Adult Preventive Medicine In Primary Care

John A. Grisnik, M.D.
John A. Grisnik, M.D. is a Clinical Assistant Professor with the
Department of Community Health and Family Medicine at the
University of Florida Health Science Center / Jacksonville.

Background

Preventive medicine is a relatively new concept and approach to the traditional clinical practice of medicine. It developed in the early 1970's in response to demands to control medical costs as well as to improve the value, quality and outcomes of healthcare. It's main goals are to protect, promote, and maintain health and well being, and to prevent disease, disability and premature death.¹ The value of preventive medicine has broad appeal and support among patients and physicians alike. For example, individuals increasingly accept responsibility for their health and well being through activities such as diet and exercise programs, and primary care physicians have come to the forefront in their support and practice of preventive medicine. Various groups and organizations—the American Cancer Society, the U.S. Preventive Services Task Force and the Canadian Task Force on the Periodic Health Examination—have made significant contributions towards establishing preventive medicine guidelines. Certain individuals, perhaps most notably Paul Frame, M.D., ² have also contributed to the promotion and development of practice guidelines for preventive medicine.

One significant benefit that preventive medicine offers is the potential to reduce morbidity and mortality associated with certain conditions. Our leading causes of death — tobacco, diet and activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and illicit drug use — are all factors amenable to preventive and public health interventions.¹

The problems of tobacco use and obesity serve to demonstrate the potential to significantly reduce disease-related morbidity and mortality. Tobacco use contributes to more than 400,000 deaths annually in the United States,³ prompting former Surgeon General C. Everett Koop to say that tobacco use is "the chief single avoidable cause of death in our society and the most important public health issue of our time".⁴ Regarding obesity, in the 25-to-45-year age bracket, the relative risk of hypertension in the obese patient is 5.6 times greater than for the non-obese. In the 20-75 year age bracket, the relative risk of Type 2 diabetes is 2.9 times greater for the obese patient as compared to the non-obese.⁵ Clearly, reductions in tobacco use and obesity have staggering health benefits and cost reduction implications for our society.

Definitions

Health promotion and disease prevention are terms frequently used in the practice of preventive medicine. Health promotion encompasses modifying personal health behaviors to reduce the risk of disease and injury.⁶ Some of the most frequently addressed issues of health promotion are listed in Table 1.

Disease prevention encompasses primary, secondary and tertiary prevention in the practice setting. Primary prevention involves the completely asymptomatic individual as in the administration of immunizations to prevent disease. Secondary prevention is identifying and treating asymptomatic persons who have already developed risk factors or pre-clinical disease, but in whom the disease itself has not become clinically apparent. Screening mammography is an example of secondary prevention. Tertiary prevention encompasses preventive measures in symptomatic patients, an example of which is treating abnormal lipid levels in a person with angina.⁶ Some of the major components of disease prevention are listed in Table 2.

In the primary care office setting, preventive medicine is practiced during the periodic health examination, the successor to the "complete annual physical examination". The periodic health examination encompasses a health maintenance schedule consisting of a series of interventions offered to patients at defined intervals. These interventions include focused history taking, procedures and counseling and are dependent upon age, risk factors and gender.⁶ Primary care physicians can tailor their own health maintenance schedules to suit their practice. An example can be seen in Figure 1.

Barriers To Preventive Medicine

Despite the fact that preventive services have become an integral component of primary care practice, compliance with guidelines has been found to be unsatisfactory for most types of preventive services.⁷ Some examples include:

• A study in Missouri revealed only 15% of sedentary patients received physician counseling to increase physical activity.⁸
• It is estimated that 52.6% of current smokers are seen by a dentist annually and more than 70% of current smokers see a physician annually. However, only 24.1% of smokers who saw a dentist in the previous year reported that they had been advised to quit smoking and only 51% of smokers who saw a physician reported that they had been given advice to stop smoking.³
• Less than 18% of current users of snuff or chewing tobacco reported that they have ever received advice from a dentist or physician to quit their tobacco habits.³
• Less than 20% of persons for whom pneumococcal vaccine is indicated received the immunization.⁶
• Physicians are more likely to provide behavioral recommendations to patients who already have a disease than those at-risk patients who are disease-free.⁹
• Insurance type has also been shown to be a factor affecting rates of screening tests and procedures. Uninsured patients receive the least amount of screening tests and procedures, followed by those with Medicaid insurance. HMO insurance type is associated with the highest provision of screening services, particularly in the areas of mammograms, Pap tests, sigmoidoscopies, and fecal occult blood testing.¹⁰

There are many reasons suggested to explain the failure to provide adequate preventive services. These include:

• Lack of physician time;
• Most physicians have had little formal training in health promotion and disease prevention;
• Inadequate reimbursement for preventive medicine services;
• Lack of office resources for tracking, promoting and performing preventive care;
• Physicians may obtain greater professional satisfaction from and perceive greater medical value in curative as opposed to preventive care.

The Future Of Preventive Care

Despite the problems and obstacles to the practice of preventive medicine, changes are taking place that will improve its effectiveness. Primary care residency programs are emphasizing health maintenance and this is beginning to expand the infrastructure of physicians who promote its' concept. Insurers—private insurance, Medicaid and HMO's—have begun to promote and reimburse annual health maintenance visits for their enrollees. Many companies, both large and small, are providing workplace health promotion programs for their enrollees.¹¹ Computer technologies hold promise in developing systems to identify patients for whom counseling and preventive services are indicated.⁹

Conclusions

The potential for preventive medicine to improve our nation's health is enormous. Although our efforts to practice in a preventive fashion have been less than adequate, changes are taking place that should significantly enhance the practice of preventive medicine.

References

1. Eggert RW, Parkinson MD. Preventive medicine and health system reform. Improving physician education, training, and practice. JAMA 1994(9); 272:688-693.
2. Frame PS. A critical review of adult health maintenance, Part 3. Prevention of cancer. J Fam Pract. 1986; 22:511.
3. Tomar SL, Husten CG, Manley MW. Do dentists and physicians advise tobacco users to quit? JADA 1996; 127:259-265.
4. Solberg LI, The Institute for Clinical Systems Integration, Minneapolis. Tobacco-use prevention and cessation for infants, children, adolescents, and adults. Tobacco-Use Cessation Guideline. 1997;101(3):292-300.
5. Melkus GD. Obesity: Assessment and intervention for primary care practice. Nurse Practitioner Forum. 1994;5(1):28-33.
6. Woolf S, Jonas S, Lawrence R. Health promotion and disease prevention in clinical practice. (Williams & Wilkins, 1996), pXXV.
7. Dickey LL, Kamerow DB. Primary care physicians' use of office resources in the provision of preventive care. Arch Fam Med 1996; 5:399-404.
8. Friedman C, Brownson RC, Peterson DE, Wilkerson JC. Physician advice to reduce chronic disease risk factors. Am J Prev Med 1994; 10(6):367-71.
9. Kreuter MW, Scharff DP, Brennan LK, Lukwago SN. Physician recommendations for diet and physical activity: which patients get advised to change? Preventive Medicine. 1997; 26:825-833.
10. Love RR, Davis JE, Mundt M, Clark C. Health promotion and screening services reported by older adult patients of urban primary care physicians. The J Family Practice 1997; 45(2):142-150.
11. O'Donnell M, Ainsworth T. Health promotion in the workplace. John Wiley & Sons, 1984.

June, 1998/ Jacksonville Medicine

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