Preventive medicine

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List of terms related to Preventive medicine

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Generally speaking, preventive medicine is the part of medicine engaged with preventing disease rather than curing it. It can be contrasted not only with curative medicine, but also with public health methods (which work at the level of population health rather than individual health).

Professionals involved in the public health aspect of this practice may be involved in entomology, pest control, and public health inspections. Public health inspections can include recreational waters, pools, beaches, food preparation and serving, and industrial hygiene inspections and surveys.

Preventive medicine or preventive care consists of measures taken to prevent diseases,[1] (or injuries) rather than curing them or treating their symptoms. This contrasts in method with curative and palliative medicine, and in scope with public health methods (which work at the level of population health rather than individual health). Occupational medicine operates very often within the preventive medicine.

Levels

Preventive medicine strategies are typically described as taking place at the primary, secondary, tertiary and quaternary prevention levels. In addition, the term primal prevention has been used to describe all measures taken to ensure fetal well-being and prevent any long-term health consequences from gestational history and/or disease.[2] The rationale for such efforts is the evidence demonstrating the link between fetal well-being, or "primal health," and adult health.[3][4] Primal prevention strategies typically focus on providing future parents with: education regarding the consequences of epigenetic influences on their child,[5] sufficient leave time for both parents, and financial support if required. This includes parenting in infancy as well.

Simple examples of preventive medicine include hand washing, breastfeeding, and immunizations. Preventive care may include examinations and screening tests tailored to an individual's age, health, and family history. For example, a person with a family history of certain cancers or other diseases would begin screening at an earlier age and/or more frequently than those with no such family history. On the other side of preventive medicine, some nonprofit organizations, such as the Northern California Cancer Center, apply epidemiologic research towards finding ways to prevent diseases.

Prevention levels[6] Doctor’s side
Disease
absent present
Patient’s
side
Illness absent Primary prevention
illness absent
disease absent
Secondary prevention
illness absent
disease present
present Quaternary prevention
illness present
disease absent
Tertiary prevention
illness present
disease present

Definitions

Level Definition
Primary prevention Methods to avoid occurrence of disease.[7] Most population-based health promotion efforts are of this type.
Secondary prevention Methods to diagnose and treat existent disease in early stages before it causes significant morbidity.[8]
Tertiary prevention Methods to reduce negative impact of extant disease by restoring function and reducing disease-related complications.[9]
Quaternary prevention Methods to mitigate or avoid results of unnecessary or excessive interventions in the health system.[10]

Universal, selective, and indicated

Gordon (1987) in the area of disease prevention,[11] and later Kumpfer and Baxley in the area of substance use[12] proposed a three-tiered preventive intervention classification system: universal, selective, and indicated prevention. Amongst others, this typology has gained favour and is used by the U.S. Institute of Medicine, the NIDA and the European Monitoring Centre for Drugs and Drug Addiction.

Tier Definition
Universal prevention Involves whole population (nation, local community, school, district) and aims to prevent or delay the abuse of alcohol, tobacco, and other drugs. All individuals, without screening, are provided with information and skills needed to prevent the problem.
Selective prevention Involves groups whose risk of developing problems of alcohol abuse or dependence is above average. Subgroups may be distinguished by traits such as age, gender, family history, or economic status. For example, drug campaigns in recreational settings.
Indicated prevention Involves a screening process, and aims to identify individuals who exhibit early signs of substance abuse and other problem behaviours. Identifiers may include falling grades among students, known problem consumption or conduct disorders, alienation from parents, school, and positive peer groups etc.

Outside the scope of this three-tier model is environmental prevention. Environmental prevention approaches are typically managed at the regulatory or community level and focus on ways to deter drug consumption. Prohibition and bans (e.g. on smoking, alcohol advertising) may be viewed as the ultimate environmental restriction. However, in practice, environmental preventions programs embrace various initiatives at the macro and micro level, from government monopolies for alcohol sales through roadside sobriety or drug tests, worker/pupil/student drug testing, increased policing in sensitive settings (near schools, at rock festivals), and legislative guidelines aimed at precipitating punishments (warnings, penalties, fines).

Professionals

Professionals involved in the public health aspect of this practice may be involved in entomology, pest control, and public health inspections. Public health inspections can include recreational waters, swimming pools, beaches, food preparation and serving, and industrial hygiene inspections and surveys.

In the United States, preventive medicine is a medical specialty, one of the 24 recognized by the American Board of Medical Specialties (ABMS). It encompasses three areas of specialization:

  • General preventive medicine and public health
  • Aerospace medicine
  • Occupational medicine

To become board-certified in one of the preventive medicine areas of specialization, a licensed U.S. physician (M.D. or D.O.) must successfully complete a preventive medicine medical residency program following a one-year internship. Following that, the physician must pass the preventive medicine board examination. The residency program is at least two years in length and includes completion of a master's degree in public health (MPH) or equivalent. The board exam takes a full day: the morning session concentrates on general preventive medicine questions, while the afternoon session concentrates on the one of the three areas of specialization that the applicant has studied.

