Health care dana bartlett, bsn, msn, ma, cspi
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P REVENTIVE
HEALTH CARE DANA BARTLETT, BSN, MSN, MA, CSPI Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 20 years of as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, written textbook chapters, and done editing and reviewing for publishers such as Elsevire, Lippincott, and Thieme. He has written widely on the subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing and mentoring nurses, emergency medical residents and pharmacy students. ABSTRACT Screening is an effective method for detecting and preventing acute and chronic diseases. In the United States healthcare tends to be provided after someone has become unwell and medical attention is sought. Poor health habits play a large part in the pathogenesis and progression of many common, chronic diseases. Conversely, healthy habits are very effective at preventing many diseases. The common causes of chronic disease and prevention are discussed with a primary focus on the role of health professionals to provide preventive healthcare and to educate patients to recognize risk factors and to avoid a chronic disease. Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 4 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 0.5 hours (30 minutes). Statement of Learning Need Health professionals need to know the recommended screening tests that may lead to early detection or prevention of medical problems that cause morbidity and mortality if left undiagnosed and untreated. Course Purpose To provide health clinicians with up-to-date knowledge of the current recommendations for preventive health screening tests and techniques, as well as recommendations in lifestyle changes that will promote preventive healthcare. Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion)
Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course.
Introduction Screening is an effective method for detecting and preventing acute and chronic diseases. Instead, healthcare in the United States is typically provided after someone has become unwell. People generally seek a physician or medical attention when sick and not before. Additionally, poor health habits play a large part in the pathogenesis and progression of many common, chronic diseases. Often people view illnesses, such as atherosclerosis, diabetes, hypertension, or obesity, as acute and unexpected rather than conditions that can be prevented through screening and follow-up with their health clinician. Collaboration In Preventative Medicine In many cases, the signs and symptoms of chronic medical problems that cause morbidity and mortality in most Americans are just confirmation of an illness that has been present for many years. For example, approximately 34% of the adults in the U.S., are obese. Obesity is a major risk factor for the development of type 2 diabetes. The primary cause of obesity is harmful patterns of food intake and energy expenditure; too many calories and not enough exercise. Studies have clearly shown that type 2 diabetes can be prevented by weight loss, dietary changes, and exercise. Healthy habits are very effective at preventing many other diseases, as well. Preventative medicine involves a collaborative effort by the healthcare community and individual patients. These include the following local healthcare and individual efforts to promote health prevention.
Screening For Disease Detection And Prevention Screening is an effective method for detecting and preventing acute and chronic diseases. However, it is important to remember the following points when broad screening guidelines are used for a heterogeneous population.
In addition, screening is most effective when a disease or disorder 1) is an important public health problem, 2) has an early, asymptomatic phase, 3) has an effective screening test that can accurately identify people who will benefit from treatment, 4) has an available treatment, and 5) involves screening tests with benefits that outweigh the risks. Screening tests should be simple to perform, cost-effective, and easy to interpret and they must be sensitive and specific. The primary source of information used in this learning module is the U.S. Preventive Services Task Force’s (USPSTF) Guide to Clinical Preventive Services 2014. The USPSTF Guide discusses many diseases and disorders. This module will for the most part only discuss ones for which the Guide provides screening recommendations but some exceptions have been made. The Guide to Clinical Preventive Services 2014 is available online.1 Alcohol Use Disorder And Addiction The unhealthy use of alcohol by Americans is endemic. The 2014 National Survey on Drug Use and Health noted that 60.9 million Americans reported binge alcohol use in the past month and 16.3 million reported heavy drinking in the past month.2 Over 17 million American adults have an alcohol use disorder, and the twelve-month and lifetime prevalence of alcohol use disorder has been estimated to be 13.9% and 29.1%, respectively.3 The unhealthy use of alcohol is often unrecognized in the primary care setting and studies support screening of the population for unhealthy alcohol use.4 Who should be screened for alcohol use, when people should be screened, and how often screening should be done depends on factors such as age and an individual’s experience with alcohol and/or drugs; and, different screening guidelines are available. The USPSTF recommendations are shown below.5 USPSTF Recommendations for Screening for Alcohol Misuse
