Evidence-Based Periodic Health

Examination

dr. Titiek Hidayati M. Kes.☻☻ Bagian Ilmu Kesehatan Masyarakat (IKM)Bagian Ilmu Kesehatan Masyarakat (IKM)

☻☻ Bag. EpidemiologyBag. EpidemiologyFakultas Kedokteran Umum UMYFakultas Kedokteran Umum UMY

LO

• Pemeriksaan kesehatan berkala yang berdasarkan pada bukti – bukti kesehatan (Evidence Based)

• Tentang berbagai tes kesehatan yang tepat guna sesuai waktu dan kegunaannya

• Task Forces on Prevention• Health Screening as a Strategy for Preventive

Medicine

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Periodic health examination (PHE)• Periodically, patients visit physicians’ office not

because they are unwell, but because they want a ‘check-up’. Such visits are referred to as health maintenance or the PHE. The PHE is an opportunity to relate to an asymptomatic patient for the purpose of case finding and screening for undetected disease and risky behavior. It is also an opportunity for health promotion and disease prevention. The decision to include or exclude a medical condition in the PHE should be based on the burden of suffering caused by the condition, the quality of the screening, and effectiveness of the intervention.

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Pencegahan lebih baik dari pada pengobatan

An ounce of Prevention equals to pounds of Cure

Task Forces on Prevention

■ The US Preventive Services Task Force (1984, 1996, 2002)■ The Canadian Task Force on Periodic Health Examination (1997)■ The Task Force on Philippine Guidelines Periodic Health Examination (2004)- Sie Promosi kesehatan, Sie P2M dan PTM

(Puskesmas, Dinkes kabupaten, Dinkes propinsi dan Depkes)

..

Health Screening as a Strategy for Preventive Medicine

(Task Force on Philippines Guidelines on PHEX, 2004)

. In the last half century, health care has seen a major shift in philosophy

from curative medicine to preventive medicine

Four major strategies used in the rapidly growing field of Preventive Medicine:1. Health Screening (doing tests for early detection of disease or risk factors for disease)2. Lifestyle change (avoidance of unhealthy habits)3. Risk factor control (treatment of factors that predispose to disease)4. Vaccination programs (immunization against infectious diseases)

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Screening (WHO, 1994):Screening (WHO, 1994):The use of presumptive methods to detect unrecognizedhealth risks or asymptomatic disease in apparently healthy individuals in order to permit prevention & timely prevention

Screening (WHO, 1994):Penggunaan metode-metode yang dianggap bisa mendeteksi risiko kesehatan yang tidak dikenal atau penyakit yang asimptomatik pada individu-individu yangtampak sehat dalam rangka membolehkan dilakukannyapencegahan atau pencegahan yang tepat pada waktunya

.Screening (executiveScreening (executivemedical check up) medical check up) is performed to categorize members of the general public into:

Higher probabilityof disease

Lower probabilityof disease

This group is urged to seek

further medicalattention for

definitive diagnosis & treatment

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Pitfalls of Screening & Other Preventive Pitfalls of Screening & Other Preventive Medicine Strategies: Medicine Strategies:

Things that ought to work do not always so

Lifestyle changesLifestyle changes such as salt restriction: have failed to lead to appreciable changes in the incidence

of stroke & coronary disease in the general population

Most dietary maneuversdietary maneuvers, like high fiber diet, have not been proven effective in cancer prevention

Risk factor controlRisk factor control has failed as well, and in some instances has even led to an increase in deaths:

The cholesterol lowering drug clofibrateclofibrate, was removed fromthe market because a trial by WHO showed more deaths

among patients who received treatment

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Many screening testsscreening tests, such as ECG: have been found to be inaccurate for detection of

early coronary disease

Consequently, many asymptomatic patients are wrongly labeled as being “ill” (false labeling)

Instead of improving the quality of life of people, false labeling has been found to wreak havoc on the social,

psychological, physical & even financial stability ofunfortunate individuals

Productive people have been denied insurance or employment or have resigned from work because of depression

