Natalie DiPietro Mager, PharmD, MPH

Mark A. Strand, PhD, CPH

Introduction

Preventive medicine, as defined by the American College of Preventive Medicine, “focuses on the health of individuals, communities, and defined populations. Its goal is to protect, promote, and maintain health and well-being and to prevent disease, disability, and death.”¹ Disease prevention utilizes screening and risk factor assessment to identify individuals and populations at elevated risk and intervenes to modify those factors to prevent the onset of disease. Health promotion can be viewed from the positive side as the promotion of healthy lifestyles which will prevent or delay the onset of disease. Disease management is also an important part of preventive medicine in that it seeks to ensure that conditions are managed according to guidelines to delay disease progression. Preventive medicine can be delivered by many healthcare professionals, including pharmacists.

Preventive medicine relies on the provision of evidence-based preventive services to individuals based on their age, sex and risk level. The United States Preventive Services Task Force (USPSTF) is a panel of experts who review the published literature and the evidence for clinical preventive services or specific populations (e.g., general adult population, pregnant women, children). The USPSTF then creates a list of recommended preventive services for each population based on the grades assigned to the services (see USPSTF Grade Definitions below).² Services evaluated encompass all levels of prevention. A common way of classifying services is by primary, secondary and tertiary prevention. Primary prevention services intervene prior to disease occurrence, secondary prevention services intervene to identify early stage disease and to lessen the disease’s impact, and tertiary prevention services manage diagnosed disease to slow or stop progression.³

USPSTF Grade Definitions²

• Grade A: The USPSTF recommends the service. There is high certainty that the net benefit is substantial.
• Grade B: The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.
• Grade C: The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.
• Grade D: The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
• Grade I: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

The USPSTF recommends that Grade A and B services be routinely offered in primary care settings to patients who meet their established criteria. Patients with symptoms of a particular disease may follow a different screening schedule. However, for patients who are uninsured or underinsured, out-of-pocket expenses may be associated with these services. The present challenge of preventive medicine is to ensure that all people have access to age- and sex-appropriate services at an affordable cost. Additionally, there is the challenge to empower and motivate individuals to practice disease prevention and health promotion.² The USPSTF guidelines provide an evidence base for routinely delivering clinical preventive services to all patients.  Pharmacists can play an important role in providing clinical preventive services as specified by the USPSTF.

Case

CC: “Every night I keep coughing, I would like to purchase a bottle of Sudafed®.”

Patient: LC is a 23-year-old female (66 in, 68 kg) agricultural worker currently working in Florida. She has been living and working in the US for four months, although she does not have authorization to work in the US. She is from southern Mexico. LC presents to the local community pharmacy for a persistent cough. She has no usual source of primary care, so she had no place else to go.

Since Sudafed® is a “behind-the-counter” medication, you conduct a short intake interview with her when she comes to the counter to request the product. As she rarely accesses the healthcare system, you recognize this as an opportunity to provide LC with a comprehensive review of recommended clinical preventive services in addition to helping her with her chief complaint.

HPI: Persistent cough for more than a week. She reports night sweats, which she dismisses as being a result of the hot and humid climate in Florida.

PMH: Mild eczema on hands and forearms; seasonal allergies (pollen); no prior hospitalizations or surgeries

FH:

• Father: T2DM, HTN
• Mother: T2DM
• Three younger siblings, alive and well

SH:

• Sexually active, in a committed relationship with a male partner; no children
• Never used tobacco or illicit drugs, but her partner smokes cigarettes

Medications:

• Loratadine 10 mg once daily PRN seasonal allergies (OTC)

Allergies: NKDA

SDH: Fluent in Spanish; conversational English only. Eight-grade education. Annual income approximately $13,500. Lives in a small trailer with 8 other adults.

Additional context: Agricultural workers, also known as farm workers or crop workers, have unique exposures and backgrounds that may increase their risk of adverse health outcomes.^4,5  It has been estimated that about 53% of agricultural workers had work authorization in the United States in 2013-2014. About 74% of agricultural workers indicate that Spanish is their preferred language. The average level of formal education completed by agricultural workers is the eighth grade, and their mean annual income is estimated to be $15,000.⁵

Only about 35% of agricultural workers have health insurance and therefore bear a high burden of out-of-pocket healthcare costs. In a national survey, 43% indicated that they paid for their last health care visit out-of-pocket, and the cost of healthcare was cited most often by agricultural workers as a challenge in accessing healthcare.⁵

Many agricultural workers have exposure to environmental hazards such as pesticides and may be at increased risk for work-related injury. “Crowded” living conditions (defined as the number of persons per room is greater than one),⁵ inadequate sanitation, and poor nutrition are common experiences for seasonal agricultural workers, all of which can facilitate spread of infectious disease.⁴

Case Questions 

1. What social determinants of health did you identify with LC?

Not having authorization to work in the US, moving back and forth from US to Mexico, working outdoors in a potentially harmful environment, coming from a high TB burden country, living in cramped quarters, low socioeconomic status, low educational attainment.

