An
Ounce of Prevention...
A Publication of the
Program on Prevention
In Education & Practice
May
2001 - Volume 1, Number 8
Update of the Third US Preventive Services Task Force
A supplement to the April 2001 issue of the American Journal of Preventive Medicine highlights the progress of the USPSTF's efforts to take an evidence-based approach to developing clinical practice guidelines. Articles about the task force, its charge, the process of making recommendations and some of the initial recommendations can be found in this supplement. As coordinator of the Methods Work Group, Russ Harris, MD, is lead author on an article explaining how the USPSTF works in "Current Methods of the US Preventive Services Task Force: A Review of the Process."
In this article the Methods Work Group explains the process of making recommendations in three steps. The initial consideration of the Task Force is to limit the number of topics it reviews to only those problems that cause a large burden of suffering to society and have a potentially effective preventive service. The Task Force uses an analytical framework to show the linkages and key questions that bridge the preventive service with health outcomes. These linkages guide the literature searches for evidence which is reviewed at three levels: 1) the individual study, 2) the body of evidence concerning a single linkage, and 3) the body of evidence concerning the entire preventive service. The Task Force gives a mark of good, fair or poor at each level. Good and fair signify that the evidence includes studies of significant design and quality to provide an unbroken chain of evidence-supported linkages, that can be generalized to the general population, and that connect the preventive service with health outcomes. A poor mark means that there is a break in the evidence chain in that the link between preventive services and health outcomes is missing. Finally, services that receive good and fair marks are put into another category of substantial, moderate, small or zero/negative based on the magnitude of benefits, harms and net benefits. From this assessment of the evidence and magnitude of net benefit, each service is coded as a letter A (strongly agree) to D (recommend against) or I (evidence is insufficient to determine benefit).
Task Force members recognize that there are some limitations in this process but appreciate the evolutionary process of such methods. They recommend more methodological research in several key areas including "efforts to determine the best factors to consider in using evidence-based principles to guide judgments about the magnitude of benefits and harms when the available evidence is fair in quality and when gaps exist in the framework supporting effectiveness." This question along with others make the Task Force's effort an ongoing work in progress.
USPSTF Recommendations
Screening for Skin Cancer-
"The USPSTF concludes that
the evidence is insufficient to recommend for or against routine screening for
skin cancer using a total-body skin examination for the early detection of cutaneous
melanoma, basal cell cancer, or squamous cell skin cancer."
I recommendation.
Clinical Considerations- Benefits from screening are unproven, even in high-risk
patients. Clinicians should remain alert for skin lesions with malignant features.
The USPSTF did not examine the outcomes related to surveillance of patients
with familial syndromes.
Screening for Bacterial Vaginosis in Pregnancy-
"The USPSTF concludes that
the evidence is insufficient to recommend for or against routinely screening
high-risk pregnant women for bacterial vaginosis." I recommendation.
" The USPSTF recommends against routinely screening average-risk asymptomatic
pregnant women for BV." D
recommendation.
Clinical Considerations- For women with a history of preterm delivery, screening for BV is an option. For clinicians electing to screen high-risk women, the optimal screening test is not certain. Neither the optimal time to screen high-risk pregnant women nor the optimal treatment regimen for pregnant women with BV is clear. Treatment is appropriate for pregnant women with symptomatic BV infection.
Screening Adults for Lipid Disorders-
"The USPSTF strongly
recommends that clinicians routinely screen men aged 35 years and older and
women aged 45 years and older for lipid disorders and treat abnormal lipids
in people who are at increased risk of coronary heart disease." A
recommendation.
"The USPSTF recommends that
clinicians routinely screen younger adults (men aged 20-35 years and women aged
20-45 years) for lipid disorders if they have other risk factors for coronary
heart disease." B recommendation.
"The USPSTF makes no
recommendation for or against routine screening for lipid disorders in younger
adults (men aged 20-35 years or women aged 20-45 years) in the absence of known
risk factors for coronary heart disease." C recommendation.
"The USPSTF recommends that
screening for lipid disorders include measurement of total cholesterol (TC)
and high-density lipoprotein cholesterol (HDL-C)." B
recommendation.