The AUDIT and the Audit-C screening tools are accurate and well validated, widely accepted and used in primary care settings for alcohol misuse. These screening tools have been shown to be useful in identifying hazardous drinking and to help initiate behavioral changes in patients who engage in harmful or hazardous drinking.6-8 The Alcohol Use Disorders Identification Test – AUDIT In the AUDIT, the answers are scored as: 0 for never and 1-4 for ascending frequency of use. Questions 9 and 10 are scored as 0, 2, and 4 for ascending frequency. A score of ≥8 is associated with harmful or hazardous drinking; and, a score of ≥13 in women and ≥ 15 or more in men is likely to indicate alcohol dependence. The healthcare professional will ask the following questions when using the AUDIT screening tool.9
Alcohol Use Disorders Identification Test-Consumption - AUDIT-C For men a score of ≥ 4 is considered positive. In women, a score of ≥ 3 or more is considered positive. Generally, the higher the AUDIT-C score the more likely drinking is affecting health and safety. The questions are listed in the table below.10
The four question CAGE screening test for alcohol use is familiar to many healthcare professionals. This test asks the following:
opener) to steady your nerves or get rid of a hangover? The CAGE test is not recommended as a screening tool for alcohol use as it is not highly sensitive or specific.4 Tobacco Or Nicotine Use And Addiction Tobacco use and its correlating problems are enormous public health concerns. Tobacco use is the leading cause of preventable death in the United States. The number of Americans who smoke has decreased by more than one-half in the past 50 years, but tobacco and cigarette smoking are still the primary causes of, or contributors to certain cancers, heart disease, common respiratory diseases, and many other acute and chronic pathology. A 2014 report from the Surgeon General noted that tobacco and smoking have “... killed ten times the number of Americans who died in all of our nation’s wars combined.”125 It has also been proven that second-hand smoke is a significant cause of serious acute and chronic heath problems in children and adults. Second-hand smoke (also called side stream smoke) is very dangerous. Second-hand smoke is smoke that is produced from burning tobacco or smoke that has been exhaled by someone using a cigarette and there is no safe level of second-hand smoke. Smoking and tobacco use are still common in the United States. Statistics from the Centers of Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Association (SAMHSA) are listed in the tables below.126-128 Smoking and Tobacco Use in the United States
The CDC as well as several other sources have published the health effects of second-hand smoke, as well as recommendations to recognize the potential and ways to avoid it.129-130 Health Effects of Second-Hand Smoke
Second-hand smoke has been estimated to increase the relative risk of developing chronic obstructive pulmonary disease (COPD), stroke, and ischemic heart disease by 1.66, 1.35, and 1.22, respectively.131 Children are especially vulnerable to the harmful effects of second-hand smoke and prenatal exposure to second-hand smoke has been identified as a risk factor for developing asthma.132 Also, close proximity is not necessary for exposure to second-hand smoke; many studies have shown that living in a multi-residential building can expose non-smokers to second-hand smoke.133 Smoking Cessation Interventions There are interventions that can prevent people from smoking and there are behavioral counseling techniques and medications that have been shown to be effective at helping smokers quit. But nicotine, the primary active component of cigarette smoke, is strongly addictive and since tobacco is legal the prevention of smoking and smoking cessation are considerable challenges. Behavioral-based interventions that can be helpful as aids to smoking cessation include direct provider to patient interaction, group therapy, specialized clinics, self-help intervention using educational resources like printed material or videos, web-based and text-based resources, and telephone applications and telephone contact counseling have all been successfully used. The specific intervention chosen will depend on availability, cost, and patient preference. Important aspects of medication and behavioral interventions as aids to smoking cessation that can increase the chance of success are discussed below.134-138 Pharmacotherapy Pharmacotherapy (with or without behavioral interventions) can significantly influence smoking cessation rates in adults. There are three drugs that are approved by the Food and Administration (FDA) for assisting patients with smoking cessation: bupropion, nicotine replacement therapy (NRT), and varenicline. Alternative approaches to support patients during their course of care in a smoking cessation program have been reported to provide value and good results of quitting smoking, such as acupuncture, hypnosis and e-cigarettes. Each year approximately two out of every three smokers will try and quit but the majority will be unsuccessful.139,140 There are many reasons why smokers find it difficult to quit and difficult to maintain abstinence, including but not limited to: side effects of cessation such as cravings and withdrawal, weight gain, mood changes, poor social support, access problems for smoking cessation programs, poor preparation for quitting, and incorrect use of medications. These issues, along with the addictive properties of nicotine, clearly present smokers with a considerable challenge when they try to quit and to cease the smoking habit long-term. Screening and Prevention Through the Electronic Health Record Improving tobacco use screening and exposure to second-hand smoke has become an area of focus for many electronic health records (EHRs) with smoking prevention and cessation patient teaching tools built into the admission process. Most clinic and hospital providers will screen for tobacco use, such as asking patients how many years or how much they smoke each day. A patient who reports a smoking history may be offered educational handouts that promote health prevention and resources for smoking cessation; several examples are listed below.
