Academic journal article Alcohol Research

Screening in General Health Care

Academic journal article Alcohol Research

Screening in General Health Care

Article excerpt

The article "Screening for Alcohol Problems" by Stewart and Connors and other articles in this issue and the companion issue of Alcohol Research & Health examine in detail how screening can be used in a variety of settings to detect harmful alcohol use. The purpose of this sidebar is to provide a broader view of screening and its role in general health care. Identifying appropriate conditions for screening and developing accurate tools for their diagnosis is an ongoing and important area of research. Here, chronic hepatitis C infection is used as an example of an alcohol-related health problem for which research on screening is urgently needed.

Brief History of Screens and Preventive Services

Screening tests, together with counseling interventions, immunizations, and chemoprophylactic regimens (i.e., courses of treatment using chemical agents to prevent disease), are all services offered in general health care settings that are designed to prevent a disease or intervene in its early stages.

Screening as a cornerstone of primary health care delivery is a relatively recent medical practice that grew out of public health advances made in the 1930s and 1940s (Berg and Allan 2001). Screening tests and primary preventive advice proliferated in the 1950s and 1960s, a period during which the now classic story of screening newborns for phenylketonuria (PKU) unfolded.

PKU is a genetic abnormality that occurs in about 1 in 12,000 North American births (O'Flynn 1992). Those afflicted are unable to metabolize the essential amino acid phenylalanine, an inability that causes severe mental retardation. If affected infants are identified early and fed a very low protein diet, this retardation can be avoided.

As screening for PKU and other simple screening methods showed their effectiveness in controlling preventable diseases or conditions, the demand for them escalated, which in turn has revealed barriers to providing preventive care. Among these barriers are inadequate reimbursement by health insurance carriers to health professionals for providing preventive services, inconsistent or inadequate health care delivery across a range of care settings, and insufficient time for busy clinicians to provide the range of recommended preventive services to all patients (U.S. Preventive Services Task Force 1996; Yarnall et al. 2003). Even in settings that do not have these problems, health professionals may fail to provide preventive services because they do not know which ones are most effective.

When deciding whether to screen asymptomatic people for disease, the care provider should determine if the potential benefits of identifying and preventing the development of a health problem outweigh the cost and potential harm associated with the screening process, according to the principles of early disease detection published by the World Health Organization (Wilson and Junger 1968). Whitby (1974) modified the principles slightly (see table 1), adding the caveat that treating a disease in the latent or early symptomatic stage should have a favorable effect on outcome.

The U.S. Preventive Services Task Force. After the publication of the WHO principles, researchers incorporated them into critical scientific reviews of screening procedures (e.g., Russell 1982). In 1984, the U.S. Public Health Service commissioned a 20-member non-Federal panel, the U.S. Preventive Services Task Force (USPSTF), to systematically review the scientific evidence on individual clinical preventive services and to make recommendations to practitioners about what services they should routinely offer (Lawrence and Mickalide 1987). Members of this panel met regularly between 1984 and 1988 and developed recommendations regarding 169 preventive services for 60 topic areas, which they published in 1989 as the Guide to Clinical Preventive Services. These recommendations influenced preventive medicine and "accelerated a growing movement to replace traditional 'expert consensus' methods for developing clinical recommendations with a systematic and explicit process for reviewing evidence and of linking clinical practice recommendations directly to the quality of the science" (Woolf and Atkins 2001, p. …

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