Clinical Preventive Medicine in Primary Care: Background and Practice: 1. Rationale and Current Preventive Practices

doi:10.4065/75.2.165

Mayo Clinic Proceedings

Volume 75, Issue 2, February 2000, Pages 165-172

https://doi.org/10.4065/75.2.165 Get rights and content

Impressive evidence supports the value of clinical preventive medicine, defined as the maintenance and promotion of health and the reduction of risk factors that result in injury and disease. Primary prevention activities deter the occurrence of a disease or adverse event, eg, smoking cessation. Secondary prevention (screening) is early detection of a disease or condition in an asymptomatic stage so treatment delays or blocks occurrence of symptoms, eg, mammographic detection of breast cancer. Tertiary prevention attempts to not allow adverse consequences of existing clinical disease, eg, cardiac rehabilitation to prevent the recurrence of a myocardial infarction. Preventive services have decreased morbidity and mortality from both acute and chronic conditions. However, these services are underutilized for numerous reasons. Barriers to their use include physician, patient, and health system factors. The traditional disease/treatment model should be modified to incorporate more preventive services. The subsequent 2 parts of this review will discuss suggestions for integrating primary preventive services and screening into primary care practice.

Section snippets

Types Of Prevention

Clinical preventive medicine is that part of preventive medicine concerned with the maintenance and promotion of health and the reduction of risk factors that result in injury and disease.¹² There are 3 main types of preventive medicine (Table 1). Primary prevention can be defined as an action or behavior that does not allow a disease or adverse event to occur. Examples of primary prevention include immunization, smoking cessation, or initiation of an exercise program with the goal of disease

Evidence Supporting Prevention

The leading causes of death in the United States have changed markedly since the beginning of this century (Table 2).^13,¹⁴ There has been a shift from acute infectious diseases to chronic diseases. Most of the current leading causes of death from chronic diseases are related to lifestyle factors, including health behaviors. The burden of suffering from the “actual” causes of death, ie, the underlying external (nongenetic) factors that contribute to mortality, have been described (Table 3).¹⁵ An

Current Preventive Practices

Currently, most physicians practice some aspects of preventive medicine although there is wide variability and, in general, preventive medicine is underutilized in most practices. Studies have shown physicians' recommendations for screening tests, immunizations, and health promotion assessment and counseling fall short of meeting expert guidelines.34, 35, 36, 37, 38 Physicians who are younger, residency trained, generalists, subspecialists within their specialty, in a group practice, and

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Cited by (59)

