Preventing cervical cancer: the Pap test and the HPV vaccine

Women look to their internists and other primary care physicians to provide preventive health care. Periodic Pap tests are as much a part of a woman's ongoing health care as periodic lipid assessments, mammograms, screening for colon cancer, or any of the other recommended screening assessments. This article provides primary care physicians with the information needed to perform Pap tests at the appropriate intervals, or if not set up to do Pap tests themselves, to make the appropriate referrals. Also provided is the necessary information to counsel women with abnormal Pap tests who may need colposcopy or other follow-up evaluation. Finally, the role of the HPV vaccine in the prevention of cervical cancer is summarized.     

Pay-for-performance incentives for preventive care: views of family physicians before and after participation in a reminder and recall project (P-PROMPT)

Objective

The Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) project was designed to increase the rates of delivery of 4 targeted preventive care services to eligible patients in primary care network and family health network practices eligible for pay-for-performance incentives.

Design

Self-administered fax-back surveys completed before and after participation in the P-PROMPT project.

Setting

Southwestern Ontario.

Participants

A total of 246 physicians from 24 primary care network or family health network practices across 110 different sites.

Interventions

The P-PROMPT project provided several tools and services, including physician and patient reminders, office management tools, and administrative database integration.

Main outcome measures

Physicians’ views about the delivery of preventive health services and pay-for-performance incentives before and after participation in the P-PROMPT project.

Results

The preintervention survey was completed by 86.2% (212 of 246) of physicians and the postintervention survey was completed by 53.3% (131 of 246) of physicians; 46.7% (114 of 246) of the physicians completed both surveys. Overall, 80.5% of physicians indicated that the P-PROMPT project was useful (scores of 5 or higher on a 7-point Likert scale). Patient reminder letters (89.1%), physician approval lists of eligible patients (75.6%), administrative assistance with management fees (79.8%), and annual bonus calculations (75.2%) were rated as the most useful features of the program. Compared with the preintervention survey, there were statistically significant increases in the mean agreement scores that the established target levels and bonuses provided appropriate financial incentive to substantially increase the uptake of mammography (P = .012) and Papanicolaou tests (P = .003) but not to increase uptake of annual influenza vaccination or childhood immunizations. There were statistically significant changes in the mean ratings of relying on an opportunistic approach (P < .001), increased agreement about the effectiveness of the current approach to delivery of preventive care (P < .001), and increased use of preventive management fees to recall patients (P < .001).

Conclusion

The preventive care management program and P-PROMPT were viewed favourably by most respondents and were perceived to be useful in improving delivery of preventive health care services.     

Cost-Effective Prevention of Coronary Heart Disease

Healthcare designed to prevent future illness and minimize progression of current illness is a powerful means to improve quality of life, minimize mortality, and decrease health care costs. Coronary heart disease (CHD) is the #1 killer of both men and women in the United States. Prevention of CHD involves early identification and management of risk factors through assessment and treatment. The goal in CHD prevention is to produce the largest relative risk reduction, the smallest number needed to treat, and the lowest cost per quality-adjusted life year saved. Evidence-based treatment strategies have been shown to cost-effectively minimize CHD risk and reduce morbidity and mortality. Approaches that encompass the lifespan, solidify assessment and treatment strategies in the primary care setting, and reach into the workplace, schools, churches, and homes to make small changes in risk factors across an entire population are important areas for improving CHD preventive care. Public health policies are also necessary to support implementation of preventive programs.     

Cancer in socioeconomically disadvantaged populations.

This article presents a summary of the health status of the disadvantaged populations in the United States, with specific regard to the incidence, treatment, and mortality of cancer. It begins with an historical overview of health care for the poor in this country, and continues with an explanation of the risk factors prevalent, if not inherent, in the life-style associated with low socioeconomic status, such as poor diet, cigarette smoking, and ignorance of preventive health measures and screening techniques. It includes a discussion of the different types that are overrepresented in this population and of the barriers to preventive care and treatment that still exist. The most important of these is decreased access to continuous medical care because of a lack of health insurance and an overdependence on emergency room treatment for all health care. The final section reviews solutions that have been preferred by physicians, nurses, lawmakers, public health workers, and community advocates for the poor. The most important parts of the solution are patient education for preventive health care, disease warning signs, and screening techniques and an overhaul of the present system of providing health care to ensure equal access and treatment for all members of the society.     

Health maintenance in clinical practice: strategies and barriers.

