Back to Basics, 2014 Population Health: Periodic Health Exam, Dr. Trevor Arnason, MD, CCFP, PGY-3 PHPM University of Ottawa Department of Epidemiology

Back to Basics, 2014Population Health:

Periodic Health Exam,

Dr. Trevor Arnason, MD, CCFP,PGY-3 PHPM University of Ottawa

Department of Epidemiology & Community Medicine

March 28, 20131

Periodic Health Examination

OverviewThe Periodic Health Examination

LMCC Objectives

Resources for the PHE

Population approach to the PHE

Selected conditions – recommendations for screening


“History, risk assessment, and a tailored physical examination that could lead to delivery of preventive services”

Review a patient’s ongoing medical issues

Counsel for preventive health issues

Improve physician patient relationship

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Use periodic health exam for health promotion disease prevention interventionsE.g. Smoking cessation, exercise, immunization

Case-finding and screening for disease & risky behavioursE.g. substance abuse

Chance to detect characteristics that are known to place patients at high risk for particular conditionsE.g. Family, socioeconomic, occupational and

lifestyle characteristics

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Structure of the PHEGet diagnostic problems out of the way, first!

History

Physical Exam

Lab tests, diagnostic imaging (“screening” tests)

Immunizations

Counselling

Other medications/interventions

Objectives – Periodic Health Examination (74)

Key Objective

Given a patient presenting for a PHE, the candidate will determine the patient's risks for age and sex-specific conditions to guide the history, physical examination, and laboratory screening

Enabling Objectives:

Given a patient presenting for a PHE, the candidate will:

Perform an appropriate history and physical examination based on the patient's age, sex, and background

List and interpret appropriate investigations, including evidence-based screening investigations specific to age and sex concerns (e.g., fasting glucose for greater than 40 years, mammography for greater than 50 years);

Objectives - Periodic Health Examination (74)

Enabling Objectives:

Construct an effective initial management plan, including communicate effectively with the patient to reach common ground regarding goals related to disease prevention and risk reduction

Recommend proven prevention strategies (e.g., smoking cessation, regular exercise)

Incorporate the periodic health examination principles in the care of a patient with a chronic disease.

WARNING! about prevention/screeningPrevention and screening seems easy, but is

actually one of the most difficult areas of medicine

No single source of recommendations – multiple organizations produce guidelines sometimes on same topics

Recommendations constantly changing with new information, research and innovation

Industry and government funding greatly influence screening/prevention practices

WARNING! about prevention/screening

Benefits of screening are often overestimated

The harms of screening/prevention practices are often ignored or minimized

Screening/prevention benefits at a population level do not necessarily apply to different sub-populations, individuals

Not always clear when patients are ‘asymptomatic’

Need to consider competing risks, a concept that is difficult for human beings to comprehend

Approach to ‘screening’ or ‘case finding’

1) Define the population

2) Define the outcomes you need to consider

3) Consider what interventions are available to prevent the outcomes

4) Consider the available evidence to support the intervention in this population to prevent the outcome(s)

For the MCCQE • Focus on the simple stuff (eg: health promotion,

things that apply to everyone)

• Controversial topics are less likely to be emphasized

• Exam is Canada-wide, so Provincial recommendations are not as important

PHE Resources

Canadian Task Force On Preventive Health Care: Clinical Guidelines

Targeted and evidence basedClinician Summary of guidelines for

common conditionsGrading of recommendation and

evidence as ‘strong’, ‘moderate’ or ‘weak’

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PHE ResourcesNational Advisory Committee on Immunizations (NACI)

http://www.phac-aspc.gc.ca/publicat/cig-gci/index-eng.php

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PHE ResourcesCFPC Preventative Care Checklist

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PHE Resources

Rourke Record

http://www.rourkebabyrecord.ca/national.asp

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Populations - InfantGet diagnostic problems out of the way, first!

History – pregnancy, birth, breastfeeding, vision, hearing, development, abuse/neglect

Physical Exam – growth charts, developmental milestones, eyes (eg: cover/uncover), hips

Lab tests, diagnostic imaging (“screening” tests) - ?hemoglobin

Immunizations – lots, annual flu (>6mos)

Counselling – car seat, sleep position, crib, poisons, firearms, smoke/CO alarms, dental health, nutrition, passive smoke

Other meds/interventions – Vitamin D 400 IU/day, home visit

Populations - Child History –pregnancy, birth, vision, hearing, development,

abuse/neglect, school readiness

Physical Exam – growth charts, developmental milestones, eyes

Lab tests, diagnostic imaging (“screening” tests) - none

Immunizations – lots, annual flu (>6mos)

Counselling – car seat/ seatbelts, bike helmets, hearing protection, poisons, firearms, smoke/CO alarms, dental health, nutrition, passive smoke, no OTC cough cold/medicines

Other meds/interventions – dentist

Populations - Adolescent History – HEADDS, diet

Physical Exam – growth charts, sexual maturity

Lab tests, diagnostic imaging (“screening” tests) – STI screening

Immunizations – DTaP (pertussis), missed childhood, HPV, Hep B, annual flu

Counselling – seatbelts, bike helmets, hearing protection, dental health, nutrition, alcohol, smoking, other drugs, occupational exposures, sun exposure

Other meds/interventions – Vitamin D, dentist

Populations – Young Adult History – HEADDS, diet

Physical Exam – Wt (BMI), BP, eyes, ears

Lab tests, diagnostic imaging (“screening” tests) – STI screening (Chlamydia/Gonorrhea), Pap smear, Hep B and C, HIV, HbA1c, fasting lipid profile

Immunizations – DTaP (pertussis), HPV, Hep B, annual flu


Other meds/interventions – folic acid, Vit D, dentist

Populations – Middle Aged Adult

History – Psychological, social and physical functioning, nutrition, physical activity, alcohol, smoking,