Clinical Preventive Medicine, Integrative Medicine, and Lifestyle Medicine: Current State and Future Opportunities in the Development of Emerging Clinical Areas
2024, AJPM Focus
Systematic review and meta-analysis of the provision of preventive care for modifiable chronic disease risk behaviours by mental health services
2019, Preventive Medicine Reports
Citation Excerpt :
This inequitable disease burden is consistently reported to be associated with a greater prevalence of four leading modifiable chronic disease risk behaviours: tobacco smoking, harmful alcohol consumption, inadequate nutrition, and inadequate physical activity (Callaghan et al., 2014; Scott and Happell, 2011; Stanley and Laugharne, 2014; Australian Institute of Health and Welfare, 2012; World Health Organization, 2013). Care to support and facilitate improvements or reductions in such modifiable chronic disease risk behaviours has been termed ‘preventive care’ (Hensrud, 2000; Woolf et al., 2006; Hulscher et al., 1997). A recommended strategy for addressing such behaviours is the provision of preventive care by health care providers, (Australian Health Ministers' Advisory Council, 2017) with Cochrane systematic review evidence supporting provision of preventive care for such behaviours in general health care settings for risk behaviour improvement (Rees et al., 2013; Hillsdon et al., 2005; Rice et al., 2013; Rigotti et al., 2012; Brunner et al., 2007; Foster et al., 2005).
People with mental illness experience increased chronic disease burden, contributed to by a greater prevalence of modifiable chronic disease risk behaviours. Policies recommend mental health services provide preventive care for such risk behaviours. Provision of such care has not previously been synthesised. This review assessed the provision of preventive care for modifiable chronic disease risk behaviours by mental health services. Four databases were searched from 2006 to 2017. Eligible studies were observational quantitative study designs conducted in mental health services, where preventive care was provided to clients for tobacco smoking, harmful alcohol consumption, inadequate nutrition, or inadequate physical activity. Two reviewers independently screened studies, conducted data extraction and critical appraisal. Results were pooled as proportions of clients receiving or clinicians providing preventive care using random effects meta-analyses, by risk behaviour and preventive care element (ask/assess, advise, assist, arrange). Subgroup analyses were conducted by mental health service type (inpatient, outpatient, other/multiple). Narrative synthesis was used where meta-analysis was not possible. Thirty-eight studies were included with 26 amenable to meta-analyses. Analyses revealed that rates of assessment were highest for smoking (78%, 95% confidence interval [CI]:59%–96%) and lowest for nutrition (17%, 95% CI:1%–35%); with variable rates of care provision for all behaviours, care elements, and across service types, with substantial heterogeneity across analyses. Findings indicated suboptimal and variable provision of preventive care for modifiable chronic disease risk behaviours in mental health services, but should be considered with caution due to the very low quality of cumulative evidence.
PROSPERO registration: CRD42016049889.
Pelvic floor muscle training for secondary prevention of pelvic organ prolapse (PREVPROL): a multicentre randomised controlled trial
2017, The Lancet
Citation Excerpt :
Conversely, clear evidence of the clinical and cost-effectiveness of this intervention in the treatment of established prolapse is now available from two randomised controlled trials.7,8 We did the PREVPROL trial to identify the clinical and cost-effectiveness of pelvic floor muscle training in the secondary prevention of prolapse symptoms,9 worsening of prolapse severity, and uptake of prolapse treatment. We specifically report symptoms and uptake of treatment in the first 2 years.
Pelvic floor muscle training can reduce prolapse severity and symptoms in women seeking treatment. We aimed to assess whether this intervention could also be effective in secondary prevention of prolapse and the need for future treatment.
We did this multicentre, parallel-group, randomised controlled trial at three centres in New Zealand and the UK. Women from a longitudinal study of pelvic floor function after childbirth were potentially eligible for inclusion. Women of any age who had stage 1–3 prolapse, but had not sought treatment, were randomly assigned (1:1), via remote computer allocation, to receive either one-to-one pelvic floor muscle training (five physiotherapy appointments over 16 weeks, and annual review) plus Pilates-based pelvic floor muscle training classes and a DVD for home use (intervention group), or a prolapse lifestyle advice leaflet (control group). Randomisation was minimised by centre, parity (three or less vs more than three deliveries), prolapse stage (above the hymen vs at or beyond the hymen), and delivery method (any vaginal vs all caesarean sections). Women and intervention physiotherapists could not be masked to group allocation, but allocation was masked from data entry researchers and from the trial statistician until after database lock. The primary outcome was self-reported prolapse symptoms (Pelvic Organ Prolapse Symptom Score [POP-SS]) at 2 years. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01171846.
Between Dec 21, 2008, and Feb 24, 2010, in New Zealand, and Oct 27, 2010, and Sept 5, 2011, in the UK, we randomly assigned 414 women to the intervention group (n=207) or the control group (n=207). One participant in each group was excluded after randomisation, leaving 412 women for analysis. At baseline, 399 (97%) women had prolapse above or at the level of the hymen. The mean POP-SS score at 2 years was 3·2 (SD 3·4) in the intervention group versus 4·2 (SD 4·4) in the control group (adjusted mean difference −1·01, 95% CI −1·70 to −0·33; p=0·004). The mean symptom score stayed similar across time points in the control group, but decreased in the intervention group. Three adverse events were reported, all of which were in the intervention group (one women had a fall, one woman had a pain in her tail bone, and one woman had chest pain and shortness of breath).
Our study shows that pelvic floor muscle training leads to a small, but probably important, reduction in prolapse symptoms. This finding will be important for women and caregivers considering preventive strategies.
Wellbeing of Women charity, the New Zealand Continence Association, and the Dean's Bequest Fund of Dunedin School of Medicine.
Improving herpes zoster vaccination rates through use of a clinical pharmacist and a personal health record
2013, American Journal of Medicine
Preventative health services, including herpes zoster vaccination rates, remain low despite known benefits. A new care model to improve preventative health services is warranted. The objective of this study is to investigate whether the functions of an electronic medical record, in combination with a pharmacist as part of the care team, can improve the herpes zoster vaccination rate.
This study was a 6-month, randomized controlled trial at a General Internal Medicine clinic at The Ohio State University. The 2589 patients aged 60 years and older without documented herpes zoster vaccination in the electronic medical record were stratified on the basis of activated personal health record status, an online tool used to share health information between patient and provider. Of the 674 personal health record users, 250 were randomized to receive information regarding the herpes zoster vaccination via an electronic message and 424 were randomized to standard of care. Likewise, of the 1915 nonpersonal health record users, 250 were randomized to receive the same information via the US Postal Service and 1665 were randomized to standard of care. After pharmacist chart review, eligible patients were mailed a herpes zoster vaccine prescription. Herpes zoster vaccination rates were compared by chi-square tests.
Intervention recipients had significantly higher vaccination rates than controls in both personal health record (relative risk, 2.7; P = .0007) and nonpersonal health record (relative risk, 2.9; P = .0001) patient populations.
Communication outside of face-to-face office visits, by both personal health record electronic message and information by mail, can improve preventative health intervention rates compared with standard care.
HIV-infected men who have sex with men and histories of childhood sexual abuse: Implications for health and prevention
2013, Journal of the Association of Nurses in AIDS Care
Citation Excerpt :
CSA in the MSM population may increase risks of HIV transmission and negatively impact physical and psychological health through depression, negative coping, and substance abuse, which are often associated with poor adherence to treatment regimens (Boarts, Sledjeski, Bogart, & Delahanty, 2006; Liu et al., 2006; Mugavero et al., 2006). For these reasons, CSA exposure should inform health care providers that approaches to HIV prevention at the primary, secondary, and tertiary levels should be implemented (Figure 1; Hensrud, 2000). Given the impact that CSA has on health, HIV primary prevention programs and clinics should consider universal abuse screening and standardized trauma histories using consistent definitions for CSA and validated tools, such as the Sexual Abuse Questionnaire (Castelda, Levis, Rourke, & Coleman, 2007).
A personal history of childhood sexual abuse (CSA) is prevalent and deleterious to health for people living with HIV (PLWH), and current statistics likely underrepresent the frequency of these experiences. In the general population, the prevalence of CSA appears to be higher in men who have sex with men (MSM) than heterosexual men, but there are limited data available for HIV-infected MSM. CSA is associated with poor mental and physical health and may contribute to high rates of HIV risk behaviors, including unprotected sex and substance abuse. CSA exposure is also associated with low engagement in care for PLWH. More information is needed regarding CSA experiences of HIV-infected MSM to optimize health and wellbeing for this population and to prevent HIV transmission. This article reviews the epidemiology, implications, and interventions for MSM who have a history of CSA.
A Primary Care Primer for Cancer Prevention in Rural Populations
2012, Disease-a-Month
Citation Excerpt :
Preventive medicine focuses on promoting health and preventing disease in individuals and defined populations by helping them enhance their own health. Typically, 75% of the United States population sees a physician each year, with the majority of the visits to primary care providers who are the dominant source of health care and health information.5 Given that cancer is the leading cause of death in the United States for those under the age of 85, interventions to prevent cancer are of utmost importance to improving the health of individuals and populations.6

