American College of Preventive Medicine: Addressing the Opioid Epidemic Through a Prevention Framework.

The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.

Recommendations for Population-Based Applications of the Adverse Childhood Experiences Study: Position Statement by the American College of Preventive Medicine.

Introduction: Childhood adversity profoundly influences health, well-being, and longevity. Prevention and interventions to mitigate its harmful effects are essential. The American College of Preventive Medicine reviewed the research literature and other professional and governmental statements about adverse childhood experiences to support the development of evidence-based and population-focused recommendations about prevention, screening, and mitigation interventions for childhood adversity. Methods: We performed an umbrella review to find, assess and synthesize the evidence from systematic reviews focused on 3 key questions: the prevention or mitigation of the effects of adverse childhood experiences; the association of screening for adverse childhood experiences with various benefits, including health outcomes; and the effectiveness and harms of interventions in individuals with elevated adverse childhood experience scores. Adverse childhood experience‒related recommendations from 6 professional and governmental organizations were also reviewed. On the basis of these reviews, the American College of Preventive Medicine developed a position statement through consensus. Results: A total of 8 systematic reviews, including 260 studies in total, were identified and combined with adverse childhood experiences‒related recommendations from 6 professional organizations to support the American College of Preventive Medicine recommendations. The American College of Preventive Medicine offers 7 adverse childhood experiences‒related recommendations focused on screening, education/training, policy/practice, and research: 2 are evidence-based, and 5 are based on expert opinion. Notably, regarding secondary prevention of adverse childhood experiences, the American College of Preventive Medicine endorses population-level surveillance and research around childhood adversity but not adverse childhood experience screening in individual clinical encounters. Conclusions: Despite limitations in the heterogeneity and quality of the published systematic reviews, the extant literature supports the American College of Preventive Medicine recommendations. Interventions to enhance protective factors and prevent and mitigate the consequences of adverse childhood experiences and other childhood adversity are promising and require further implementation and research.

Intimate Partner Violence Screening and Intervention: The American College of Preventive Medicine Position Statement.

The purpose of this paper is to produce a position statement on intimate partner violence (IPV), a major sociomedical problem with recently updated evidence, systematic reviews, and U.S. Preventive Services Task Force guidelines. This position statement is a nonsystematic, rapid literature review on IPV incidence and prevalence, health consequences, diagnosis and intervention, domestic violence laws, current screening recommendations, barriers to screening, and interventions, focusing on women of childbearing age (15-45 years). The American College of Preventive Medicine (ACPM) recommends an integrated system of care approach to IPV for screening, identification, intervention, and ongoing clinical support. ACPM only recommends screening that is linked to ongoing clinical support for those at risk. ACPM recommends greater training of clinicians in IPV screening and interventions and offers health systems and research recommendations.

Electronic Nicotine Delivery Systems or E-cigarettes: American College of Preventive Medicine's Practice Statement.

INTRODUCTION: E-cigarettes or or electronic nicotine delivery systems (ENDS) have rapidly gained popularity in the U.S. Controversy exists about the safety and efficacy of ENDS. The American College of Preventive Medicine's Prevention Practice Committee undertook a consensus-based evidence review process to develop a practice statement for the American College of Preventive Medicine. METHODS: A rapid review of the literature was performed through June 2017 to identify efficacy, patient-oriented harms, and the impact on population health. RESULTS: On an individual level, limited evidence suggests that ENDS may be effective at reducing cigarette use among adult smokers intending to quit. There is insufficient evidence addressing potential long-term harms of ENDS, and limited evidence is available about short-term harms of ENDS and the impact of secondhand exposure. Although ENDS appear safer than combustible cigarettes, they are not without risk. Among youth there is no known benefit and significant concern for harm. On a population level, there may be significant harms associated with ENDS, particularly among youth nonsmokers. The long-term balance of potential benefits versus harms from the individual and population perspectives are unclear. CONCLUSIONS: The American College of Preventive Medicine developed practice recommendations that include encouraging screening for ENDS use, strategies to prevent the initiation of ENDS use in nonsmokers, particularly in youth, adoption of a harm reduction model for smokers intending to quit in those who refuse or fail to quit with evidence-based smoking-cessation methods, recommendations on policy and regulatory strategies to decrease public use of ENDS and regulation of their components, and future research needs.