Lab tests, diagnostic imaging (“screening” tests) – Blood glucose, lipid profile, osteoporosis, Cancer – breast, prostate, colon

Immunizations – DTaP (pertussis), annual flu



Populations – Older Adult History – Psychological, social and physical functioning, nutrition,

physical activity, alcohol, smoking, fracture and fall prevention, dementia screening, elder abuse

Physical Exam – Wt (BMI), BP, eyes (Snellen), ears

Lab tests, diagnostic imaging (“screening” tests) – Blood glucose, lipid profile, osteoporosis, Cancer – breast, cervical, colon (prostate), AAA

Immunizations – DTaP (pertussis), annual flu, pneumococcal, HZV



Populations – Common themes

History – nutrition, physical activity, substances (smoking/EtOH)


Lab tests, diagnostic imaging (“screening” tests) – nothing

Immunizations – routine and annual flu

Counselling – injury prevention (eg: seatbelts, bike helmets), dental health, nutrition, substances, sun exposure


Management“Recommend proven prevention strategies”

Smoking Cessation

Regular Exercise

Nutrition

Alcohol reduction

Generally not used for screening (asymptomatic)TSH

CBC

Electrolytes, Cr

Vitamin B12

ALP

ECG

Urinalysis

Condition Specific Recommendations &

Screening

RecommendationsOsteoporosis

Prevention<50 years old

Consume 100-1500 mg elemental Ca/day 400-1000 IU per day (if low risk for deficiency)

>50 years old Dose of 1200mg elemental Ca/day Supplement if not achievable by diet 800-1000 IU /day (50 + or moderate risk of deficiency)

*Osteoporosis Society of Canada 2010

Recommendations - Screening

Osteoporosis screening - BMD

“2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary” (CMAJ, 2010)


Blood pressure

Population: Adults 18+ without previous Dx of HTN

Prevalence: HTN in 19% of Canadian adults; prevalence increases with age, comorbidites

Intervention: Screening by BP measurementAt all appropriate health care visitsMeasured according to Canadian Hypertension

Education Program (CHEP) recommendationsApply CHEP criteria for assessment and diagnosis of

hypertension


Cervical CancerIncidence increases significantly after

age 25, peaks in 5th decadeIntervention: Screening with cervical

cytologyPopulation: asymptomatic women;

have been or are sexually activeRecommendation: Screen women ≥ 25

with a pap test q3 years

PHE - Screening

Age (yrs) Recommendation Rationale<20 No routine screening Very low

incidence/mortalityEvidence of harm

20-24 No routine screening Uncertain benefit of screening, high false +

25-29 Routine screening, every 3 years

Small benefit of screening, ing Cervical CA incidence and mortality in age group

30-69 Routine screening, every 3 years

Evidence of effectiveness of screening

≥70 No screening if 3 successive neg Paps in last 10 yrs

If not adequately screened, recommend screening every 3 years until 3 success negative Paps

Cervical Cancer – PAP Smear Recommendations (CTFPHC)

Recommendations - Screening Type 2 Diabetes

• Prevalence:• 6.8% of Canadians Type 1 or 2 Diabetes (2008/2009)

• ~50% of new cases diagnosed in adults age 45-64

• Population for screening: asymptomatic adults

• Risk level: FINDRISC tool

• Intervention: HbA1C (Fasting glucose, OGTT)• Harms: small $, discomfort, anxiety, over-

diagnosis and investigation

PHE Screening Type 2 Diabetes

Category Low to Moderate Risk

High Risk Very high risk

Level of Risk(10 year risk of diabetes)

Low: 1-4%Moderate: 17%

33% 50%

Routine Screening Recommended?

NO q3-5 years annually

Rationale No evidence of improved outcomes

Evidence for MI rates

Cost vs. annual screening

Evidence for DM complications & death


Breast Cancer

• 22,700 new cases, 5400 deaths annually (2009)

• Incidence & Case-fatality rate increase with age

• Intervention: Mammography

• Population considered for screening:• Age 40-74• No personal or Family Hx of Breast CA• No known BRCA1 or 2 mutation• No previous chest wall radiation


Breast Cancer - Mammography

Age 40-49 50-69 70-74

Routine Screening Recommended?

NO q 2-3 years q 2-3 years

Rationale Lower likelihood of breast cancer

Greater likelihood of false + in age group

720 women would need to be screened q2-3 yrs to save 1 life

450 women would need to be screened q2-3 yrs to save 1 life

PHE - ScreeningBreast Cancer – Special Considerations

Certain ethnic groups have higher (Ashkenzai Jews) or lower rates (East Asians)

Benefit of screening uncertain for those with life expectancy shortened by comorbid conditions

Can provide “ Decision Aid for Breast Cancer Screening in Canada” available from PHAC

Key points - Structure of the PHE

Get diagnostic problems out of the way, first!

History

Physical Exam

Lab tests, diagnostic imaging (“screening” tests)

Immunizations

Counselling

Other medications/interventions

Key points - Approach to ‘screening’ or ‘case finding’

1) Define the population

2) Define the outcomes you need to consider

3) Consider what interventions are available to prevent the outcomes

4) Consider the available evidence to support the intervention in this population to prevent the outcome(s)

Key point - Management:“Recommend proven prevention strategies”

Smoking Cessation

Regular Exercise

Nutrition

Alcohol reduction

Thanks

Acknowledgements: •This was developed based on a previous presentation by Dr. Laura Bourns•Thanks to Dr. Cleo Mavriplis for providing content on screening/prevention.

Documents

Back to Basics, 2014 Population Health: Periodic Health Exam, Dr. Trevor Arnason, MD, CCFP, PGY-3 PHPM University of Ottawa Department of Epidemiology