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ReviewClinical Preventive Medicine in Primary Care: Background and Practice: 1. Rationale and Current Preventive Practices

Section snippets

Types Of Prevention

Evidence Supporting Prevention

Current Preventive Practices

Am J Hypertens

Soc Sci Med

Am J Prev Med

Mayo Clin Proc

Prev Med

Mayo Clin Proc

Healthy People 2000: National Health Promotion and Disease Prevention Objectives

Physician contacts by sociodemographic and health characteristics: United States, 1982-83

Vital Health Stat 10

A study of preventive health attitudes and behaviors in a family practice setting

J Fam Pract

Historical changes in the objectives of the periodic health examination

Ann Intern Med

The periodic health examination; genesis of a myth

Ann Intern Med

A critical review of periodic health screening using specific screening criteria, part 1 : selected diseases of respiratory, cardiovascular, and central nervous systems

J Fam Pract

A critical review of periodic health screening using specific screening criteria, part 2: selected endocrine, metabolic, and gastrointestinal diseases

J Fam Pract

A critical review of periodic health screening using specific screening criteria, part 3: selected diseases of the genitourinary system

J Fam Pract

A critical review of periodic health screening using specific screening criteria, part 4: selected miscellaneous diseases

J Fam Pract

The periodic health examination

Can Med Assoc J

Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions

ACPMNews

Vital Statistics Rates in the United States 1900-1940

Deaths: final data for 1996

Natl Vital Stat Rep

Actual causes of death in the United States

JAMA

Update: vaccine side effects, adverse reactions, contraindications, and precautions; recommendations of the Advisory Committee on Immunization Practices (ACIP)

MMWR Morn Mortal Wkly Rep

Healthy People 2000 Review

The changing pattern of hypertension and the declining incidence of stroke

JAMA

The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Arch Inlern Med

Trends in the prevalence of hypertension, antihypertensive therapy, and left ventricular hypertrophy from 1950 to 1989

N Engl J Med

Stroke incidence, prevalence, and survival : secular trends in Rochester, Minnesota, through 1989

Stroke

The decline in Ischemie heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle

Ann Intern Med

Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994

N Engl J Med

The recent decline in mortality from coronary heart disease, 1980-1990: the effect of secular trends in risk factors and treatment

JAMA

Recent trends in acute coronary heart disease: mortality, morbidity, medical care, and risk factors

JV EnglJ Med

Cancer undefeated

N Engl J Med

Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention

Guide to Clinical Preventive Services

The periodic physical examination in adults

Ann Intern Med

A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors

Patient Edite Couns

The cost-effectiveness of mammographie screening strategies

JAMA

The weight of an ounce

JAMA

Internists' practices in health promotion and disease prevention

Ann Intern Med

Disease prevention and health promotion practices of primary care physicians in the United States

Am J Prev Med

Performance of cancer screening in a university general internal medicine practice

J Gen Intern Med

Review
Clinical Preventive Medicine in Primary Care: Background and Practice: 1. Rationale and Current Preventive Practices