Lung Cancer Lung cancer is the most common cause of death from cancer in American adults.73 The National Cancer Institute estimates that in 2016 there will 224,390 new cases of lung cancer and that lung cancer will account for more than one-fourth of all cancer deaths.74 Cigarette smoking is the primary cause of lung cancer. Most lung cancers are discovered when they are in the late stage. Targeted screening is advised. The USPSTF and the American Cancer Society recommends that asymptomatic adults aged 55 to 80 years who have a 30 pack-year history of smoking and currently smoke or have quit smoking within the past 15 years should have annual screening with low dose computed tomography.5,75 The 2014 Clinical Guidelines state: “Annual screening for lung cancer with low-dose computed tomography is of moderate net benefit in asymptomatic persons who are at high risk for lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking.”5 Breast Cancer Breast cancer is the most common cancer in women, excluding skin cancer. In 2013, 230,815 women and 2109 men were diagnosed as having breast cancer. That same year, 40,860 women and 464 men died from breast cancer in the United States.11 Risk factors for breast cancer include age, age at first live childbirth, age at menarche, alcohol use, body mass index, breast density, diet, estrogen and progesterone use, menopause status or age, number of first-degree relatives with breast cancer, personal history of ductal or lobular carcinoma in situ, personal history of breast biopsy, physical activity, and race/ethnicity.5 Screening for breast cancer includes screening for neoplasms and screening for genetic susceptibility to breast cancer. American Cancer Society Screening Recommendations The American Cancer Society’s breast cancer screening recommendations are outlined below.12
USPSTF Screening Recommendations The USPSTF recommendations for breast cancer screening are reviewed in this section.5 Women aged 40-49 should be considered for a biennial mammogram. The decision to do a mammogram should be made on an individual basis, depending on the woman’s circumstances and values. Women aged 50-74 should have a mammogram every two years. The USPSTF does not include a recommendation for the use of mammograms in women age 75 or older. The USPSTF recommendations apply to women aged ≥40 years that are not at increased risk by virtue of a known genetic mutation or history of chest radiation. Increasing age is the most important risk factor for most women. There is convincing evidence that using mammography to screen for breast cancer reduces overall mortality from breast cancer. This reduction in risk becomes increased for women aged 50 to 74 years. Harms of screening include psychological effect, additional medical visits, imaging, and biopsies in women without cancer, inconvenience due to false-positive screening results, harms of unnecessary treatment, and radiation exposure. The level of harm appears to be moderate for each age group. USPSTF Recommendations for Genetic Testing The population for screening is asymptomatic women who have not been diagnosed with BRCA-related cancer. Genetic testing for breast cancer is recommended for women whose family history may be associated with an increased risk for potentially harmful breast cancer mutations.5 Genetic risk assessment and breast cancer mutation testing involves identification of women who may be at increased risk for potentially harmful mutations, genetic counseling, and genetic testing of selected high-risk women when indicated. If the screening tests are positive women should receive genetic counseling and, if indicated after counseling, breast cancer mutation testing. Tests for breast cancer mutations are highly sensitive and specific for known mutations, but interpretation of results is complex and generally requires post-test counseling. In women whose family history is associated with an increased risk for potentially harmful BRCA mutations, the net benefit of genetic testing and early intervention is moderate. Interventions in women who are BRCA mutation carriers include earlier, more frequent, or intensive cancer screening, use of risk-reducing medications such as tamoxifen or raloxifene, and risk-reducing surgery such as mastectomy or salpingo-oophorectomy. Genetic counseling and testing for breast cancer mutations is not recommended for women whose family history is not associated with an increased risk for potentially harmful breast cancer mutations. Cervical Cancer In 2103, 11,955 women in the United States were diagnosed with cervical cancer and 4,217 women died from the disease.13 Risk factors for cervical cancer include cigarette smoking, early onset of sexual activity, infection with high-risk strains of human papilloma virus (HPV), immunosuppression, multiple sex partners, oral contraceptive use, and persistent HPV infections.14 Cervical cancer screening decreases the incidence and mortality of cervical cancer. In the U.S., it has been estimated that screening has decreased mortality from this disease by 70%,15 and “… reviews and meta-analyses of observational studies provide consistent and compelling evidence that screening leads to a decrease in incidence and mortality from cervical cancer.”14 The harmful effects of cervical cancer screening include cost, psychosocial consequences, and discomfort. In addition, screening may lead to unneeded diagnostic and/or treatment procedures (which have risks), particularly in women <21 years in whom HPV testing may detect abnormalities that are transient.14 The USPSTF recommendations for cervical cancer screening are listed below. These recommendations are identical to the recommendations of the American Congress of Obstetricians and Gynecologists.16 USPSTF Screening Recommendations The USPSTF recommendations for cervical cancer screening are highlighted below.5
