Chapter 9

Screening

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Screening
Primary objective: Detection of a disease in its
early stages in order to treat it and deter its
progression.
Secondary objective: Reduce cost of disease
management by avoiding costly interventions
required at later stages.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Selection of a Screenable
Disease

Does its significance warrant its consideration as

a community problem?
Can the disease be detected by screening?
Should screening for disease be done?

Health benefits
Cost

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Significance

The significance of a disease is the level of

priority assigned to the disease or disorder as a
public health concern
Determinants of significance

Quality of life
Subjective; difficult to estimate
Quantity of life
Disease-specific mortality rates
Prevalence ratesexisting cases (chronic disease)
Incidence ratesnew cases (acute disease)
Cost to treat (e.g., PKU)
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Is This Disease/Disorder
Screenable?

Diagnostic criteria

Well-documented diagnostic criteria desired

Screening instruments

Must be safe, cost-effective, accurate

Reliability
Reproducibility of test results
Interobserver vs. intraobserver
Validity
Accuracy of the test (distinguish those with/without disease)
Sensitivity: Proportion with disease who test positively
Specificity: Proportion with disease who test negatively
Consider efficiency/efficacy of mass screening programs
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Is This Disease/Disorder
Screenable? (Cont.)

Community resources

Funds, workers, follow-through, treatment sources,

administrative personnel

Development of community health program

Lead agencyoversees development

Partners with community stakeholders

Community assessmentsystematic data collection

Target population, resources, health needs, program
strategies identified
Program constraints (e.g., financial, accessible followup services) must be addressed
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Should Screening for the

Disease/Disorder Be Done?

Is there any benefit to early detection?

Are there effective treatments available?
Interventions/treatment modalities

Need specific interventions that will affect disease

progression to justify screening
Follow-up critical to aid implementing interventions
Need to consider safety of intervention; avoid risks
or harmful effects

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Ethical Considerations

Request for participation implies a health benefit

Limitations of results

Not diagnostic; identifies those at risk or who need

further evaluation

Controversies of screening results

Misinterpretation
False positives, false negatives: Duty to inform?

Cutoff points: Alters when person is disease positive

or disease negative
Borderline casesinterpretation changes as
guidelines change; when to refer/not refer
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

Economic Feasibility

Cost-benefit ratio

Cost-effectiveness

Comparison of various outcomes in monetary values

(which outcome most beneficial at most reasonable
cost)
Optimal use of resources to reach desired health
outcome

Cost-efficiency

Purpose: Efficiency; limited budget to achieve as

much desired outcome as possible
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

10

Selection of a Screenable
Population

Person-dependent factors

Age, gender, race/ethnicity, income level, and

lifestyle

Environment-dependent factors

Conditions of the workplace, home, and

community

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

11

Recommended Screenings of the

USPSTF

The US Preventive Services Task Force has

identified 16 categories in their Guide to Clinical
Preventive Services
Also includes a section on recommendations for
children and adolescents
Recommended screenings can be obtained at
www.uspreventiveservicestaskforce.org/recommendatio
ns.htm

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

12

The Affordable Care Act and

Prevention Incentives

Affordable Care Act (ACA) was passed in 2010

Mobilized a public health movement focused on

prevention and health promotion; resulted in the National
Prevention Strategy
ACA requires that preventives services be covered
without co-payment or coinsurance by more insurance
plans/policies including Medicare and private insurance
Introduced Medicare-covered annual wellness programs
Created the National Prevention Council, a group
comprised of 17 heads of Federal government agencies,
departments, and offices focused on promoting
prevention and wellness.
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

13

Nurses Role

Development and implementation of screening

programs
Decision maker
Planner
Education
Follow-up

Copyright 2014 by Mosby, an imprint of Elsevier Inc.

14

Community Guide

On the community level, many on-line resources

currently exist and are being continually developed
according to best practice guidelines, to support the
nurse in providing optimal preventive services .
One excellent free resource is the Community
Preventive Services community guide.
www.thecommunityguide.org/index.html
Another resource is the CDC Reach U.S. community
website
www.cdc.gov/chronicdisease/resources/publicaions/
AAG/reach.htm
Copyright 2014 by Mosby, an imprint of Elsevier Inc.

15