Health Maintenance for Adults: Introduction
On the average, each day longer you live the longer you are likely to live, yet the closer to dying you become.
In this chapter, the findings and positions of the United States Preventative Service Task Force (USPSTF) are emphasized because it generates the most comprehensive and evidence-based recommendations of any organization. Hence, knowing the USPSTF grading system for its recommendations is important (Table 15-1). The USPSTF it is sponsored by the Agency for Healthcare Research and Quality (AHRQ) and is the leading independent panel of private-sector experts in prevention and primary care. The rest of this chapter lays out HM by the age groups 18-39, 40-49, 50-59, 60-74, and 75 years or older. USPSTF Grade A & B recommendations are emphasized with highlights some areas of special interest or controversy, including sections on immunizations and aspirin. Health maintenance involves three types of prevention: primary, secondary, and tertiary (Figure 15-1).
| 1. The condition being screened for is an important health problem. |
| 2. The natural history of the condition is well understood. |
| 3. There is be a detectable early stage. |
| 4. Treatment at an early stage is of more benefit than at a later stage. |
| 5. A suitable test is available for the early stage. |
| 6. The test is acceptable. |
| 7. Intervals for repeating the test are determined. |
| 8. Adequate health service provision is made for the extra clinical workload resulting from screening. |
| 9. The risks, both physical and psychological, are less than the benefits. |
| 10. The costs are balanced against the benefits. |
Targets individuals who may be at risk to develop a medical condition and intervenes to prevent the onset of that condition (eg, childhood vaccination programs, water fluoridation, smoking prevention programs, clean water, and sanitation). The disease does not exist. The goal is to prevent development of disease.
Targets individuals who have developed an asymptomatic disease and institutes treatment to prevent complications (eg, routine Papanicolaou smears, and screening for hypertension, diabetes, or hyperlipidemia). The disease does exist, but the person is unaware (asymptomatic). The goal is to identify and treat people with disease.
Targets individuals with a known disease, with the goal of limiting or preventing future complications (eg, rigorous treatment of diabetes mellitus, and post–myocardial infarction treatment with β-blockers and aspirin). The disease exists and there are symptoms. The goal is to prevent complications.
Secondary and tertiary prevention require some type of screening: who should get screened, for which disease(s), and with what test(s)? (Table 15-2.)
| Grade | Definition | Suggestions for Practice |
|---|---|---|
| A | The USPSTF recommends the service. There is high certainty that the net benefit is substantial. | Offer or provide this service. |
| B | The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. | Offer or provide this service. |
| C | The USPSTF recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient. There is at least moderate certainty that the net benefit is small. | Offer or provide this service only if other considerations support the offering or providing the service in an individual patient. |
| D | The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. | Discourage the use of this service. |
| I Statement | The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. | Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms. |
The disease must have a period of being detectable before the symptoms start so it can be found and treated, for example, colon cancer has no early symptoms but can be detected with screening. The disease cannot appear too quickly (eg, a cold, certain lung cancers). The disease must be common in the target population, for example, stomach cancer is not screened for in the United States (uncommon), but it is screened for in Japan where is it is more common.
Ideally the screening test will identify all people with disease and only people with disease will test positive. The reality: screening tests are acceptable if they do the job well enough—sensitive enough to have few false negatives and specific enough to have few false positives. Screening test should also be cost-efficient, easy, reliable, and as painless as possible.
When screening for disease, treatment must be available, acceptable, and have benefits that outweigh the risk. Mortality is the most often used endpoint. If a group of people who are screened and then treated live longer or better than a group of people who are not screened, then the screening test may be good for that population. If the two groups of people die at the same rate, there is usually no point in screening for the disease.
Conditions for which the USPSTF recommends against routine screening in asymptomatic adults:
- Aspirin to prevent myocardial infarction in men younger than 45 years old
- Asymptomatic bacteriuria in men and nonpregnant women
- Bladder cancer
- Carotid artery stenosis
- Chronic obstructive pulmonary disease
- Electrocardiography (ECG)
- Genital herpes
- Gonorrhea in low-risk men and women
- Heart disease in low-risk men and women using ECG, EBCT
- Hemochromatosis
- Hepatitis B
- Hepatitis C
- Ovarian cancer
- Pancreatic cancer
- Peripheral arterial disease
- Routine aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) for primary prevention of colorectal cancer for average risk
- Scoliosis
- Stress echocardiogram
- Syphilis
- Testicular cancer
- Vitamin supplements with β-carotene to prevent cancer and cardiovascular disease (CVD)
Conditions for which the USPSTF found insufficient evidence to promote routine screening in asymptomatic adults at low risk:
- Chlamydia in men
- Dementia
- Diabetes mellitus
- Drug abuse
- Family violence
- Glaucoma
- Lung cancer
- Oral cancer
- Prostate cancer
- Skin cancer
- Suicide
- Thyroid disease
- Vitamin supplementation with A, C, E, multi to prevent cancer and heart disease
The role of aspirin in health maintenance and promotion is dependent on whether it is used for primary or secondary/ tertiary prevention. For the latter it is generally beneficial (Table 15-3). For primary prevention it is not that simple (Tables 15-4, 15-5, and 15-6). Evidence is unclear in terms of risk-to-benefit for the role of aspirin in colorectal cancer prevention.
