
Patient population
- Screening for microscopic blood in stool
Types of screening tests
- FOBT (performed in exam room with DRE-card with guaiac)
- Home test (3 cards with guaiac, collect 2 samples from 3 separate consecutive stool samples, mail the cards to office/lab)
Sigmoidoscopy and Colonoscopy
- Endoscopy (principle screening for adenomatous polyps and CRC)
- Detect and remove precancerous polyps
Sigmoidoscopes
- measure 60 to 65cm in length
- inspect distal 3rd of colon (colorectal malignancies most likely occur here)
- Anxiolytics or sedative can be prescribed day of (reduce anxiety)
CRC mortality by 60%
Colonscopy
- Can inspect entire colon to cecum (conscious sedation)
- CRC mortality by 60%
Preparation = bowel evacuation 24-38hrs before
Mammography
Patient populations
- All women 50-74 years, biennial mammography
- Discuss the risks and benefits of screening for W 40 to 50 years
- Screening offers limited value to those with <10 yr life expectancy
Recommendations
- Clinicians should screen if pts have increased risk for potentially harmful mutations; refer them for genetic counseling= BRCA mutation
Tuberculin Skin Testing
Patient populations
Individuals at high risk for TB
- Persons infected with HIV
- Close contacts of persons known or suspected to have TB
- Persons with medical conditions that increase the risk of infection
(Immunosuppressed)
Types of Screening tests
- Purified protein derivative (PPD) called the Mantoux test (0.1%)
Pt return to office 48 to 72 hours, arythema alone is insignificant, measure size of induration
- Quantiferon-TB Gold blood test
Abdominal Ultrasonography for Abdominal Aortic Aneurysm
Patient population
- Males between ages 65 and 75 years, with current or past hx of smoking
Recommendations
- Role of clinician in AAA screening is to identify pts due, refer to ultrasonography facility, verify pt obtains studies, and ensure proper interpretation of results.
Types of screening tests
- Ultrasoun- AAA present with diameter >3 cm
Indicate glucose measurements that are consistent with prediabetes and diagnostic for diabetes mellitus
A1C test Fasting blood sugar Glucose tolerance Random blood sugar
Diabetic <6.5% 126mg/dL (more) 200mg/dL (more). 200mg/dL ( or more)
Predaibete. 5.7-6.4%. 100-125mg/dL 140-199mg/dL N/A
Normal below 5.7% 99mg/dL (less) 140mg/dL (less) N/A
Indicate the recommendations by the American Diabetes Association (ADA) for optimal lipid levels in adults with diabetes mellitus.
- A1C is <7.0%
- Preprandial capillary plasma glucose is 80-130mg/dL
- Peak postprandial is <180mg/dL
Define metabolic syndrome and further describe the diagnostic criteria
Metabolic syndrome: a constellation of abnormalities caused by insulin resistance accompanying further excessive adipose deposition and function.
Pt has at least 3 of the following:
- Fasting glucose >100 mg/dL (or receiving drug therapy for hyperglycemia)
- Waist measurement > 35 in W, >40 in M
- Elevated BP or receiving Tx for hypertension
- Elevated triglycerides or receiving Tx for hypertriglycerdemia
- Low HDL-C: <40 mg/dL in M, <50 mg/dL in W
(“Heavenly” fat- this is the good fat you want in the body)
List the seven steps in responding to an abnormal screening result.
- Verifying the accuracy of the results
- Interpreting the result’s significance in the context of the individual pt
- Applying the result to the diagnostic criteria for the target condition
- Developing a plan for assessment of other risk factors for the target condition
- Setting Tx goals
- Recommending a treatment plan
- Implementing longitudinal follow-up and monitoring
Laboratory screening tests, history and physical exam performed on asymptomatic for?
- Early detection
- Risk factor
- Preclinical disease
What to consider with laboratory screening tests
- USPSTF recommendations
- AAFP (academy of family physicians)
- Cost
- Access to care
- Insurance coverage
- Sensitivity, Specificity, Positive prediction value of screening (PPV)
Screening vs Confirmatory
- Screening = detect early disease or dysfunction before person normally seek med care
- Diagnostic = test that confirm/rule out med condition in person w/concerning sxs or out of range screening test
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Images of Health, Models of Health Promotion, and the Physician Assistant Role12
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Risk Assessment11
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Healthcare Epidemiology15
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Social Determinants of Health6
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Role of Public Health1
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The History & Physical as related to Health Promotion/ Disease Prevention6
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Oral Health4
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Laboratory Screening24
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Cancer Prevention in Adults & Chemoprophylaxis7
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Nutrition and Weight Management in Preventive Medicine13
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Exercise in Preventive Medicine12
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Principles of Behavior Change & Motivational Interviewing0