In addition, there are two subspecialty areas of certification:

These certifications require sitting for an examination following successful completion of an MT or UHB fellowship and prior board certification in one of the 24 ABMS-recognized specialties.

Prophylaxis

Prophylaxis (Greek: προφυλάσσω to guard or prevent beforehand) is any medical or public health procedure whose purpose is to prevent, rather than treat or cure a disease. In general terms, prophylactic measures are divided between primary prophylaxis (to prevent the development of a disease) and secondary prophylaxis (whereby the disease has already developed and the patient is protected against worsening of this process).

Examples

Some specific examples of prophylaxis include:

Limitations

Since preventive medicine deals with healthy individuals or populations the costs and potential harms from interventions need even more careful examination than in treatment. For an intervention to be applied widely it generally needs to be affordable and highly cost effective.

For instance, intrauterine devices (IUD) are highly effective and highly cost effective contraceptives, however where universal health care is not available the initial cost may be a barrier.[20] IUDs work for several years (3 to 7 or more) and cost less over a year or two's time than most other reversible contraceptive methods.[21] They are also highly cost effective, saving health insurers and the public significant costs in unwanted pregnancies.[21] Making contraceptives available with no up front cost is one way to increase usage, improving health and saving money.[22]

Preventive solutions may be less profitable and therefore less attractive to makers and marketers of pharmaceuticals and medical devices. Birth control pills which are taken every day and may take in a thousand dollars over ten years may generate more profits than an IUD, which despite a huge initial markup only generates a few hundred dollars over the same period.[20]

Leading cause of preventable death

Leading causes of preventable death worldwide as of the year 2001[23]
Cause Deaths caused (millions per year)
Hypertension 7.8
Smoking 5.0
High cholesterol 3.9
Malnutrition 3.8
Sexually transmitted infections 3.0
Poor diet 2.8
Overweight and obesity 2.5
Physical inactivity 2.0
Alcohol 1.9
Indoor air pollution from solid fuels 1.8
Unsafe water and poor sanitation 1.6
Leading preventive interventions that reduce deaths in children 0–5 years old worldwide[24]
Intervention Percent of all child deaths preventable
Breastfeeding 13
Insecticide-treated materials 7
Complementary feeding 6
Zinc 4
Clean delivery 4
Hib vaccine 4
Water, sanitation, hygiene 3
Antenatal steroids 3
Newborn temperature management 2
Vitamin A 2
Tetanus toxoid 2
Nevirapine and replacement feeding 2
Antibiotics for premature rupture of membranes 1
Measles vaccine 1
Antimalarial intermittent preventive treatment in pregnancy <1%
Leading causes of preventable deaths in the United States in the year 2000[25]
Cause Deaths caused % of all deaths
Tobacco smoking 435,000 18.1
Poor diet and physical inactivity 365,000 15.2
Alcohol consumption 85,000 3.5
Infectious diseases 75,000 3.1
Toxicants 55,000 2.3
Traffic collisions 43,000 1.8
Firearm incidents 29,000 1.2
Sexually transmitted infections 20,000 0.8
Drug abuse 17,000 0.7

As a medical specialty

In the United States, preventive medicine is a medical specialty, one of the 24 recognized by the American Board of Medical Specialties (ABMS). It encompasses three areas of specialization:

  • General preventive medicine and public health
  • Aerospace medicine
  • Occupational medicine

In order to become board-certified in one of the preventive medicine areas of specialization, a licensed U.S. physician (M.D. or D.O.) must successfully complete a preventive medicine medical residency program following a one year internship. Following that, the physician must complete a year of practice in that special area and pass the preventive medicine board examination. The residency program is at least two years in length, and includes completion of a post-graduate masters degree in public health (MPH) or equivalent. The board exam takes an entire day: The morning session concentrates on general preventive medicine questions. The afternoon session concentrates on the one of the three areas of specialization that the applicant has studied.

In addition, there are two subspecialty areas of certification:

  • Medical toxicology (MT)
  • Undersea and hyperbaric medicine (UHB), formerly "undersea medicine"

These certifications require sitting for an examination following successful completion of an MT or UHB fellowship and prior board certification in one of the 24 ABMS-recognized specialties

Rose's theorem

Rose's Theorem states that "a large number of people at small risk may give rise to more cases of disease than a small number who are at high risk."[26]