Many times, the side effects of screening have been far worse than the effects of the diseases which

we were trying to prevent in the first place

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Although treating early disease may be cheaper & easier, the savings are often offset by the costs of having to do

the screening tests on large numbers of apparently healthy individuals

Curative surgery for a case of coronary artery disease (CAD) may cost half a million pesos (Rp 100juta) in the Philippines

In contrast, primary prevention of a single death from cardiovascular disease may entail treating at least 143 patients

For high cholesterol with a statin statin for 5 years.depending on the statin used , this may costs as much as

20 million pesos (Rp 4 milyar)

Indeed, sometimes, ““pounds of prevention” translates to just “an ounce of cure”“an ounce of cure”

Criteria for the use of screening test(Blueprints Family medice, Martin S. Lipsky)

• Criteria for the use of screening tests include the following :- The disease is common and significantly affects individuals and society- Effective treatments for the disease are available- The screening tests or procedures are accurate and reasonable in terms of cost, comfort and complications- Characteristics that measure the accuracy of screening tests include sensitivity, speciticity, positive and negative predictive values

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Criteria for Screening Criteria for Screening (Task Force on Philippines Guidelines on PHEX, (Task Force on Philippines Guidelines on PHEX,

20042004))

. Because health screening carries the potential for harm & because it can lead to huge increments,

criteria need to be set on when screening for early disease should be done

Four criteria

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1. Treatment for the asymptomatic condition must have been evaluated using well-designed randomized controlled trials (RCTs) that observed effects on clinical outcomes

2. The burden of illness from asymptomatic condition must have been measured accurately in locally-conducted community-based community-based studiesstudies (disease prevalence or its impact on people’s lives)

3. Accuracy of the screening test for the asymptomatic condition must have been evaluated in validation studiesvalidation studies done in the communitydone in the community (false positive & false negative errors)

4. Cost-effectiveness of the screening test, as well as treatment for the disease, should have been evaluated locally in properly conducted economic analysiseconomic analysis (studies that evaluate costs, risks & benefits of treatment)

• VS VS Community-Community-

based based StudiesStudies

Hospital-Hospital-based based

Studies:Studies:Hospitalized patients tend

to have more advanced illness (easier to detect):

Exaggerate the Exaggerate the prevalence of the prevalence of the

conditioncondition

Recommendation Scale Recommendation Scale (Task Force on Philippines Guidelines on PHEX, (Task Force on Philippines Guidelines on PHEX,

20042004))

. Level 1: Recommendation satisfies all the above criteria

Level 2: Recommendation satisfies no. 1, but not all no.2, no.3 & no.4

Level 3: Recommendation satisfies no.2, no.3 & no.4, but not no.1

Level 4: Recommendation satisfies none of the criteria

Executive Summary of Various Screening Recommendation

(Task Force on Philippines Guidelines on PHEX, 2004)

.Screening Tests for Adults: Screening Tests for Adults: Table A-1 for Adults: Screening tests recommended for the general populationTable A-2 for Adults: Screening tests recommended for selected populationsTable A-3 for Adults: Screening tests cannot be recommended routinely Table A-4 for Adults: Screening tests not recommended

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Screening Tests for Children:Screening Tests for Children: Table B-1 for Children: Screening tests recommended for the general populationTable B-2 for Children: Screening tests recommended for selected populationsTable B-3 for Children: Screening tests cannot be recommended routinely Table B-4 for Children: Screening tests not recommended

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Screening Tests for Pregnant Women: Table C-1 for Pregnant Women: Screening tests recommended for the general populationTable C-2 for Pregnant Women: Screening tests recommended for selected populationsTable C-3 for Pregnant Women: Screening tests cannot be recommended routinely Table C-4 for Pregnant Women: Screening tests not recommended

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Immunizations for Adults: Table D-1 for Adults: Immunizations recommended for the general populationTable D-2 for Adults: Immunizations recommended for selected populationsTable D-3 for Adults: Immunizations cannot be recommended routinely Table D-4 for Adults: Immunizations not recommended

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Preventive care(Blueprints Family medice, Martin S. Lipsky)

• The focus of preventive care is age-dependent, reflecting the changes in disease prevalance across the adult life span. In the secondary prevention to prevent or limit future disease is important.