Practice Policy Statement: Integrating Effective Weight Management Into Practice.

The American College of Preventive Medicine Prevention Practice Committee contributes to policy guidelines and recommendations on preventive health topics for clinicians and public health decision makers. As an update to a previously published statement on weight management counseling of overweight adults, the College is providing a consensus-based recommendation designed to more effectively integrate weight management strategies into clinical practice and to incorporate referrals to effective evidence-based community and commercial weight management programs. The goal is to empower providers to include lifestyle interventions as part of the foundation of clinical practice.

Choosing Wisely® in Preventive Medicine: The American College of Preventive Medicine's Top 5 List of Recommendations.

The Choosing Wisely(®) initiative is a national campaign led by the American Board of Internal Medicine Foundation, focused on quality improvement and advancing a dialogue on avoiding wasteful or unnecessary medical tests, procedures, and treatments. The American College of Preventive Medicine (ACPM) Prevention Practice Committee is an active participant in the Choosing Wisely project. The committee created the ACPM Choosing Wisely Task Force to lead the development of ACPM's recommendations with the intention of facilitating wise decisions about the appropriate use of preventive care. After utilizing an iterative process that involved reviewing evidence-based literature, the ACPM Choosing Wisely Task Force developed five recommendations targeted toward overused services within the field of preventive medicine. These include: (1) don't take a multivitamin, vitamin E, or beta carotene to prevent cardiovascular disease or cancer; (2) don't routinely perform prostate-specific antigen-based screening for prostate cancer; (3) don't use whole-body scans for early tumor detection in asymptomatic patients; (4) don't use expensive medications when an equally effective and lower-cost medication is available; and (5) don't perform screening for cervical cancer in low-risk women aged 65 years or older and in women who have had a total hysterectomy for benign disease. The Task Force also reviewed some of the barriers to implementing these recommendations, taking into account the interplay between system and environmental characteristics, and identified specific strategies necessary for timely utilization of these recommendations.

The American College of Preventive Medicine Position Statement on Hepatitis C Virus Infection.

The American College of Preventive Medicine Prevention Practice Committee contributes to policy guidelines and recommendations on preventive health topics for clinicians and public health decision makers. After review of the currently available evidence, the College is providing a consensus-based set of recommendations designed to increase screening for and prevention of hepatitis C virus infection, increase linkage to care, improve access to treatment, and encourage development of hepatitis C virus-related quality measures.

Preventing texting while driving: a statement of the American College of Preventive Medicine.

The American College of Preventive Medicine (ACPM) is providing a set of recommendations designed to reduce the morbidity and mortality associated with distractions due to texting while driving. According to the National Highway Traffic Safety Administration, 12% of all fatal crashes involving at least one distracted driver are estimated to be related to cell phone use while driving. Given the combination of visual, manual, and cognitive distractions posed by texting, this is an issue of major public health concern for communities. Therefore, the ACPM feels it is timely to discuss this issue and provide the following recommendations: 1. Encourage state legislatures to develop and pass legislation banning texting while driving, while simultaneously implementing comprehensive and dedicated law enforcement strategies including penalties for these violations. Legislatures should establish a public awareness campaign regarding the dangers of texting while driving as an integral part of this legislation. 2. Promote further research into the design and evaluation of educational tools regarding texting while driving that can be incorporated into the issuance of driver's licenses. 3. Provide primary care providers with the appropriate tools to educate patients of all ages. 4. Conduct additional studies investigating the risks associated with cell phone usage while driving, particularly texting, with motor vehicle crashes.

What is new in HIV infection?

