A Publication of the
Program on Prevention
In Education & Practice
September
2001 - Volume 1, Number 9
We have recently welcomed students
back to another school year.
We encourage you to call on the Program on Prevention in your course development
and teaching duties.
We are happy to provide assistance in incorporating prevention content into
your courses.
Priorities Project 
As we have discussed before, the US Preventive Task Force (USPSTF) makes evidence-based recommendations concerning clinical preventive services. But the Task Force does not prioritize among the preventive services it recommends, nor does it place emphasis on cost-effectiveness. A recent article in the American Journal of Preventive Medicine provides results of a long-term project designed to do just that- prioritize the recommendations of the USPSTF. "This is the first such attempt to apply a structured analysis in a consistent fashion across a full set of recommended clinical preventive services to determine their importance to the US population."
The project represents a priority ranking of 30 services recommended by the USPSTF. The recommendations were prioritized based on both "clinically preventable burden" (CPB) of the problem and cost effectiveness of the interventions. CPB is the "proportion of disease and injury prevented by the clinical preventive service in usual practice if the service were delivered to 100% of the target population at recommended intervals" and is the product of both the burden of disease targeted by the service and the effectiveness of the service. Cost effectiveness (CE) is the "net cost of the clinical preventive service divided by quality adjusted life years (QALY's) saved." The 30 services were ranked 1-5 (with 5 being the best possible score) on CPB and CE. The CPB score was added to the CE score to give an overall ranking score.
Not so surprising, the services found to have the highest priority are childhood vaccinations (including DTP/DTaP, MMR, Oral Polio/IPV, Hib, Hep B, Varicella). Other services that were high on the priorities list were assessing and counseling for tobacco use and screening for vision impairment in adults 65 or over. At the very bottom of the list, with the lowest priority, were screening for rubella among women of childbearing age and vaccinating against tetanus-diphtheria. ( Go to the article for a complete list of prioritized recommendations.)
The project begins with the premise that clinicians and policity-makers should prioritize services that provide the greatest benefit for the public and are most cost-effective. The goal of the project was to help decision-makers chose where to provide resources to improve delivery rates. The results can be used at all levels in the health care system- from administrator to health care provider to patient. Administrators can use the information to set priorities for programs to increase delivery of recommended services. For insurance companies and their consumers, the list should guide service coverage for preventive care and hold plans accountable for delivery of these services. Health care providers now have guidance on how to make patient encounters more effective and efficient. And patients may learn information about preventive services that could be of substantial benefit to them. This is a tool that may provide opportunity for us to increase usage rates of those clinical preventive services that are truly most important.
Coffield A, Maciosek M, McGinnis M, Harris J, Caldwell B, Teutsch S, Atkins D, Richaland J, Haddix A. Priorities among recommended clinical preventive services. Am J Prev Med. 2001;21(1):1-9.
Influenza Vaccination Effectiveness
Number 10 on the Priorities List above is immunizing adults over 65 for influenza. An article from JAMA last year by Bridges et al. examined the cost effectiveness of vaccinating healthy working adults under age 65 as well, the goal being to reduce the number of lost work days due to illness.
Observational studies show significant effectiveness of the flu vaccine for the prevention of serious complications and death in persons aged 65 and older. Even though younger adults get influenza more frequently, complications causing hospitalization (and thus expensive medical bills) are less common. Therefore, guidelines and vaccination programs have been targeted at people most likely to experience complications from the disease- persons aged 65 and older and younger people with chronic conditions that make them more succeptible to complications.
Bridges' study found that although influenza vaccination for young healthy adults provides some clinical benefit (fewer lost work days and fewer physician visits when the vaccine and circulating virus are similar), the magnitude of benefit is less than for people 65 and older. Thus when there is a shortage of flu vaccine (as we will have again this year during October and November) people at higher risk (ages 65 and over and people younger than 65 with chronic illness) should receive priority.
Bridges C et al. Effectiveness and cost-benefit of influenza vaccination of healthy working adults. JAMA. 2000; 284:1655-1663.
No Cause for Celebration
of this 20th Anniversary 
Amazing... It's been 20 years since the first HIV outbreaks in New York and California. June 5 and July 3, 1981 marked the beginning of the AIDS epidemic. Who knew the toll it would take on over 58 million people who have been infected worldwide? Some 23 million of those individuals have died as a result.
