Disease Prevention & Health Promotion

General Approach To The Patient

The medical interview serves several functions. It is used to collect information to assist in diagnosis (the “history” of the present illness), to assess and communicate prognosis, to establish a therapeutic relationship, and to reach agreement with the patient about further diagnostic procedures and therapeutic options. It also serves as an opportunity to influence patient behavior, such as in motivational discussions about smoking cessation or medication adherence. Interviewing techniques that avoid domination by the clinician increase patient involvement in care and patient satisfaction. Effective clinician-patient communication and increased patient involvement can improve health outcomes.

 Patient Adherence

For many illnesses, treatment depends on difficult fundamental behavioral changes, including alterations in diet, taking up exercise, giving up smoking, cutting down drinking, and adhering to medication regimens that are often complex. Adherence is a problem in every practice; up to 50% of patients fail to achieve full adherence, and one-third never take their medicines. Many patients with medical problems, even those with access to care, do not seek appropriate care or may drop out of care prematurely. Adherence rates for short-term, self-administered therapies are higher than for long-term therapies and are inversely correlated with the number of interventions, their complexity and cost, and the patient’s perception of overmedication.

As an example, in HIV-infected patients, adherence to antiretroviral therapy is a crucial determinant of treatment success. Studies have unequivocally demonstrated a close relationship between patient adherence and plasma HIV RNA levels, CD4 cell counts, and mortality. Adherence levels of > 95% are needed to maintain virologic suppression. However, studies show that over 60% of patients are < 90% adherent and that adherence tends to decrease over time.

Patient reasons for nonadherence include simple forgetfulness, being away from home, being busy, and changes in daily routine. Other reasons include psychiatric disorders (depression or substance abuse), uncertainty about the effectiveness of treatment, lack of knowledge about the consequences of poor adherence, regimen complexity, and treatment side effects.

Patients seem better able to take prescribed medications than to adhere to recommendations to change their diet, exercise habits, or alcohol intake or to perform various selfcare activities (such as monitoring blood glucose levels at home). A 2008 review on the effectiveness of interventions to improve medication adherence found that for shortterm regimens, adherence to medications can be improved by giving clear instructions. Writing out advice to patients, including changes in medication, may be helpful. Because low functional health literacy is common (almost half of English-speaking US patients are unable to read and understand standard health education materials), other forms of communication—such as illustrated simple text, videotapes, or oral instructions—may be more effective. For non–English-speaking patients, clinicians and health care delivery systems can work to provide culturally and linguistically appropriate health services.

To help improve adherence to long-term regimens, clinicians can work with patients to reach agreement on the goals for therapy, provide information about the regimen, ensure understanding by using the “teach-back” method, counsel about the importance of adherence and how to organize medication-taking, reinforce selfmonitoring, provide more convenient care, prescribe a simple dosage regimen for all medications (preferably one or two doses daily), suggest ways to help in remembering
to take doses (time of day, mealtime, alarms) and to keep appointments, and provide ways to simplify dosing (medication boxes). Single-unit doses supplied in foil wrappers can increase adherence but should be avoided for patients who have difficulty opening them. Medication boxes with compartments (eg, Medisets) that are filled weekly are useful. Microelectronic devices can provide feedback to show patients whether they have taken doses as scheduled or to notify patients within a day if doses are skipped. Reminders, including cell phone text messages, are another effective means of encouraging adherence. The clinician can also enlist social support from family and friends, recruit an adherence monitor, provide a more convenient care environment, and provide rewards and recognition for the patient’s efforts to follow the regimen. Collaborative programs that utilize pharmacists to help ensure adherence have also been shown to be effective.

Adherence is also improved when a trusting doctor-patient relationship has been established and when patients actively participate in their care. Clinicians can improve patient adherence by inquiring specifically about the behaviors in question. When asked, many patients admit to incomplete adherence with medication regimens, with advice about giving up cigarettes, or with engaging only in
“safer sex” practices. Although difficult, sufficient time must be made available for communication of health messages. 

Medication adherence can be assessed generally with a single question: “In the past month, how often did you take your medications as the doctor prescribed?” Other ways of assessing medication adherence include pill counts and refill records; monitoring serum, urine, or saliva levels of drugs or metabolites; watching for appointment nonattendance and treatment nonresponse; and assessing predictable drug effects such as weight changes with diuretics or bradycardia from β-blockers. In some conditions, even partial adherence, as with drug treatment of hypertension and diabetes mellitus, improves outcomes compared with nonadherence; in other cases, such as HIV antiretroviral therapy or treatment of tuberculosis, partial adherence may be worse than complete nonadherence. 

