Progress in Chronic Disease Prevention Chronic Disease Control Activities of Medical and Dental Organizations

A meeting of representatives of selected medical and dental organizations was convened by the Clinical Services Branch, Office of Disease Prevention and Health Promotion, Public Health Service, U.S. Department of Health and Human Services, in September 1987 to discuss future directions for implementing preventive services in clinical settings.* Organizations were asked to report on their current activities in disease prevention and health promotion. These reports indicate that organized medicine and dentistry are offering a variety of programs to prevent and control chronic diseases in the United States.

Periodic Health Examinations

Several organizations have issued recommendations on screening for reversible risk factors and early disease. The American Academy of Pediatrics (AAP) has published periodic updates of its recommendations for well-child care, Guidelines for Health Supervision. The American College of Obstetricians and Gynecologists (ACOG) has published "Technical Bulletins" on gynecologic cancer screening and, in cooperation with AAP, on perinatal care. The scientific basis for various components of periodic health examinations is being evaluated by the American College of Physicians (ACP) as part of its Clinical Efficacy Assessment Program. Other organizational programs have emphasized selected aspects of periodic health examinations. For example, the American Academy of Family Physicians (AAFP) cosponsors with the American Society of Gastrointestinal Endoscopists a training program on flexible sigmoidoscopy for family physicians. The Journal of the American Medical Association (JAMA) has published background papers and recommendations issued by the U.S. Preventive Services Task Force on components of the periodic health examination.

Smoking Cessation

AAFP has developed for its members a package of smoking cessation materials, the Stop Smoking Kit, which includes medical records forms, waiting room posters, and information on smoking cessation counseling techniques. AAFP has produced a self-help booklet and audiotape for patients who wish to quit smoking. The dangers of smoking in pregnancy have been emphasized by ACOG in The Standards for Obstetric-Gynecologic Services and in its Technical Bulletin entitled "Cigarette Smoking and Pregnancy." The Clinical Efficacy Assessment Program of ACP has evaluated office-based smoking cessation methods. The American Medical Association (AMA) has worked for the creation of smoke-free public environments, and the American Dental Association (ADA) has sponsored professional and public education on the use of smokeless tobacco. Smoking cessation techniques have also been taught in continuing medical education programs of the American Osteopathic Association (AOA).

Injury Control

The Injury Prevention Program of AAP provides pediatricians with safety surveys, information sheets, and other materials to inform parents about childhood injury prevention. The American College of Preventive Medicine (ACPM) has produced continuing education materials on the prevention of motor-vehicle trauma. An AMA monograph, Medical Conditions Affecting Drivers, and a JAMA review by AMA staff on medical standards for civilian pilots (1) both focus on the prevention of injuries. AMA has held several conferences on injury prevention since 1983.

Immunizations

The Report of the Committee on Infectious Diseases (popularly known as the "Red Book"), published by AAP, and the Guide for Adult Immunization ("Green Book"), published by ACP, offer recommendations on pediatric and adult immunizations, respectively. ACPM has been part of a national initiative to promote adult immunization and, in particular, reimbursement through Medicare for pneumococcal vaccine.

Oral Health

ADA promotes the use of dental sealants, fluoridation of water systems, the prevention of caries associated with nursing bottles (in collaboration with AAP), and the prevention of dental complications from medical illness, including human immunodeficiency virus infection.

Other Areas

ACOG has developed Adolescent Sexuality: Guides for Professional Involvement, a manual for physicians working with schools and public education programs on unwanted teenage pregnancy. ACOG has also prepared technical bulletins on the prevention of osteoporosis. Other educational programs include the National High Blood Pressure Education Program and the National Cholesterol Education Program.

Implementation

Medical and dental organizations have also taken steps to facilitate the implementation of clinical preventive services. These efforts include professional education, patient and public education, and public policy changes, as follows:

Professional education. Education of health professionals at the undergraduate, graduate, and postgraduate levels is an important component of organizational initiatives in chronic disease prevention and control. AOA requires training in prevention beginning with the first year of undergraduate training and continuing through residency. AOA's continuing medical education courses have featured a number of prevention-related topics. Recent courses offered by AMA have included environmental risk assessment and the diagnosis and management of hyperlipidemia. ACPM cosponsors the PREVENTION conference series and also markets the "Dietary Inventory of Nutritional Experience," a computer software program that teaches physicians about nutrition and how to improve nutritional behavior. Both AAFP and AAP have organized numerous continuing medical education courses in prevention and regularly feature articles about health promotion and disease prevention in their respective journals, American Family Physician and Pediatrics.

Patient and public education. Many organizational chronic disease prevention and control projects include components on patient or public education. AAP's injury prevention program, for example, includes educational materials for patients. ACOG's efforts to prevent osteoporosis and unwanted teenage pregnancy include patient education pamphlets and television advertising. Patient education materials also have been produced by ACP, ADA, and AAFP.