• Ht is a significant risk factor for heart disease and stroke. The consequences of Ht may not be seen for years after a person develops high blood pressure. So, BP evaluation & tx is preventive measure for future disease that may not manifest itself until the patient is 70 years of age or beyond.

• The most common causes of death in adults aged 19 to 40 years are accident, homicides and suicides.

• Screening for cardiovasculer risk factors and malignancy become a focus of health care visits for individuals over age 40.

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.Each recommendation statement was followed by a Summary of Evidence as follows:1. Burden of the Illness2. Accuracy & Reliability of the Test3. Availability of the Effective Treatment for the illness being screened for 4. Cost-effectiveness issues5. Recommendations of other organizations & other countries

Screening for Hypertension Screening for Hypertension (Task Force on Philippines Guidelines on PHEX, (Task Force on Philippines Guidelines on PHEX,

20042004))

. Recommendations: Recommendations:

1. Screening for hypertension is recommended (level 2)

2. The auscultatory method using a mercury sphygmomanometer is recommended for the diagnosis of hypertension as well as for the monitoring of blood pressure (level 2)

3. Ambulatory blood pressure monitoring is not recommended for screening (level 2)

Screening for Dyslipidemia Screening for Dyslipidemia (Task Force on Philippines Guidelines on PHEX, (Task Force on Philippines Guidelines on PHEX,

2004)2004)

.Recommendations:

1. Screening for dyslipidemia using a non-fasting total cholesterol level alone should be done in individuals aged 40 or above with no other risk factors (level 2)

2. Screening for dyslipidemia using a complete lipid profile [Total Cholesterol, Low Density Lipoprotein (LDL), High Density Cholesterol (HDL) & Triglycerides) should be done in: a. Patients with two or more of the following risk factors (smoker, obese, post-menauposal) b. Patients with evidence of familial dyslipidemia (xanthoma, family history of early cardiovascular disease) (level 2)

Screening for Diabetes Screening for Diabetes (Task Force on Philippines Guidelines on PHEX, (Task Force on Philippines Guidelines on PHEX,

2004)2004)

.Recommendations: Recommendations:

1. Selective screening using fasting plasma glucose is recommended for high-risk individuals (patients 40 y.o. and above, smokers, obese, patients, with a family history of DM, patients with evidence of familial dyslipidemia & those with history of delivery of babies large for gestatitional age (level 2)

2. Mass screening for DM using fasting plasma glucose (FPG) levels or the oral glucose tolerance test (OGTT) is not recommended (level 2)

Screening for Obesity Screening for Obesity (Task Force on Philippines Guidelines on PHEX, (Task Force on Philippines Guidelines on PHEX,

2004)2004)

.Recommendations: Recommendations:

Screening for obesity using the waist-to-hip ratio (WHR) or body mass index (BMI) is recommended for apparently healthy individuals (level 3)

The US Preventive Services Task The US Preventive Services Task ForceForce

.Recommendations covers:Recommendations covers:

1. Various age groups: ● Birth to 10 years ● Ages 11 to 24 years ● Ages 25 to 64 years ● Ages 65 years and older 2. Four aspects: ● Screening ● Counseling ● Immunizations ● Chemoprophylaxis

Screening for Sedentary Lifestyle Screening for Sedentary Lifestyle (Task Force on Philippines Guidelines on PHEX, (Task Force on Philippines Guidelines on PHEX,

2004)2004)

.Recommendations: Recommendations:

Screening with regard to sedentary lifestyle is recommended (Level 4)

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Assignments

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1. Burden of Illnesses (Morbidity & Mortality) in Indonesia & the World

2. Perilaku Hidup Bersih & Sehat (PHBS)

3. PHE in the US from Rakel

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