Guiding Principles of Car

Ethical decisions are often called for in medical practice, at both the “micro” level of the individual patient-clinician relationship and at the “macro” level of the allocation of resources. Ethical principles that guide the successful approach to diagnosis and treatment are honesty, beneficence, justice, avoidance of conflict of interest, and the pledge to do no harm. Increasingly, Western medicine involves patients in important decisions about medical care, including how far to proceed with treatment of patients who have terminal illnesses (see Chapter 5).

The clinician’s role does not end with diagnosis and treatment. The importance of the empathic clinician in helping patients and their families bear the burden of serious illness and death cannot be overemphasized. “To cure sometimes, to relieve often, and to comfort always” is a French saying as apt today as it was five centuries ago—as is Francis Peabody’s admonition: “The secret of the care of the patient is in caring for the patient.” Training to improve mindfulness and enhance patient-centered communication increases patient satisfaction and may also improve clinician satisfaction.

Table 1–1. Leading causes of death in the United States, 2008.

Category -EstimateAll causes - 2,472,6991. Diseases of the heart - 617,527
2. Malignant neoplasms - 566,137
3. Chronic lower respiratory diseases - 141,075
4. Cerebrovascular diseases - 133,750
5. Accidents (unintentional injuries) - 121,207
6. Alzheimer disease - 82,476
7. Diabetes mellitus - 70,601
8. Influenza and pneumonia- 56,335
9. Nephritis, nephrotic syndrome, and nephrosis - 48,283
10. Septicemia - 35,961

Source: National Center for Health Statistics 2010.

Health Maintenance & Disease Prevention

Preventive medicine can be categorized as primary, secondary, or tertiary. Primary prevention aims to remove or reduce disease risk factors (eg, immunization, giving up or not starting smoking). Secondary prevention techniques promote early detection of disease or precursor states (eg, routine cervical Papanicolaou screening to detect carcinoma or dysplasia of the cervix). Tertiary prevention
measures are aimed at limiting the impact of established disease (eg, partial mastectomy and radiation therapy to remove and control localized breast cancer). Tables 1–1 and 1–2 give leading causes of death in the United States and estimates of deaths from preventable causes.

Many effective preventive services are underutilized, and few adults receive all of the most strongly recommended services. The three highest-ranking services in terms of potential health benefits and cost-effectiveness include discussing aspirin use with high-risk adults, tobacco-use screening and brief interventions, and immunizing children. Other high-ranking services with data with substantial room for improvement in utilization are screening adults aged 50 and older for colorectal cancer, immunizing adults aged 65 and older against pneumococcal disease, and screening young women for Chlamydia.

Several methods, including the use of provider or patient reminder systems, reorganization of care environments, and possibly provision of financial incentives, can increase utilization of preventive services, but such methods have not been widely adopted.

 Table 1–2. Deaths from all causes attributable to common preventable risk factors. (Numbers given in the thousands.)

Risk Factor                                        Male (95% CI)      Female (95% CI)    Both Sexes (95% CI)

Tobacco smoking                               248 (226–269)      219 (196–244)          467 (436–500)         

High blood pressure                           164 (153–175)      231 (213–249)          395 (372–414)                

Overweight–obesity (high BMI)        114 (95–128)        102 (80–119)            216 (188–237)         
Physical inactivity                               88 (72–105)         103 (80–128)            191 (164–222)         
High blood glucose                             102 (80–122)         89 (69–108)            190 (163–217)          
High LDL cholesterol                           60 (42–70)           53 (44–59)              113 (94–124)            
High dietary salt (sodium)                    49 (46–51)           54 (50–57)              102 (97–107)            
Low dietary omega-3                                                                                                                         

fatty acids (seafood)                             45 (37–52)           39 (31–47)                 84 (72–96)             
High dietary trans fatty acids               46 (33–58)            35 (23–46)                82 (63–97)             
Alcohol use                                           45 (32–49)           20 (17–22)                64 (51–69)             
Low intake of fruits and vegetables      33 (23–45)          24 (15–36)                 58 (44–74)             
Low dietary polyunsaturated fatty                                                                                                     

acids (in replacement of saturated                                                                                                     

fatty acids)                                                9 (6–12)                6 (3–9)                   15 (11–20)           

BMI, body mass index; CI, confidence interval; LDL, low-density lipoprotein. Note: Numbers of deaths cannot be summed across categories. Used, with permission, from Danaei G et al. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med. 2009 Apr 28;6(4):e1000058.