"The USPSTF concludes
that the evidence is insufficient to recommend for or against triglyceride measurement
as part of routine screening for lipid disorders." I
recommendation.
Clinical Considerations- TC and HCL-C can be measured on nonfasting or fasting samples. Screening is recommended for men aged 20-35 and women aged 20-45 years in the presence of any of diabetes or a family history of CVD before age 50 years in male relatives and 60 years in female relatives. The optimal interval for screening is uncertain. An age to stop screening is not established. Treatment decisions should take into account overall risk of heart disease rather than lipid levels alone. Treatment choice should take into account cost and patient preferences. All patients, regardless of lipid levels, should be offered counseling about the benefits of a diet low in saturated fat and high in fruits and vegetables, regular physical activity, avoiding tobacco use and maintaining a healthy weight.
Screening for Chlamydial Infection-
"The USPSTF strongly
recommends that clinicians routinely screen all sexually active women aged 25
years and younger, and other asymptomatic women at increased risk infection,
for chlamydial infection." A recommendation.
"The USPSTF makes no
recommendation for or against routinely screening asymptomatic low-risk women
in the general population for chlamydial infection." C
recommendation.
"The USPSTF recommends
that clinicians routinely screen all asymptomatic pregnant women aged 25 years
and younger and others at increased risk for infection for chlamydial infection."
B recommendation.
" The USPSTF makes no
recommendation for or against routine screening of asymptomatic, low risk pregnant
women aged 26 years and older for chlamydial infection." C
recommendation.
"The USPSTF concluded
that the evidence is insufficient to recommend for or against screening asymptomatic
men for chlamydial infection." I recommendation.
Clinical Considerations- Women and adolescents through age 20 years are at highest risk for chlamydial infection, but most reported data indicate that infection is prevalent among women aged 20-25. Clinicians should consider the characteristics of the communities they serve in determining appropriate screening strategies for their patient population. The optimal interval for screening is uncertain. The optimal timing of screening in pregnancy is also uncertain. Screening high-risk young men is a clinical option. Partners of infected individuals should be tested and treated if infected or treated presumptively. Clinicians should remain alert for findings suggestive of chlamydial infection during pelvic examination of asymptomatic women. Clinicians should be sensitive to the potential effect of diagnosing a sexually transmitted disease on a couple.
Atkins D, Best D & Shapiro E. The Third US Preventive Services Task Force: Background, Methods, and First Recommendations. Am J Prev Med. 2001;20(3S).
Study
Identifies Population Health Faculty at US Medical Schools 
"If medical schools are going to teach the population health perspective and its application in the United States, then US medical schools are going to need to have an appropriately trained faculty."
This is the premise of a study done by a former Tarheel, Ed Dismuke, MD, MSPH, which looked at the number and location of full-time faculty formally trained in the population health sciences. This study came as a result of the AAMC's publication of their Population Health Perspective Panel findings, part of the Medical School Objectives Project. The panel suggested that all undergraduate medical students should learn the basic concepts of population health.
The study looked at the AAMC Faculty Roster System to determine the number of full-time faculty who had either completed an MPH degree, a public health (PH)-related doctoral degree, a preventive medicine residency, or board certification in preventive medicine in 1990-1998. Overall 2.3% of all faculty have MPH degrees and 3.6% have either an MPH or doctoral degree in public health. While Internal Medicine, Family Practice and Pediatrics all had significant numbers of these faculty, over half (1,010/2,007) were in non-primary-care departments, according to the 1998 data. Interestingly, full-time faculty with MPH degrees and PH-related doctoral degrees have grown faster (67% and 41% respectively) than total faculty or faculty in various departments since 1990. However, faculty with preventive medicine residency training or board certification has grown much more slowly (17% and 26% respectively.) Another interesting note is that only two thirds of the permanent chairs of preventive medicine are physicians. Only half have completed a preventive medicine residency and only 42% are board certified.
What are the implications of this study? According to the authors, following the AAMC recommendations of teaching concepts of population health is quite difficult without properly trained faculty. The 1998 AAMC Senior Questionnaire that graduates complete upon finishing medical school also suggest that students feel inadequate time is devoted to population health. Although the study cannot say whether schools have enough population health-trained faculty, the authors do say that faculty are diffused across multiple departments and that the discipline has very low visibility compared to more traditional departments.
