Topics in Prevention:
Feb 2022

Delivering Preventive Services -
Opportunistic vs. Planned

Audience Participation:

• In your breakout groups you have 7 minutes...

• develop at least THREE statements (thoughts) about the question of whether we...

  • schedule routine preventive services visits vs.

  • just try to meet prevention guidelines "on the fly."

When you return, type them into the chat.

Prevention visits:

• Prenatal care visits

• Well-child visits

• Sports physicals

• Medicare Annual Wellness visits

• "work physicals", "insurance physicals", "executive physicals"

• Well-woman exams?

• Routine health maintenance visits?

What is important in a prevention visit?

• 17 trials, 15 of which reported outcome data (251,891 participants).

• Risk of bias was generally low for our primary outcomes.

• total mortality (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.97 to 1.03; 11 trials; 233,298 participants and 21,535 deaths; high certainty evidence, I² = 0%),

• cancer mortality (RR 1.01, 95% CI 0.92 to 1.12; 8 trials; 139,290 participants and 3663 deaths; high certainty evidence, I² = 33%)

• cardiovascular mortality (RR 1.05, 95% CI 0.94 to 1.16; 9 trials; 170,227 participants and 6237 deaths; moderate certainty evidence; I² = 65%).

• fatal and non-fatal ischemic heart disease (RR 0.98, 95% CI 0.94 to 1.03; 4 trials; 164,881 persons, 10,325 events; high certainty evidence; I² = 11%)

• fatal and non-fatal stroke (RR 1.05 95% CI 0.95 to 1.17; 3 trials; 107,421 persons, 4543 events; moderate certainty evidence, I² = 53%).

• authors:

  • one reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.

  • those at high risk of developing disease may not attend general health checks when invited or may not follow suggested tests and treatments.

• me:

  • was this a standard intervention?

Low value care and opportunity cost

Things Dietitians Would Love for Primary Care Doctors to Know

Lifestyle Preventive Interventions & Actual Causes of Death

What is the point of clinical prevention?

• Put your answers in the chat...

Clinical prevention prevents:

• Premature death

• Morbidity

• Decreased quality of life

• Disability

  • DALY (Dr. Morrow's father)

  • QALY

In 1990...

The most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400000 deaths), diet and activity patterns (300 000), alcohol (100 000), microbial agents (90 000), toxic agents (60 000), firearms (35 000), sexual behavior (30 000), motor vehicles (25 000), and illicit use of drugs (20 000). Socioeconomic status and access to medical care are also important contributors, but difficult to quantify independent of the other factors cited.

Then in 2000...

Smoking and Alcohol

• USPSHS Tobacco Cessation Guideline - update 2008

• Unhealthy Alcohol Use - Virginia

Q: Why do we care about government diet and exercise guidelines?

A: Most of the evidence in the USPSTF recommendations is based on these.

Common Interventions:

• health.gov recommendations for diet and exercise

• Intensive

  • 26-52 contact hours over 1 years for childhood obesity

  • 12 contacts for 1/2 hour each over 1 year for adults with CVD risk

  • 12 contacts for adults, pregnancy, obesity

• Multicomponent

  • motivational interviewing, goal-setting, self-monitoring, addressing barriers/problem solving, counseling, mailings/educational materials

  • other-than-physician involvement - dietitian, trainer, counselor

New Pneumococcal Vaccine Recommendations

PCV XX vs. PPSV 23 - what's the difference? Why do we use both?

Invasive pneumococcal disease - bacteremic pneumonia, sepsis, meningitis.

Current Recommendations:

• PCV13 series in childhood

• 19-64 years

  • immune compromised:

    • PCV13

    • PPSV23 after 1 year

    • PPSV23 after 5 years

  • chronic conditions:

    • PPSV23 once

• 65+

  • immune compromised or high-risk

    • PCV 13

    • PPSV23 after one year

  • average risk or chronic conditions, not particularly high-risk

    • PPSV23 once

Newly licensed in 2021:

• PCV 20 - Pfizer

• PCV 15 - Merck

• immunogenicity, serotypes covered, no head-to-head comparisons

• cost-effectiveness favors PCV 20, safety equally good

• Recommendations:

  • Two equally-recommended options:

    • PCV 20

    • PCV 15, then PPSV 23 in one year

  • 19-64 years

    • immunocompromised OR chronic conditions - give one option

    • average risk - none

  • 65+ years

    • give one option

  • Had PPSV23?

    • give either PCV 20 or PCV 15

  • Had PCV13?

    • give PPSV23

PneumoRecs VaxAdvisor Mobile App

The path becomes a little smoother...

Behavioral Economics and Prevention - Nudges and Sludges

Nudge (Thaler and Sunstein) - "any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates. Putting the fruit at eye level counts as a nudge. Banning junk food does not."

Audience participation:

In small groups - think of nudges you could use to encourage preventive services.

Sludge (Sunstein) - “excessive or unjustified frictions, such as paperwork burdens, that cost time or money; that may make life difficult to navigate; that may be frustrating, stigmatizing, or humiliating; and that might end up depriving people of access to important goods, opportunities, and services”

Audience Participation:

• In the Chat - post examples of sludge that you've seen getting in the way of your patient getting needed care.

Million-Dollar Question: What is one method for analyzing and removing sludge for your patients?

• Routine Health Checks

  • standardize

  • concentrate on what works, don't waste time on things that don't matter

• Opportunistic Prevention

  • Have a robust reminder system and use it all the time

  • Engage your team and delegate authority

• Low value care and opportunity cost

• Things that dietitians want primary care docs to know

• Actual Causes of Death

• Diet Recommendations

• Physical Activity Recommendations

• Effective practice interventions

  • multicomponent

  • intensive, longitudinal

  • goal-setting, self-monitoring, reducing barriers

• PCV 15 and PCV 20 recommendations

• Nudges and Sludges