Public policy. Numerous organizations have played an active role in advocating health-related changes in public policy. Child safety-seat laws were a focus of legislative action by AAP, and members of that association have testified before Congress on bills relevant to child health, have lobbied for improved access to health care for children, and have helped organize a child health advocacy coalition. ACOG has mounted policy initiatives on improved access to prenatal care and on contraceptive advertising. The expansion of community water fluoridation is a continuing concern of ADA. Several medical and dental organizations have worked together on various immunization policy questions. Reported by: American Academy of Family Physicians, Kansas City, Missouri. American Academy of Pediatrics, Elk Grove Village, Illinois. American College of Obstetricians and Gynecologists, Washington, DC. American College of Physicians, Philadelphia, Pennsylvania. American College of Preventive Medicine, Washington, DC. American Dental Association, Chicago, Illinois. American Medical Association, Chicago, Illinois. American Osteopathic Association, Chicago, Illinois. Office of Disease Prevention and Health Promotion, Public Health Svc, Dept of Health and Human Svcs. Editorial Note: The clinical setting offers an important opportunity for health professionals to provide services designed to control chronic disease (2). Clinicians, through their frequent contact with patients, have many opportunities to initiate disease prevention activities. In 1985, for example, the average American had contact with a physician 5.2 times (3). In addition to offering clinical preventive services such as screening tests, physicians can promote behavioral risk reduction through patient education and counseling (4). Clearly, the delivery of these preventive services during the clinical encounter serves an important public health role in the national strategy to prevent and control chronic disease (5,6).

At the same time, there are barriers to implementing preventive services in the clinical setting. There is evidence, for example, that physicians do not perform cancer screening and other preventive services in accordance with published recommendations (7,8). Despite these difficulties, however, physicians are beginning to adopt primary and secondary prevention as legitimate concerns (9) and appear to have a better understanding of how to change medical practices to comply with recommendations (10). This report suggests that, at the organizational level, physicians and dentists are developing programs for professional education and support, educational materials for patients, public education campaigns, and various policy initiatives to promote the implementation of disease prevention activities on a national scale.

For additional information, contact: American Academy of Family Physicians Scientific Activities Division P.O. Box 8723 Kansas City, MO 64114-0723 American Academy of Pediatrics Division of Maternal, Child, and

Adolescent Health 141 Northwest Point Boulevard P.O. Box 927 Elk Grove Village, IL 60009-0927 American College of Obstetricians and

Gynecologists Resource Center 600 Maryland Avenue, SW Washington, DC 20024-2588 American College of Physicians Publications Department 4200 Pine Street Philadelphia, PA 19104 American College of Preventive Medicine 1015 15th Street, NW, Suite 403 Washington, DC 20005 American Dental Association Division of Education and Health Affairs 211 E. Chicago Avenue Chicago, IL 60611 American Medical Association Department of Public Health 535 N. Dearborn Street Chicago, IL 60610 American Osteopathic Association 142 E. Ontario Street Chicago, IL 60611 References

1. Engelberg AL, Gibbons HL, Doege TC. A review of the medical standards for civilian airmen: synopsis of a two-year study. JAMA 1986;255:1589-99.

2. Stott NC, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979;29:201-5.

3. National Center for Health Statistics. Health, United States, 1986. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1986:137; DHHS publication no. (PHS)87-1232.

4. Louis Harris and Associates. Health maintenance: a nationwide survey of the barriers toward better health and ways of overcoming them, conducted among representative samples of the American public, business and labor leaders. Newport Beach, California: Pacific Mutual Life Insurance, 1978.

5. Last JM, Adelaid MB. The iceberg: "completing the clinical picture" in general practice. Lancet 1963;2:28-31.

6. Centers for Disease Control, Association of State and Territorial Health Officials. First National Conference on Chronic Disease Prevention and Control: identifying effective strategies--conference summary. Atlanta: US Department of Health and Human Services, Public Health Service, 1987:9-10.

7. McPhee SJ, Richard RJ, Solkowitz SN. Performance of cancer screening in a university general internal medicine practice: comparison with the 1980 American Cancer Society guidelines. J Gen Intern Med 1986;1:275-81.

8. Battista RN, Spitzer WO. Adult cancer prevention in primary care: contrasts among primary care practice settings in Quebec. Am J Public Health 1983;73:1040-1.

9. Goldstein B, Fischer PM, Richards JW Jr, Goldstein A, Shank JC. Smoking counseling practices of recently trained family physicians. J Fam Pract 1987;24:195-7.

10. Greer AL. The two cultures of biomedicine: can there be consensus? JAMA 1987; 258:2739-40. *Participating members: Herbert F. Young, MD, Kenneth W. Whittington, MD (American Academy of Family Physicians); Karen Palchick, LPN, Kenneth O. Johnson, MD (American Academy of Pediatrics); Shirley Shelton, John T. Queenan, MD (American College of Obstetricians and Gynecologists); Margaret Radany, MD (American College of Physicians); William M. Kane, PhD, David Harris, MD (American College of Preventive Medicine); James Marshall, James V. Huerter, DDS (American Dental Association); Alan L. Engelberg, MD, Ray W. Gifford, Jr., MD (American Medical Association); Douglas Ward, PhD, Frederic N. Schwartz, DO (American Osteopathic Association).

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