Dismuke, SE and Sherman, L. Identifying population health faculty in U.S. medical schools. Am J Prev Med. 2001;20(2):113-117.
Newsworthy
Notes 
Prevention News Around The Program...
PACT Retires Current Co-Presidents and Appoints New President
As Anna Frick and Brian Lewis begin their third year clerkship rotations, not only do they leave Berryhill Hall, but also their posts as Prevention in ACTion CO-Presidents The group finished off the year by having a presentation on Substance Abuse Prevention by Bill Renn, Director of the Substance Abuse Clinic here at UNC. We wish Brian and Anna best wishes as they continue in their education.
Rising MS2 Carolyn Chu has been appointed as president of the organization for next year. Carolyn is energetic and has some exciting ideas for the direction of PACT next year. Carolyn also works with SHAC and the IFC homeless shelter which may provide an opportunity to combine the organizations' efforts. Welcome, Carolyn. We're thrilled to have you on board. (See below for additional information on Carolyn's SHAC efforts!)
Two of Our Own
Students are Recognized 
Carolyn Chu (see above) and David Yale, rising MS4 and MPH candidate, were recognized in the Chapel Hill News May 6, for making a big difference in improving access to care for older, less mobile residents in the Chapel Hill-Carrboro area. Taking SHAC on the road was envisioned by David Yale as an MS2 involved in SHAC. This year the Mobile SHAC program was funded $3,000 by a UNC student organization public service grant and uses students from schools of medicine, nursing, pharmacy, public health, social work and dentistry to provide care to patients that can't get to the SHAC clinic. The SHAC clinic is an interdisciplinary clinic that has been in existence for 32 years- the oldest student-run free clinic in the nation.
With this program, not only are patients being provided care they might not receive elsewhere but students are gaining valuable experience in the community setting, talking to patients they might not otherwise see. Yale says that "being on the patients' turf is very disorienting, but also valuable education." Students involved in Mobile SHAC act as patient advocates, "a bridge, connecting patients and physicians at UNC Hospitals by assessing their health and reporting findings to the appropriate medical professionals." In addition, medical students gain valuable experience in working with students from other disciplines, which will be a critical skill in the real world of medicine.
UNC Students Take a Year Off from Medical
School to Obtain a Masters in Public Health Degree
Fifteen UNC medical students will take next year to complete an MPH degree in the School of Public Health. The number of students taking this option is down slightly from eighteen last year, but nonetheless continues to be a popular option. A continuing trend is the high number of students selecting the Health Care & Prevention (HC&P) MPH option. UNC students in HC&P will begin their program July 5th. We welcome the following UNC medical students into the HC&P Program:
Juanita Edwards
Keith Kocher
Patrick Link
Rachel Reisner (former PACT
Co-President)
Keith Sigel
Tana Tyler
Anna Zimmerman
2001-2002 distribution
of UNC medical students in MPH degree programs
Program on Prevention Receives Two Technology Grants
The Program on Prevention recently received approval for an OIS mini-grant for $2,000. This mini-grant will fund a student for the summer to work on the Program's ongoing patient education project. The student will work with the Program and OIS to develop an optimal patient education website with preapproved links to sites full of valuable and credible patient education material.
In addition, we also received an ATN technology grant for $500. The funds will allow the program to investigate options for creating an online syllabus for PUBH 250, Strategies of Prevention for Clinicians, which Linda Kinsinger and Russ Harris teach in the fall.
Both grants will give us the
opportunity to expand our reach and investigate online options for educating
our medical students and patients.
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 site is nicely laid out and easy to follow and helps women design a nutritional
program and workout program especially for their needs. Patients can do a personal
nutrition assessment, get recipes and also learn how to plan meals.
http://www.cyberdiet.com/modules/ew/nutrition/basics/dietary_guidelines.html
This an American Heart Association page about fitness.
It allows patients to get up-to-date fitness information, receive personal information
on particular fitness styles, track your progress and sign up for a virtual
personal trainer.
http://www.justmove.org/home.cfm
Look for our next edition
of "An
Ounce of Prevention" in July,
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