See also

References

  1. Preventive+Medicine at the US National Library of Medicine Medical Subject Headings (MeSH)
  2. Primal Research Centre, London
  3. Primal Health Research Databank
  4. Effect of In Utero and Early-Life Conditions on Adult Health and Disease, by P.D.Gluckman et al., N ENGL J MED 359;1
  5. Origins: How the nine months before birth shape the rest of your life, by Annie Murphy Paul, Time magazine, 176.14, 2010
  6. Kuehlein T, Sghedoni D, Visentin G, Gérvas J, Jamoule M. Quaternary prevention: a task of the general practitioner. PrimaryCare. 2010; 10(18):350-4.
  7. Primary+Prevention at the US National Library of Medicine Medical Subject Headings (MeSH)
  8. Secondary+Prevention at the US National Library of Medicine Medical Subject Headings (MeSH)
  9. Tertiary+Prevention at the US National Library of Medicine Medical Subject Headings (MeSH)
  10. Gofrit ON, Shemer J, Leibovici D, Modan B, Shapira SC. Quaternary prevention: a new look at an old challenge. Isr Med Assoc J. 2000;2(7):498-500.
  11. Gordon, R. (1987), ‘An operational classification of disease prevention’, in Steinberg, J. A. and Silverman, M. M. (eds.), Preventing Mental Disorders, Rockville, MD: U.S. Department of Health and Human Services, 1987.
  12. Kumpfer, K. L., and Baxley, G. B. (1997), 'Drug abuse prevention: What works?', National Institute on Drug Abuse, Rockville.
  13. Lars Bo Andersen; et al. (2000). "All-cause mortality associated with physical activity during leisure time, work, sports, and cycling to work". Archives of Internal Medicine. 160 (11): 1621–8. doi:10.1001/archinte.160.11.1621. PMID 10847255. Unknown parameter |month= ignored (help)
  14. United States Department of Agriculture. "Why is it important to eat fruit?". United States Department of Agriculture. Retrieved 8 February 2012.
  15. de Oliveira JC, Martinelli M, D'Orio Nishioka SA; et al. (2009). "Efficacy of antibiotic prophylaxis prior to the implantation of pacemakers and cardioverter-defibrillators: Results of a large, prospective, randomized, double-blinded, placebo-controlled trial". Circulation: Arrhythmia and Electrophysiology. 2 (1): 29–34. doi:10.1161/CIRCEP.108.795906. PMID 19808441.
  16. Qaseem A, Chou R, Humphrey LL; et al. (2011). "Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians". Annals of Internal Medicine. 155 (9): 625–632. doi:10.1059/0003-4819-155-9-201111010-00011. PMID 22041951.
  17. Lederle FA, Zylla D, MacDonald R; et al. (2011). "Venous Thromboembolism Prophylaxis in Hospitalized Medical Patients and Those With Stroke: A Background Review for an American College of Physicians Clinical Practice Guideline". Annals of Internal Medicine. 155 (9): 602–615. doi:10.1059/0003-4819-155-9-201111010-00008. PMID 22041949.
  18. Kahn SR, Lim W, Dunn AS; et al. (2012). "Prevention of VTE in Nonsurgical Patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 suppl): e195S–e226S. doi:10.1378/chest.11-2296. PMID 22315261. Unknown parameter |month= ignored (help)
  19. Ip S, Chung M, Raman G, ChewP, Magula N, DeVine D, Litt M, Trikalinos T, Lau J. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Report/Technology Assessment Number 153. 2007 April; AHRQ Publication No. 07-E007.
  20. 20.0 20.1 J. Joseph Speidel, Cynthia C. Harper, and Wayne C. Shields (2008). "The Potential of Long-acting Reversible Contraception to Decrease Unintended Pregnancy". Contraception. Unknown parameter |month= ignored (help)
  21. 21.0 21.1 James Trussell, Anjana Lalla, Quan Doan, Eileen Reyes, Lionel Pinto, Joseph Gricar (2009). "Cost effectiveness of contraceptives in the United States". Contraception. 79 (1): 5–14. doi:10.1016/j.contraception.2008.08.003. PMID 19041435.
  22. Monea J, Thomas A (2011). "Unintended pregnancy and taxpayer spending". Perspectives on Sexual and Reproductive Health. 43 (2): 88–93. doi:10.1363/4308811. PMID 21651707. Unknown parameter |month= ignored (help)
  23. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ (2006). "Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data". Lancet. 367 (9524): 1747–57. doi:10.1016/S0140-6736(06)68770-9. PMID 16731270. Unknown parameter |month= ignored (help)
  24. Jones G, Steketee R, Black R, Bhutta Z, Morris S, and the Bellagio Child Survival Study Group* (2003). "How many child deaths can we prevent this year?". Lancet. 362 (9524): 1747–57. Unknown parameter |month= ignored (help)
  25. Mokdad AH, Marks JS, Stroup DF, Gerberding JL (2004). "Actual causes of death in the United States, 2000" (PDF). JAMA. 291 (10): 1238–45. doi:10.1001/jama.291.10.1238. PMID 15010446. Unknown parameter |month= ignored (help)
  26. Rose, G.: The Strategy of Preventive Medicine. Oxford, England, Oxford University Press; 1992.

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