Human immunodeficiency virus (HIV) prevention and treatment updates include screening recommendations, fourth-generation testing, preexposure prophylaxis, and a paradigm shift; treatment is prevention. The U.S. Preventive Services Task Force recommends routine HIV screening in persons 15 to 65 years of age, regardless of risk. Fourth-generation testing is replacing the Western blot and can identify those with acute HIV infection. The U.S. Food and Drug Administration approved the OraQuick In-Home HIV Test; however, there are concerns about reduced sensitivity, possible misinterpretation of results, potential for less effective counseling, and possible cost barriers. Preexposure prophylaxis (effective in select high-risk adult populations) is the combination of safer sex practices and continuous primary care prevention services, plus combination antiretroviral therapy. Concerns for preexposure prophylaxis include the necessity of strict medication adherence, limited use among high-risk populations, and community misconceptions of appropriate use. Evidence supports combination antiretroviral therapy as prevention for acute HIV infection, thus lowering community viral loads. Evidence has increased supporting combination antiretroviral therapy for treatment at any CD4 cell count. Resistance testing should guide therapy in all patients on entry into care. Within two weeks of diagnosis of most opportunistic infections, combination antiretroviral therapy should be started; patients with tuberculosis and cryptococcal meningitis require special considerations.

Development of Verbal HITS for intimate partner violence screening in family medicine.

BACKGROUND AND OBJECTIVES: Researchers in intimate partner violence (IPV) screening have developed a short written tool called HITS. The acronym corresponds to questions that elicit information about how often a woman's male partner physically Hurts, Insults, Threatens harm, and Screams at her. The purpose of this study was to develop a verbal form of the HITS and to compare it to the published written version. METHODS: A secondary analysis of data from prior HITS research was conducted. From this, the screening questions were modified for oral presentation so that patients could respond with a yes or no answer. To test the comparability of the two screening formats, 103 adult female patients completed both forms of the HITS during routine office visits. Phase one of this study used Optimal Data Analysis (ODA) on 210 cases from prior HITS research to create a cut score that differentiates clinic patients from self-identified victims of abuse. From this, written HITS questions were modified for verbal administration. Phase two of this study used t test, ANOVA, and classification of two screening formats to compare the written and verbal HITS administered to 103 adult female family medicine patients. RESULTS: Responses to both types of screening were related. The mean score on the written HITS was statistically higher for respondents who reported "yes" to a Verbal HITS question. This was consistent across all four questions. Also, the mean written HITS score increased linearly as a function of the number of yes answers on the Verbal HITS. The screening classification (positive, negative) from both forms of the HITS was the same for 83% of the respondents. CONCLUSIONS: The verbal and written HITS comprise two ways that clinicians can screen for domestic violence.

Policies to restrict secondhand smoke exposure: American College of Preventive Medicine Position Statement.

Secondhand smoke (SHS) exposure poses serious health risks for all nonsmokers, especially children and pregnant women. SHS is estimated to contribute to heart attacks in nonsmokers and nearly 53,800 deaths in the U.S. annually. A literature review of English-language articles was performed using PubMed, organizational websites, and pertinent review articles. Over the past 25 years, smokefree policies have protected nearly half the U.S. population from the adverse health effects of SHS. Smokefree policies have been shown to improve health outcomes with no consequences to local businesses. As of April 2013, a total of 24 states and 561 municipalities and territories, including the District of Columbia, New York City, Puerto Rico, and the U.S. Virgin Islands, have established laws that require nonhospitality workplaces, restaurants, and bars to be 100% smokefree. Four other states-Florida, Indiana, Louisiana, and Nevada-have smokefree laws that cover restaurants but provide an exemption for stand-alone bars. At least 14 states have no smokefree laws. This paper describes the benefits of policies that reduce SHS and concludes with recommendations for future directions. The American College of Preventive Medicine (ACPM) recommends expanded clean indoor air policies for workplaces, stand-alone bars, restaurants, and multi-use family housing such as apartment buildings. ACPM recommends clean air policies for all university campuses, secondary school campuses, primary schools, child care centers, and city landmarks to further shift social norms and protect the health of children, adolescents, and adults. ACPM recommends closing existing gaps in clean indoor air policies.

Screening for osteoporosis in the adult U.S. population: ACPM position statement on preventive practice.

