Dana Bartlett, Bsn, Msn, Ma, Cspi

PREVENTIVE

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 attentionis 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)

Course Author & Planning Team Conflict of Interest Disclosures

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.

1.One of the limitations of screening tests is:

1. Guidelines are often changed and updated.
2. They rarely provide a high degree of specificity or sensitivity.
3. They can only be used for adolescents and adults.
4. The benefits seldom outweigh the risks.

2.Screening tests must be used with the understanding that

1. they are seldom able to detect diseases.
2. most of them are associated with harmful side effects.
3. they are not diagnostic.
4. they cannot be used for children.

3.Adults should be screened for alcohol misuse if they

1. are males over age 35.
2. drink hard liquor.
3. use illicit drugs.
4. engage in risky drinking behavior.

4.Breast cancer is

1. only found in post-menopausal women.
2. the second most common cancer in women.
3. primarily caused by cigarette smoking.
4. not detectable without a biopsy.

5.Breast cancer screening may include

1. an x-ray.
2. a CT scan.
3. a biopsy.
4. mammography and genetic testing.

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 generallyseek 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.

• The healthcare community identifies the diseases that affect, or are likely to affect a specific population.
• The healthcare community screens for acute and chronic health problems and identifies people at risk.
• The healthcare community delivers specific interventions and therapies that will prevent disease, i.e., vaccinations.
• The healthcare community provides consumers with information about behaviors and interventions that can help prevent chronic illness.
• The healthcare community supports consumers in a life-long commitment to healthy life style choices
• The individual makes the changes in diet, exercise, and other life style factors that influence his/her health.

Screening For Disease Detection And Prevention

Screening is an effective methodfordetecting 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.

• Not all cases of disease can or will be detected.
• Screening guidelines are always being changed and updated.
• Screening should be done on a case-by-case basis and when appropriate, screening should be accompanied by an examination and interview with a healthcare professional.
• A screening test is not a diagnostic test.

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) hasan 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.2Over 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.4Who 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. Thesescreening tools have been shown to be useful in identifying hazardous drinking and to helpinitiate 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

1. How often did you have a drink containing alcohol in the past year? If the answer is never, score questions 2 and 3 as zero.

1. How many drinks did you have on a typical day when you were drinking in the past year?

1. How often did you have 6 or more drinks on one occasion in the past year?

The four question CAGE screening test for alcohol use is familiar to many healthcare professionals. This test asks the following:

• Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever taken a drink first thing in the morning (Eye-

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. A2014 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

• In 2014, almost 17 of every 100 U.S., adults aged 18 years or older (16.8%) currently smoked cigarettes. This means an estimated 40 million adults in the United States currently smoke cigarettes. There are also millions of people who use smokeless tobacco and e-cigarettes.

• Cigarette smoking is the leading cause of preventable disease and death in the United States, accounting for more than 480,000 deaths every year, or 1 of every 5 deaths.

• More than 16 million Americans live with a smoking-related disease.

• Current smoking has declined from nearly 21 of every 100 adults (20.9%) in 2005 to nearly 17 of every 100 adults (16.8%) in 2014.

• In 2014, an estimated 66.9 million Americans aged 12 or older were current users of a tobacco product (25.2%). Young adults aged 18 to 25 had the highest rate of current use of a tobacco product (35%), followed by adults aged 26 or older (25.8%), and by youths aged 12 to 17 (7%).

• In 2014, the prevalence of current use of a tobacco product was 37.8% for American Indians or Alaska Natives, 27.6% for whites, 26.6% for blacks, 30.6% for Native Hawaiians or other Pacific Islanders, 18.8% for Hispanics, and 10.2% for Asians.

The CDC as well as several other sourceshave 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.132Also, 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