Individual Health vs. Public Health If you’re the 1/1000, it’s a 100% for you What absolute...
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Transcript of Individual Health vs. Public Health If you’re the 1/1000, it’s a 100% for you What absolute...
Individual Health vs. Public Health
• If you’re the 1/1000, it’s a 100% for you
• What absolute level of risk will society/an individual tolerate?
• Population-based approach should account for safety, cost, availability
Medicare 1998 - 2001
Average Risk
• FOBT Annually• Flex Sig q 4 yrs
Screening Colonoscopy q 10 yrs
High Risk
• 1st degree relative w/adenoma or CA• FAP, HNPCC• Personal hx adenoma or CA or IBD
Colonoscopy q 2 yrs
Uncertainty in 50-64 age group
Prevalence of FOBT/Sigmoidoscopy - 1997
AGE 50
FOBT - 1 Year FS/Procto - 5 Years
Total M F Total M F
19.8 18.4 21.0 30.6 35.2 26.8
Behavioral Risk Factor Surveillance System
Ries L, Cancer 2000;88:2398
• Risk Appropriate Screening
• Provider Endorsement/Education
• Public Acceptance
• Cost/Efficiency
• Help Physicians
• Risk Appropriate Screening
• Provider Endorsement/Education
• Public Acceptance
• Cost/Efficiency
• Help Physicians
Sigmoidoscopy Use in 1o Care Physicians in Allegheny County
• Surveyed 400 physicians - 70% response rate• Median age 44; most full time clinicians
Training: 44% rigid; 28% flexible
Proficiency: 32% rigid; 22% flexible
Schoen RE, Weissfeld JL, Kuller LH; Preventive Medicine 1995
49% equipment available
Regularly refers or schedules pts: 34%Of those: 50% 5 pts/month
Sigmoidoscopy Use in 1o Care Physicians in Allegheny County - Attitudes
• 83% sigmoidoscopy impt
• 88% agree with ACS rec’s
Factors that influence decision to recommend:
Cost - 62%
Low prob finding a lesion - 52%
Patient discomfort - 48%
Provider Endorsement
Medical services are not baseball stadiums:
“Build it and they will come” does NOT Apply
• Risk Appropriate Screening
• Provider Endorsement/Education
• Public Acceptance
• Cost/Efficiency
• Help Physicians
Satisfaction with Flexible Sigmoidoscopy (N=1221)
General % Strongly Agree
Very Satisfied with care 97.6
Pain/Discomfort (Didn’t) have a lot of pain 96.2 More comfortable than expected 68.5 (Didn’t) cause me great discomfort 78.1
Enthusiasm
Willing to have another 93.1 Sigmoidoscopy will benefit my health 91.1 Strongly recommend to friends 74.9
Schoen. Arch Intl Med 2000;160:1790
• Risk Appropriate Screening
• Provider Endorsement/Education
• Public Acceptance
• Cost/Efficient Delivery
• Help Physicians
NP’s and Sigmoidoscopy
Back to Back FSG, N = 249
PerPolyp
Missed Adenomas
Missed Adenomas 1 cmPer Patient
No polyp FS #1, Polyp FS #2
No adenoma FS #1, Adenoma FS #2
GI
20% (6/30)
2/10
21% (3/14)
0/4.91
NP P
Schoenfeld. Gastro 1999;117:312
12%
3%
6%
2%
.12
.43
10,164
AvailableT3 Visit
1,360
Did not completeT3 FSG
8,804 (86.4%)Completed
T3 FSG
Adherence with T3 Flexible Sigmoidoscopy
688Had T3 Visit
672No T3 Visit
Weissfeld. Cancer 2002 (in press)
Sigmoidoscopy & Mammography
• Need training for proficiency• Need Consistent Experience to Maintain
Proficiency• Need Current Technology• Infection Control• High Through-Put• Standardize Reporting/Terminology• Follow outcome
• Risk Appropriate Screening
• Provider Endorsement/Education
• Public Acceptance
• Cost/Efficiency
• Help Physicians
Systems Approach to Prevention
• GAPS
• Put Prevention Into Practice (AHRQ)
Goal setting regarding preventive careAssessment of existing routinesPlanning to modify existing routinesStarting and maintaining improved preventive care system
Deitrich. Arch Family Med 1994;3:126
• PPP