CONTEXT: Osteoporosis is a common and costly disease that is associated with high morbidity and mortality. There is a lack of direct evidence supporting the benefits of bone mineral density (BMD) screening on osteoporosis outcomes. However, there is indirect evidence to support screening for osteoporosis given the availability of medications with good antifracture efficacy. This paper addresses the position of the American College of Preventive Medicine (ACPM) on osteoporosis screening. EVIDENCE ACQUISITION: The medical literature was reviewed for studies examining the benefits and harms of osteoporosis screening. An overview is also provided of available modalities for osteoporosis screening, risk-assessment tools, cost effectiveness, benefits and harms of screening, rationale for the study, and recommendations from leading health organizations and ACPM. A review was done of English language articles published prior to September 2008 that were retrieved via search on PubMed, from references from pertinent review or landmark articles, and from websites of leading health organizations. EVIDENCE SYNTHESIS: There were no randomized controlled trials (RCTs) of osteoporosis screening on fracture outcomes. However, there was one observational study that demonstrated reduced fracture incidence among recipients of BMD testing. Dual energy x-ray absorptiometry is currently one of the most widely accepted and utilized methods for assessing BMD. Other potential tests for detecting osteoporosis include quantitative ultrasound, quantitative computer tomography, and biochemical markers of bone turnover. Testing via BMD is a cost-effective method for detecting osteoporosis in both men and women. Osteoporosis risk-assessment tools such as the WHO fracture-risk algorithm are useful supplements to BMD assessments as they provide estimates of absolute fracture risks. They can also be used with or without BMD testing to assist healthcare providers and patients in making decisions regarding osteoporosis treatments. CONCLUSIONS: All adult patients aged >or=50 years should be evaluated for risk factors for osteoporosis. Screening with BMD testing for osteoporosis is recommended in women aged >or=65 years and in men aged >or=70 years. Younger postmenopausal women and men aged 50-69 years should undergo screening if they have at least one major or two minor risk factors for osteoporosis. It is also recommended that clinicians consider using an osteoporosis risk-assessment tool to evaluate absolute fracture risk to determine appropriate osteoporosis therapies.

Screening for prostate cancer in U.S. men ACPM position statement on preventive practice.

INTRODUCTION: Prostate cancer is the leading cancer in U.S. men, and the third leading cause of cancer deaths. Principal screening tests for detection of asymptomatic prostate cancer include digital rectal examination (DRE) and measurement of the serum tumor marker, prostate-specific antigen (PSA). There are risks and benefits associated with prostate cancer screening. Randomized controlled trials of screening by DRE and PSA are limited to two previously published studies. Two other large-scale randomized controlled trials are currently in progress. METHODS: This study reviewed the efficacy of DRE and PSA for prostate cancer screening found in the medical literature prior to July 2007. RESULTS: Applications of PSA screening tests used in clinical practice include (1) a PSA cutoff of 4 ng/ml, (2) age-specific PSA, (3) PSA velocity, (4) PSA density, and (5) percent free PSA. Prostate cancer screening can detect early disease and offers the potential to decrease morbidity and mortality. Prostate cancer screening benefits, however, remain unproven, pending results of ongoing trials. There is currently no convincing evidence that early screening, detection, and treatment improves mortality. Limitations of prostate cancer screening include potential adverse health effects associated with false-positive and negative results, and treatment side effects. CONCLUSIONS: The American College of Preventive Medicine concludes that there is insufficient evidence to recommend routine population screening with DRE or PSA. Clinicians caring for men, especially African-American men and those with positive family histories, should provide information about potential benefits and risks of prostate cancer screening, and the limitations of current evidence for screening, in order to maximize informed decision making.

Factors influencing community health centers' efficiency: a latent growth curve modeling approach.

The objective of study is to examine factors affecting the variation in technical and cost efficiency of community health centers (CHCs). A panel study design was formulated to examine the relationships among the contextual, organizational structural, and performance variables. Data Envelopment Analysis (DEA) of technical efficiency and latent growth curve modeling of multi-wave technical and cost efficiency were performed. Regardless of the efficiency measures, CHC efficiency was influenced more by contextual factors than organizational structural factors. The study confirms the independent and additive influences of contextual and organizational predictors on efficiency. The change in CHC technical efficiency positively affects the change in CHC cost efficiency. The practical implication of this finding is that healthcare managers can simultaneously optimize both technical and cost efficiency through appropriate use of inputs to generate optimal outputs. An innovative solution is to employ decision support software to prepare an expert system to assist poorly performing CHCs to achieve better cost efficiency through optimizing technical efficiency.