Obstacles to the implementation of preventive services in clinical practice include barriers raised by patients, physicians and the health care delivery system itself. Physicians may overcome these barriers to a great extent by improving their time management skills, practice organization system and reinforcement mechanisms. For clinical prevention to be successfully initiated and maintained in practice: (1) the program must be simple and include only procedures the providers believe are worthwhile; (2) an organized record system should be used; (3) a system of checks and reinforcements for prevention must be instituted in the practice routine, and (4) adequate time for preventive services must be allocated, either by using paramedical personnel or by restricting the practice size.     

Preventive health care for older patients

This chapter addresses key components of screening and preventive care for the older population. The older population is heterogeneous, ranging from the competent, active, well individual to the frail, demented individual. Certain preventive measures are important for all individuals such as counseling on exercise and screening for high blood pressure. However, universal cancer, cholesterol, or dementia screening may not be cost effective and beneficial in all older adults. These preventive measures should be guided by the individuals' circumstances including their life expectancy, co-morbid illnesses, functional capacity, and quality of life. Clinicians may be able to individualize preventive medicine decisions by stratifying their patients into well and frail using the guidelines we have provided. The goal of prevention and screening in older patients is to improve function and quality of life. Primary care physicians should facilitate discussion of preventive measures with their older patients as part of their ongoing health care.     

Travelling on parallel tracks: patient and physician perspectives on why women delay seeking care for breast cancer symptoms

In the breast cancer literature, "delayed presentation" is defined as a delay of > 3 months from the self-detection of a new breast cancer symptom until presentation to a health care provider. It has been established that early detection of breast cancer is associated with better health outcomes. The purpose of this qualitative study was to explore reasons why women delay seeking care for their breast cancer symptoms by asking both women and family physicians for their perspectives. Narrative analysis was used to reveal the ways in which people make sense of their experiences and which parts of their stories are most important to them. We found differences in the explanatory narratives of women versus those of family physicians when it came to understanding delay. Suggestions to promote earlier presentation include improving physician-patient communication and encouraging physician and health care professional neutrality in making attributions about women's delay.     

Cancer at the workplace: health promotion and care programs

The "Europe Against Cancer" initiative seeks to reduce the prevalence of cancer by 15% by the year 2000. This has stimulated an increased awareness of cancer by health care professionals. A training manual was designed to provide opportunities for workplace health care professionals in Northern Ireland to make an impact in the area of prevention and early detection of cancer. The training manual examines attitudes and knowledge about cancer and discusses relevant, effective programs for the prevention and early detection of cancer. It also seeks to enable the development of care and rehabilitation support programs in the workplace. The process of developing the training manual involving occupational health and health education staff is considered to be part of its success.     

Physician perceptions of nurse practitioners: a replication study

Purpose: To replicate and update findings from an earlier study on the perceived incentives of physicians to work with nurse practitioners (NPs).
Data sources: Four hundred and three questionnaires were mailed to NPs who distributed them to their collaborating physicians.
Conclusion: Physicians ranked "accessibility to health care" and the "quality of care" as equally important and more important than "physician satisfaction" and "economic incentives." The findings were consistent with findings from the earlier study; however, the original study demonstrated a much clearer distinction among the four groups of incentives.
Implications for practice: These findings imply that collaboration between physicians and NPs is maturing as NPs move into more arenas in health care.     

Clinical Prevention and Population Health Curriculum Framework: the nursing perspective.

The Clinical Prevention and Population Health Curriculum Framework (Curriculum Framework) was developed by the Healthy People Curriculum Task Force comprised of representatives from allopathic and osteopathic medicine, dentistry, nursing and nurse practitioners, pharmacy and physicians assistants. This multidiscipline Task Force was covened to address the Healthy People 2010 objective of increasing the health promotion/prevention content in health professional education. A focus on clinical prevention and population health activities is central to the goal of improving the health status of the nation and offers the greatest potential to reduce many leading causes of death and improve quality of life across diverse populations. The Curriculum Framework provides a set of 4 components (evidence base for practice, clinical preventive services, health systems/health policy and community aspects of practice) and 19 domains for organizing and implementing the curriculum. The title "Clinical Prevention and Population Health" includes both individual and population focused health promotion and prevention efforts. The role of nursing in developing the Curriculum Framework, and the tailoring and implementation of the Curriculum Framework for undergraduate and graduate programs in nursing is discussed.     