The understanding of AIDS has been remarkably successful. Although public education efforts have been courageous and somewhat effective, AIDS still seems unstoppable without a vaccine. Commentary in a recent issue of The Lancet highlights the 20 year anniversary of this disease noting that control must come through prevention with continued public education, advocating safe sex and condom use, blood screening and perhaps the biggest hope... a vaccine. With two-thirds of the 36 million current cases in sub-Saharan Africa, 6 million in Asian countries, and a predicted rapid spread in Russia, India and China, prevention efforts must occur throughout the world... in lands that have many fewer resources than America.
On a personal note, we saw the last exhibit of the AIDS quilt, a tribute to those who have lost their lives to AIDS, in Washington, DC in 1996 when it stretched the entire length of the Mall- from the Washington Monument to the Capital Building. It will never be displayed like that again because it's now too large to be shown together in any one location.
Weiss R. AIDS: Unbeatable 20 years on. The Lancet. 20011; 357:2073.
Law Enforcement Officers and Firearm Storage
Research has shown that the most effective way to prevent firearm-related injury is to have no firearms in the household. Since law enforcement agents play an important role in preventing firearm-related injuries, Tamera Coyne-Beasley, MD, MPH from the Departments of Pediatrics and Internal Medicine and colleagues, surveyed officers in a law enforcement agency in the South to examine their firearm ownership and storage practices as well as their opinions about gun control. The study results were recently published in the American Journal of Preventive Medicine.
The results were surprising. The majority of respondents were white (60%) and male (89%) and 55% of the officers surveyed had children. Eighty percent of officers had at least one gun in addition to the one used for work. Fifty-nine percent stored their guns unlocked and 68% stored their guns loaded. Almost half (44%) stored guns both unlocked and loaded. Eighty-five percent felt they needed easy access to firearms to protect themselves and their families due to their line of work. They perceived themselves as vulnerable to attack from those they have arrested. Those officers with children at home tended to have safer storage practices than those without children. However, over one third of those with children kept their guns unlocked and loaded.
Unsafe firearm storage is counterproductive
to theories of self-protection. Having high firearm ownership rates and relatively
unsafe storage practices makes this population at high risk for firearm-related
injuries. The authors recognize that officers should feel safe in their own
homes, reducing the feeling of need for self-protection. This phenomenon may
be less common for people in the communities at-large. 
Coyne-Beasley T, Johnson R, Charles L, Shoenbach V. Firearm storage practices of officers in a law enforcement agency in the South. Am J Prev Med. 2001;21:118-123.
Study Identifies Prevention Practices of Family Medicine Preceptors
In the latest issue of Academic Medicine, some of our own faculty in the Department of Family Medicine report on a study to determine what types of prevention practices are employed by Family Medicine Clerkship preceptors. Providing a uniform clerkship experience for all students is difficult, considering the large number of sites across North Carolina. By determining the types of practices occurring in individual offices, the clerkship coordinators can better know what students are being exposed to during their rotations. An earlier study by Vicki Kowlowitz, PhD, showed that students in community-based clerkships were getting training in prevention, however, this new study was aimed at discovering the specific areas students were exposed to, as well as the physician's comfort level in practicing prevention.
Family Medicine Clerkship preceptors were surveyed by questionnaire during the 1995-96 school year. Preceptors were asked about their level of preparation to counsel patients, the types of prevention services they offered and their level of success in modifying patients' behaviors. Preceptors' prevention practices were analyzed in terms of year of graduation from medical school (before or after 1987), to determine if the recency of training influenced their practices.
Over 50% felt "very prepared" to counsel patients on smoking cessation, sexually transmitted diseases, exercise, alcohol use, and age-specific services (53-74%). Over 60% said they "almost always" offered preventive services for smoking cessation, exercise, diet and nutrition, and age-specific services (62-86%). Unfortunately, preceptors reported having very little influence in changing their patients' behavior on smoking, exercise, diet and nutrition and other important issues (1-8%).
One interesting, but perhaps not surprising, finding was preceptors who had graduated recently (since 1987) compared with earlier graduates, were more likely to offer preventive services for smoking cessation (93% vs. 77%), alcohol (64% vs 44%) and illicit drug use (96% vs. 24%). They were also more likely to offer preventive services for family or social relationships and for HIV and AIDS. Another interesting finding was that women preceptors felt more prepared than their male counterparts to counsel for HIV and AIDS and reported being more successful at helping patients modify risk behaviors related to the disease. The authors used the results of the study to improve the students' prevention curriculum. Finding ways to increase physicians' self-efficacy in assisting their patients along the path to behavior change should be a high priority.