Prostate Cancer Prostate cancer is the most commonly diagnosed cancer in men.81 Each year more than 200,000 men in the United States are diagnosed with prostate cancer and it is the second leading cause of death from cancer in men in the United States.81,82 Risks for prostate cancer include age, African American ethnicity, and a family history of the disease. The need for and the usefulness of screening for prostate cancer is a complex and controversial topic and a full discussion of the issue is beyond the scope of this module. Prostate cancer is very common but death from this disease is relatively uncommon. The death rate of men who have prostate cancer has been estimated to be 2.9% and the disease progresses so slowly that most men with prostate cancer die from other causes.83 Screening for prostate cancer by measuring prostate-specific antigen (PSA) and digital rectal examination can reduce the mortality rate prostate cancer but this reduction is very small and does not outweigh the risks.83 The USPSTF does not recommend routine screening for prostate cancer and the 2014 Guidelines state: “There is convincing evidence that PSA-based screening programs result in the detection of many cases of asymptomatic prostate cancer, and that a substantial percentage of men who have asymptomatic cancer detected by PSA screening have a tumor that either will not progress or will progress so slowly that it would have remained asymptomatic for the man’s lifetime (i.e., PSA-based screening results in considerable over-diagnosis).”5 The 2014 Guidelines further state that, “The reduction in prostate cancer mortality 10 to 14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55 to 69 years [and the] benefits of PSA-based screening for prostate cancer do not outweigh the harms.”5 The American Urological Association (AUA) and the American Cancer Society (ACS) advise that the decision to screen or not screen should be made by the patient and his primary care physician after a discussion of the risks and benefits.82,83 Skin Cancer Skin cancer is divided into two categories, non-melanoma and melanoma. Basal cell carcinoma and squamous cell carcinoma are the two non-melanoma skin cancers. These cancers are not usually reported to cancer registries so their true incidence and prevalence are not known:84,85 They account for approximately 97% of all skin cancers but the incidences of morbidity and mortality from these neoplasms are very small.86,87 Malignant melanoma is much less common than the non-melanoma skin cancers but it is much more serious. Malignant melanoma can metastasize to any organ (most often the skin and lymph nodes) and the incidence of malignant melanoma and deaths from this cancer have been increasing for years.88 Risk factors for non-melanoma and melanoma skin cancer include (but are not limited to: 1) Caucasian ethnicity, 2) exposure to sunlight, 3) indoor tanning, 4) immunosuppression, 5) fair skin, 6) family history of melanoma, 7) atypical nevi, 8) advanced age, 9) psoralen, and 10) UVA light therapy. Unfortunately, there does not seem to be any benefit from universal screening for skin cancer.5,87,89 The USPSTF does not recommend routine screening for skin cancer, noting that there is “… insufficient evidence to assess the balance of benefits and harms of whole body skin examination by a clinician or patient….“5 Clinicians and patients should remember that skin lesions should be considered potentially malignant if they are rapidly changing or if A, B, C, D is present, as shown below: Asymmetry Border irregularity Color variability Diameter > 6 mm Colorectal Cancer In 2103, 136,119 people in the U.S., were diagnosed with colorectal cancer and 51,813 people in the U.S., died from colorectal cancer.17 Colorectal cancer is the second leading cause of death from cancer in the U.S., and approximately one of three people diagnosed with the disease will die five years after it is discovered.18 Risk factors for colorectal cancer include a family history for colorectal cancer, African American ethnic status, alcohol use, cigarette smoking, Crohn’s disease, diabetes mellitus and insulin resistance, diet, inflammatory bowel disease, obesity, and radiation therapy for abdominal cancer. There is unequivocal evidence that colorectal cancer screening and removal of pre-malignant adenomas can decrease the incidence and mortality of colorectal cancer.5,18,19 The specific risks of the invasive screening procedures, of colonoscopy and sigmoidoscopy, include infection, adverse effects from sedating drugs used during the procedures, perforation and bleeding. Major adverse effects after flexible sigmoidoscopy and colonoscopy examinations are very unusual, occurring is less than 1% of all patients.20-22 The risk of contrast enemas and CT colonography is exposure to radiation. Several methods are used to detect colorectal cancer. An individual’s risk profile will determine which one is appropriate. USPSTF Screening Recommendations The USPSTF recommendations for colorectal cancer screening are highlighted below.
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