| Topic | Available Guidelines and Recent Evidence |
|---|---|
| Diabetes Secondary prevention | ADA Diabetes Guidelines 2010: • Men > 50 (women > 60) years of age and one of the following: family history of CVD, smoking, hypertension, dyslipidemia, albuminuria BMJ 2009 Meta-analysis: • No difference in risk of major CV events, CV mortality, or all-cause mortality between ASA and placebo → Role of ASA in this population questioned • Decreased risk of MI in men, but not in women (significant study heterogeneity) |
| Heart failure Secondary prevention | ACC/AHA Update to Heart Failure Guidelines 2009: No recommendation at this time due to controversial evidence • Aspirin may negate the positive effect of angiotensin-converting enzyme (ACE) inhibitor therapy |
| Dual therapy (ASA + warfarin) Secondary prevention | ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008: • Patients with mechanical heart valves 1. And a history of coronary artery disease, peripheral arterial disease, or other risk factors for atherosclerotic disease (1B) 2. Who have additional risk factors for thromboembolism: atrial fibrillation, hypercoagulable state, or low ejection fraction (1B) a. Consider if bioprosthetic heart valves and additional risk factors for thromboembolism (2C) b. Particularly in patients with a history of atherosclerotic disease. c. Following clopidogrel discontinuation in patients on triple therapy. d. No dual therapy if at high risk for bleeding—history of GI bleed or age > 80 years (2C) |
| Dual antiplatelet therapy (ASA + clopidogrel) Secondary and tertiary prevention | ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008: primary prevention • Recommend against routine use of aspirin and clopidogrel (1A) ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008: secondary prevention • NSTE ACS: clopidogrel × 12 months (1A) • Symptomatic coronary artery disease (2B) • PCI with bare-metal stent: clopidogrel × 12 mo (1A) • PCI with drug-eluting stent: clopidogrel × 12 mo (1B) • Indefinitely if low risk of bleeding and combination tolerable (2C). |
| Triple therapy (ASA + clopidogrel + warfarin) Tertiary prevention | ACCP Antithrombotic and Thrombolytic Therapy Guidelines 2008: • PCI with bare-metal stent and strong indication for warfarin: clopidogrel × 4 wk (2C) • PCI with drug-eluting stent and strong indication for warfarin: clopidogrel × 12 mo (2C) • Consider warfarin INR goal of 2.0-2.5 |
| 1A | 1B | 1C | 2A | 2B | 2C | |
|---|---|---|---|---|---|---|
| Definition | Strong recommendation, high-quality evidence | Strong recommendation, moderate-quality evidence | Strong recommendation, low- or very-low-quality evidence | Weak recommendation, high-quality evidence | Weak recommendation, moderate-quality evidence | Weak recommendation, low- or very-low-quality evidence |
| Prevention Outcome & Increased Risk | Men | Women |
|---|---|---|
| Cardiovascular events | ✓ | ✓ |
| Myocardial infarctions | ✓ | |
| Ischemic stroke | ✓ | |
| Cardiovascular mortality or all-cause mortality | ||
| Hemorrhagic stroke | ✓ | |
| Gastrointestinal bleeding | ✓ | ✓ |
 |
| One of the Following | Two of the Following |
|---|---|
| Concomitant other NSAID use | Age <60 y |
| History of ulcer complication | Corticosteroid steroid use |
| History of ulcer disease | Dyspepsia |
| Concomitant antiplatelets | Gastroesophageal reflux disease symptoms |
| Concomitant anticoagulants | |
| History of gastrointestinal bleeding |
Table 15-7 summarizes USPSTF recommendations for average risk 18- to 39-year-olds.
| Age (Years) | Female | Male | |
|---|---|---|---|
| 18-24 | Screen | Hypertension (A) | Hypertension (A) |
| Cervical cancer, start at age 21 if has had sexual debut (A) | |||
| Chlamydia, if sexually active (A) | |||
| Tobacco use and counsel as needed (A) | Tobacco use and counsel as needed (A) | ||
| Obesity (B) | Obesity (B) | ||
| Alcohol use disorders (B) | Alcohol use disorders (B) | ||
| Depression if system in place to manage (B) | Depression (B) | ||
| Rubella susceptibility by history of vaccination or serology (B) | |||
| Counsel | HIV risk factors/prevention (B) | HIV risk factors/prevention (B) | |
| Contraception to prevent unintended pregnancy (B) | |||
| 25-34 | Same as 18-24 | Same as 18-24 | |
| Screen for Chlamydia if high risk (A) | |||
| 35-39 | Same as 25-34 | Same as 25-34 | |
| Screen for hyperlipidemia (A) |
Screening tests in focus: hypertension, cervical cancer, Chlamydia, lipid disorders, depression, tobacco, and risk-targeted.