Slatt L, Frasier P, Strayhorn G, Kowlowitz V. Prevention practices of family medicine clerkship preceptors in North Carolina. Acad. Med. 2001;76:722-726.
Newsworthy
Notes 
Prevention News Around Campus...
Health and Wellness for Women with Disabilities
The North Carolina Office on Disability and Health, located on the UNC campus, recently released Orchid, a magazine aimed at providing women with disabilities important information on health and wellness. A collaboration between the Women's and Children's Health Section of the Division of Public Health and the Frank Porter Graham Child Development Center, the office is responsible for promoting the health and wellness of persons with disabilities in North Carolina through an integrated program concentrating on policy, practice and research. The office with six staff members, is guided by an advisory committee and task forces, made up of physicians, social workers, nurses, public health specialists and individuals with disabilities who help with the design and implementation of projects.
Orchid is a wonderful publication full of important health information, bright colorful photographs, and personal stories of women with disabilities. One way to view health is by"maximizing ones potential along various dimensions." This view of health includes a dynamic balance of physical, social, emotional, spiritual, and intellectual factors. With this definition, disability poses no obstacle to maximizing health and one's potential.
Sections include information on health care, leisure and physical activity, nutrition, and relationships. Much of the magazine is relevant to all women, but includes specific information for women with disabilities on topics such as getting the most from health care visits; dealing with specific insurance issues; special health concerns, including breast health, for women with disabilities; aging with a disability; dealing with depression; self-acceptance; traveling tips; making leisure activities such as gardening and canoeing accessible; joining a gym; and parenting issues.
Pam Dickens is the Managing Editor for the publication at the NC Office on Disability and Health. Dickens said that each topic also includes numerous references and sources, such as web sites and publications, where readers can find additional information. "We hope that Orchid will help women with disabilities be more proactive regarding their health rather than just react to problems after they occur. We also hope that this information will be useful to health care providers as they become partners in the care of women with disabilities."
The office has developed numerous booklets and pamphlets on health-related issues for people with disabilities. These free publications are available by going to the NCODH website or calling 966-2932.
In addition, the office is interested in becoming more involved in medical education... supporting providers to increase their knowledge and sensitivity in working with individuals with disabilities- an area that is overlooked in the medical school curriculum. For more information contact Pam Dickens.
The Orchid project was funded by the Centers for Disease Control and Prevention and the Federal Bureau of Maternal and Child Health.
Around The Program...
New Program Assistant- We Welcome Leslie to the Program
Our new Program Assistant, Leslie Gray, began with the Program on May 21st and we are very happy to have her join our team. Leslie comes to us from the Department of Radiology, where she was and Accounting Tech. Leslie spent several years in contracts and grants and that experience will come in handy as she takes over our budget and other very important Program duties.
Patient Education Website
The Program has been working for a year to develop patient-education sites at two community practices and the ACC. We have expanded our work group to include representatives from the Women's Hospital, the Healthcare system's E-health Committee and the upcoming Wellness Center. We've also been working this summer with OIS to create a comprehensive website for potential use by all of the UNC Healthcare system. At this point we are using a simplified version of the website within the three practices as a trial but continue to work to improve the more comprehensive site to include the needs of all parties involved. Keep your eyes pealed for future updates.
Around the World Wide Web...
People have more access to health care information than ever before. Not only do they hear about health news in the media but more and more individuals are looking to the WWW for information. Directing your patients to credible and reliable information is key. The Web can be a valuable resource for educational material for patients and providers alike if it is used wisely.
This American Cancer Society site is designed to be user-friendly and easy to
navigate to obtain the information on the particular disease of interest. This
is a good site for patients because it provides valuable easy to understand
clinicial information valuable in helping them make decisions. http://www.cancer.org
Look for our next edition
of "An
Ounce of Prevention" in November,
2001.
If you have comments or questions
about this newsletter or its contents, please e-mail alward@med.unc.edu.
Program Co-Directors:
Russ Harris, MD, MPH and Linda Kinsinger, MD, MPH
Education Coordinator
& Editor: Amy L. Ward
Go to the Program on Prevention Homepage