Health screening in older women

Health screening is an important aspect of health promotion and disease prevention in women over 65 years of age. Screening efforts should address conditions that cause significant morbidity and mortality in this age group. In addition to screening for cardiovascular disease, cerebrovascular disease and cancer, primary care physicians should identify risk factors unique to an aging population. These factors include hearing and vision loss, dysmobility or functional impairment, osteoporosis, cognitive and affective disorders, urinary incontinence and domestic violence. Although screening for many conditions cannot be proved to merit an "A" recommendation (indicating conclusive proof of benefit), special attention to these factors can decrease morbidity and improve quality of life in aging women.     

Knowledge and beliefs about end-of-life care and the effects of specialized palliative care: a population-based survey in Japan

To clarify the knowledge and beliefs of the Japanese general population related to legal options, pain medications, communication with physicians, and hydration/nutrition in end-of-life care, and to explore the associations between end-of-life care they had experienced and these beliefs, a questionnaire survey was conducted on two target populations: 5000 general population subjects and 866 bereaved family members of cancer patents who died in 12 palliative care units in Japan. The respondents were requested to report the legal knowledge about end-of-life options, pain-related beliefs, communication-related beliefs, and hydration/nutrition-related beliefs, and their experiences with end-of-life care. A total of 3061 responses were analyzed (effective response rate, 54%). The respondents were classified into six groups: no bereavement experience (n = 949), those who had lost family members within the past 10 years from noncancer diseases at institutions (n = 673), those who lost family members from noncancer disease at home (n = 264), those who lost family members from cancer at institutions other than palliative care units (n = 525), those who lost family members from cancer at home (n = 86), and those who lost family members from cancer at palliative care units (n = 548). Across groups, 32-45% and 50-63% of the respondents stated that treatment withdrawal and double effect act were legal, respectively. Between 34% and 44% believed that cancer pain is not sufficiently relieved, 27-38% believed that opioids shorten life, and 24-33% believed that opioids cause addiction. Communication-related beliefs potentially resulting in barriers to satisfactory end-of-life discussion were identified in 31-40% ("physicians are generally poor at communicating bad news") and in 14-25% ("physicians are not comfortable discussing death"). The bereaved family members of the patients who died in palliative care units were significantly more likely than the other groups to believe that cancer pain is sufficiently relieved, and significantly less likely to believe that opioids shorten life, that opioids cause addiction, that physicians are generally poor at communicating bad news, and that physicians are uncomfortable discussing death. Between 33% and 50% of the respondents, including families from palliative care units, believed "artificial hydration should be continued as the minimum standard until death," while 15-31% agreed that "artificial hydration relieves patient symptoms." A significant proportion of the Japanese general population has beliefs about legal options, pain medications, and communication with physicians that potentially result in barriers to quality end-of-life care. As their experiences in specialized palliative care significantly influenced their belief, systematic efforts to spread quality palliative care activity are of value to lessen these barriers and achieve quality end-of-life care.     

Sexually transmitted infection. A challenge for nurses working with adolescents

Sexually active adolescents have high rates of STIs and many barriers to prevention and treatment because of developmental immaturity, difficulty with access to health care, and need for confidential care. Serious health consequences of STIs may occur many years after infection, further compounding adolescents' ability to link cause and effect. Nurses who are committed to the challenge of providing services for adolescents to prevent STIs can help by providing access to confidential care and promoting sexual health. High-risk youth require intensive preventive efforts. Nurses are in an ideal position to meet this challenge in their roles as providers, counselors, and sexuality educators in individual health care encounters and in prevention programs in clinics, schools, and community centers. Effective STI prevention programs should apply theories of behavior change, incorporate adolescents' attitudes and beliefs, and solicit input from the adolescents themselves.     

The use of cancer treatment summaries and care plans among Massachusetts physicians

Purpose

Cancer survivorship presents many challenges for affected individuals and their health care providers. Reports from The Institute of Medicine document these challenges and recommend the use of survivorship treatment summaries and care plans to improve communication and coordination of care for cancer survivors. The purpose of our study was to assess current use of treatment summaries and care plans in Massachusetts and identify obstacles to greater use.

Methods

A survey was mailed to cancer specialist physicians (CSPs) and primary care physicians (PCPs) in Massachusetts. The survey asked CSPs about their preparation of treatment summaries and care plans for their cancer survivor patients and perceived barriers to the provision of these documents. PCPs were asked about receipt and utility of treatment summaries and care plans and information they would like to see in these reports.