2. What USPSTF-recommended clinical preventive services (Grade A or B only) is this patient eligible for based on established criteria?

• 4 Grade A recommendations:
  • Folic acid supplementation
  • Cervical cancer screening
  • HIV screening
  • Blood pressure screening
• 8 Grade B recommendations:
  • Alcohol misuse screening (and counseling, if needed)
  • Chlamydia screening
  • Depression screening
  • Gonorrhea screening
  • Intimate partner violence screening
  • Latent TB infection screening
  • Obesity screening
  • Counseling to prevent skin cancer – note that the patient may or may not be eligible for this service based on her skin type. Per USPSTF, this service should be offered to patients with fair skin type.  This is a good opportunity to talk to students about how detailed some of the USPSTF recommendations are and that is important to read them carefully to assess whether a patient should be offered a particular service.

3. Which of the services above could be considered as primary prevention services? Secondary prevention? Tertiary prevention?

• Primary
  • Folic acid supplementation
  • Counseling to prevent skin cancer
• Secondary
  • Cervical cancer screening
  • HIV screening
  • Blood pressure screening
  • Alcohol misuse screening (and counseling, if needed)
  • Chlamydia screening
  • Depression screening
  • Gonorrhea screening
  • Intimate partner violence screening
  • Latent TB infection screening
  • Obesity screening
• Tertiary
  • None of the USPSTF services recommended for this patient are examples of tertiary prevention

4. Which services do you think should be prioritized for her to receive first? And how will you make this decision?

Since you don’t know her background, and only have a limited amount of time, you will want to focus during this visit on those which seem most important presently.  However, it will be important to ensure that the patient receives comprehensive counseling on all needed services and a plan to either return to the pharmacy and/or be referred to another location for a particular service.  The following may be prioritized, based on the ability to be conducted readily in almost all community pharmacies:

• Folic acid supplementation
• Blood pressure screening
• Obesity screening
• Counseling to prevent skin cancer (if patient meets criteria)

Additionally, based on the community pharmacy services and training of the pharmacist, the following could be provided in a community pharmacy:

• Alcohol misuse screening and counseling
• Depression screening (with appropriate referral)
• Intimate partner violence screening
• Latent TB infection screening

Given that her symptoms may be indicative of TB, that screening should be prioritized, even if not offered in the community pharmacy.  The pharmacist should ensure appropriate referral for that test as needed.

5. What can the community pharmacist to do increase the likelihood that LC will receive the other needed services?

Have a good relationship with clinic that will accept patients referred to them, such as the Federally Qualified Health Center across the street.  Community pharmacists play an important role in clinical-community linkages and should have referral sites established for the various USPSTF recommended services.  Pharmacists and pharmacy staff can help facilitate patient appointments at the various locations and could provide patients with written appointment reminders detailing the time and place for them to receive the service.  In addition, provision of patient education materials explaining specific disease states or preventive services could be provided to patients.

Author Commentary

Pharmacists’ services, especially those being provided in community pharmacies, can fill important gaps in care for vulnerable populations. Depending on worksite and resources available, pharmacists will be involved in provisions of clinical preventive services to varying degrees. Most community pharmacies typically provide several preventive services, such as vaccinations; and blood pressure, glucose, and/or lipid screenings.  However, the community pharmacy is often one of the only healthcare facilities that some uninsured or underinsured people will visit. Therefore, it is advantageous to use the patient encounter to discuss preventive services with these patients and to offer services as available or refer for services as appropriate. Having a collaboration with a nearby clinic or health center is an opportunity to make referrals for patients to receive additional preventive services that are not offered in the pharmacy. In this way, pharmacists can truly realize their role in clinical-community linkages.

Patient Approaches and Opportunities

When working with patients for whom English is not their first language, you should first determine whether the patient’s English or your foreign language level is adequate to communicate effectively. If not, trained medical interpreters or telephone-based interpretation services may need to be utilized during the patient encounter.

Community pharmacists have the unique opportunity to offer face-to-face interventions every day. Collecting a comprehensive medical history during the patient’s first visit is a great way to identify opportunities to apply strategies from the USPSTF; however, some community pharmacies’ workflow may limit this opportunity. Realize that you may not have all of the patient information that you may need or want, like information on childhood illnesses or vaccination status, and consider how you will handle that limitation in patient information. Remember to use best practices related to cultural competency and low health literacy. You may need to determine, based on eventual disease diagnoses, whether there are any intervention(s) that need to be provided to a patient’ partner(s) and/or close contacts. Assuring the patient that you will respect confidentiality regarding their information is critical to developing a trusting relationship.

Finally, because the guidelines are updated by USPSTF as new information becomes available, pharmacists should stay up-to-date on the current USPSTF Grade A&B recommendations for various patient populations. The AHRQ electronic Preventive Services Selector (ePSS) referenced below is a valuable tool to quickly identify services appropriate for an individual patient.