Hypertension is a common disease that contributes to significant adverse health outcomes, including premature deaths, heart attacks, renal insufficiency, and stroke. Blood pressure measurement identifies individuals at increased risk for cardiovascular disease. Treatment of hypertension decreases the incidence of cardiovascular disease events.
Hypertension in adults is defined as a systolic blood pressure of 140 mm Hg or higher, or a diastolic blood pressure of 90 mm Hg or higher on at least two separate obtained on at least two visits over a period of one to several weeks.
The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends screening every 2 years in persons with blood pressure less than 120/80 mm Hg and every year with systolic blood pressure of 120-139 mm Hg or diastolic blood pressure of 80-90 mm Hg. The American Heart Association (AHA) has issued similar recommendations beginning at age 20.
Cervical cancer screening is discussed in detail in Chapter 25.
The USPSTF recommends screening for Chlamydia infection for all sexually active women 24 years of age and younger and for women 25 years of age and older who are at increased risk, regardless of pregnancy status. Chlamydia trachomatis infection is the most common sexually transmitted bacterial infection in the United States. In women, genital infection may result in urethritis, cervicitis, pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain. Infection during pregnancy is related to adverse pregnancy outcomes, including miscarriage, premature rupture of membranes, preterm labor, low birth weight, and infant mortality. The benefits of screening and subsequent treatment in high-risk pregnant and nonpregnant individuals are substantial.
The USPSTF found no evidence of benefit of screening women who are not at increased risk for Chlamydia infection. In a lower-risk population the certainty is moderate that the benefits outweigh the harms of screening to only a small degree.
Nucleic acid amplification tests (NAAT) for Chlamydia have high specificity and sensitivity as screening tests. However, in low-prevalence populations, a positive test is more likely to be a false positive than a true positive: low positive predictive value. NAAT can be used with urine and vaginal swabs, enabling screening when a pelvic examination is not performed.
Screening of pregnant women for Chlamydia infection is recommended at the first prenatal visit. For pregnant women who remain at increased risk and acquire a new risk factor, such as a new sexual partner, a screening should occur during the third trimester. The optimal screening interval for nonpregnant women is unknown. The CDC recommends at least annual screening for women at increased risk.
High levels of total cholesterol and LDL and low levels of HDL are important risk factors for coronary heart disease. Men older than the age of 35 should be screened for lipid disorders. This age may be reduced to 20 if there is an increased risk for coronary heart disease. Screening for women does not need to start until age 45. At least two serum lipid measurements are necessary to ensure that true values are within 10% of the mean of the measurements.
The optimal interval for screening is uncertain. Reasonable options include every 5 years, with shorter intervals for those with risk factor and/or lipid levels close to those warranting therapy.
While high levels of total cholesterol and low-density lipoprotein-cholesterol (LDL-C) and low levels of high-density lipoprotein-cholesterol (HDL-C) are important risk factors for coronary heart disease (CHD), the risk for CHD is highest in those with a combination of risk factors. Therefore, a careful review of the complete risk factor profile is necessary to assess the benefit of screening and subsequent lowering of high cholesterol levels with medications. (Please see the Chapter 21 for a fuller discussion of lipid disorders.)
The USPSTF recommends screening adults for depression only when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up (Grade B). It recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place (Grade C). There may be considerations that support screening for depression in an individual patient.
Cessation of tobacco use may be the single most important lifestyle intervention for the maintenance and improvement of health. All adults should be assessed for tobacco use and tobacco cessation interventions provided for those who use tobacco products. Tobacco use, cigarette smoking in particular, is the leading cause of preventable death in the United States, resulting in more than 400,000 deaths annually from cardiovascular disease, respiratory disease, and cancer. Smoking during pregnancy results in the deaths of about 1000 infants annually and is associated with an increased risk for premature birth and intrauterine growth retardation. Environmental tobacco smoke may contribute to death in up to 38,000 people annually.
Cessation of tobacco use is associated with a corresponding reduction in the risk of heart disease, stroke, and lung disease. Tobacco cessation at any point during pregnancy yields substantial health benefits for the expectant mother and baby.
Smoking cessation interventions, including brief (<10 minutes) behavioral counseling sessions and pharmacotherapy delivered in primary care settings, are effective in increasing the proportion of smokers who successfully quit and remain abstinent for 1 year. Even minimal counseling interventions (<3 minutes) are associated with improved quit rates. One of several screening strategies aimed at engaging patients in smoking cessation discussions is the “five As” behavioral counseling framework:
Ask about tobacco use
Advise to quit through clear personalized messages
Assess willingness to quit
Assist to quit
Arrange follow-up and support
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