Results

One hundred eight CSPs and 400 PCPs answered the survey. Fifty-six percent of CSPs reported that they, or their staff, prepared treatment summaries for their cancer survivor patients; however, only 14% reported preparing care plans. Fifty-four percent of PCPs reported ever receiving a treatment summary, but only 16% ever received a care plan. CSPs cited lack of training, reimbursement, and templates as barriers to preparing care plans.

Conclusions

Interventions are needed to make treatment summaries and care plans a part of standard care for all cancer survivors. Increasing the use of treatment summaries and care plans will require specific training and reimbursement and may be facilitated by templates that capture automated data.     

Sun exposure and skin cancer prevention in children and adolescents.

Skin cancer is the most common form of malignancy today, and its incidence is rapidly increasing worldwide. Sun exposure is believed to be the primary factor behind this trend. Nearly 80% of a person's lifetime sun exposure occurs before age 21. Many skin cancer risk behaviors begin in early childhood; therefore, it is important to target the pediatric population for skin cancer prevention education. Parents, teachers, day care providers, and health care professionals should make sun safety a regular part of their practice. School nurses, in particular, are in a prime setting for educating the greatest number of children about sun safety. Age-appropriate skin cancer prevention education should become a routine part of the health curriculum at all grade levels. Numerous on-line resources are available to assist school nurses in the development of age-appropriate teaching materials and sun exposure policies for schools.     

Vitamins and cancer prevention. How much do we know?

Foods rich in vitamins, especially those containing beta carotene and vitamin C, lower the risk of cancer in humans. Whether vitamins alone are responsible for this reduced risk is not known. They may work synergistically with increased dietary fiber and decreased fat intake. Vitamin supplementation at doses higher than the recommended daily allowance is, at present, an unknown factor in preventing cancer and may cause toxic effects in some instances. Consuming megadoses doses of any vitamin or mineral as a cancer preventive should be discouraged. Physicians need to take a more aggressive stance against alternative health care providers who recommend questionable dietary or nutritional regimens. Because of the proliferation of food quacks in recent years and the danger they represent to the general public, physicians need to make preventive health care an important part of their responsibility. This includes educating patients on proper nutrition.     

The ups and downs for children with chronic illnesses

Children with chronic illnesses have the same basic need for preventive care as their healthy peers. In Michigan a Medicaid Physician Sponsor Plan was established to provide that care for this special population. Incentives and barriers for both physicians and families were identified as well as the advantages to providing care in a managed care delivery system.     

Barriers to health promotion and disease prevention in the Latino population

The Latino population of the United States is expected to increase substantially in the next 25 years. Although recent health promotion and disease prevention interventions have improved the health of the majority of Americans, the Latino community has derived less benefit from these advances. This is due to a number of interrelated factors, including a disproportionate representation of Latino Americans in the low socioeconomic strata and in the uninsured population. Even when insured, Latino Americans face significant barriers to health promotion and disease prevention. This policy analysis identifies barriers at the organizational and structural level of health care delivery, as well as at the level of the medical encounter. It provides a practical framework for intervention that is founded on the recruitment of Latino Americans into the health care workforce and leadership, the restructuring of health systems to be more responsive to the needs of diverse populations, and health care provider education on how to improve cross-cultural understanding and communication. By investing in a multifaceted approach that addresses barriers to health promotion and disease prevention in the Latino population, we can improve the quality of care delivered to this population and help eliminate racial and ethnic disparities in health care.     

Cancer screening promotion among medically underserved Asian American women: integration of research and practice

Mammography and Pap smear tests are known to be effective early detection measures for breast and cervical cancers, respectively, but Asian Americans are reluctant to make visits for routine preventive care. Quantitative and qualitative research conducted by the Healthy Asian Americans Project (HAAP) between 1996 and 1999 indicated that Asian residents in southeastern Michigan, like the general Asian population in the US, underutilized early cancer screening programs due to cultural, psychosocial, linguistic, and economic barriers. This article reports how the HAAP's research findings guided the Michigan Breast and Cervical Cancer Control Program (BCCCP) promotion (conducted from 2000 to 2001 among medically underserved Asian women residing in southeastern Michigan), and how evaluation of the HAAP's BCCCP promotion will direct future research and health promotion programs. The article presents strategies used to improve access to cancer screening programs for diverse Asian sub-groups as well as outcomes of the 2-year HAAP's BCCCP promotion among the target population. Discussion regarding lessons and experiences gained from integration of research and practice has implications on design and implementation of the cancer screening promotion for the rapidly increasing Asian American population as well as other medically underserved minority populations in the US.