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Periodic Health Examinations Periodic Health Examinations

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

PO Box 27121 – Riyadh 11417Tel: 4912326 – Fax: 4970847

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Aim-Objectives

• At the end of this presentation the participants will be;– Able to describe the role of PHE in primary care

– Able to count three diseases with highest mortality

– Able to define PHE

– Able to explain the effective screening criteria used in PHE

– Aware of the risks in PHE

– Able to count non-evidence based check up activities of daily life

– Aware of the importance of PHE and preventive medicine in primary care.

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What are primary care physicians doing?Health Care

Health promotion

Risk prevention

Early diagnosis

Complication reduction

Risk reduction

Personal Preventive Medicine!

Primary Prevention Secondary PreventionTertiary

Prevention

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Prevention of what?

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Reasons of diseases (%)

0

5

10

15

20

25

30

35

40

45

50

Access Genetic Environment Behaviour

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Insurance companies:“Mortality decreases in persons undergoing regular health checks!”

CHECK-UP(1921)

PERIODIC HEALTH EXAM was introduced.(1970)

Some diseases don’t have enough clues at the beginning, and when able to diagnose there was no time for treatment: check-up

gone. Changing by personal factors such as age, exposure, sex, and risk

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Definition

Evaluation of apparently health individuals in certain time periods, using a number of standard procedures such as counseling, physical examination, immunization, and laboratory investigations is called Periodic Health Examination.

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Does it work?

• USA: Mortality from stroke has decreased by 50% since 1972– Early diagnosis and treatment of hypertension

• Mortality from cervix cancer decreased by 80%• Neonatal screening

– Decrease in mental retardation• Phenylketonuria screening• Congenital hypothyroidism

National Center for Health Statistics. http://www.cdc.gov/nchs/r&d/ndi/ndi.htm

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Immunization and Polio• Polio figures in KSA

0

0,5

1

1,5

2

2,5

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Incidence 2,6 1,8 1,1 1,2 1,2 0,3 0,1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1980

81 82 83 84 85 86 87 88 891990

91 92 93 94 95 96 97 98 992000

2001

2002

-

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Think of your daily life

• A 30-year old woman applies to your office. She has no history of disease but afraid of becoming breast cancer. – Should you perform a breast exam?

– Should you teach her breast self exam?

– Should you order a mammography?

• How do you decide?

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1. Prevalence of the disease should be highNo sense to screen diseases with low prevalance.

- Osteogenesis imperfecta: incidence 1/10 000/year

Effective screening criteria

Medline Plus. Medical Encyclopedia. Osteogenesis imperfecta. http://www.nlm.nih.gov/medlineplus/ency/article/001573.htm

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2. Predictive risk factors or tests should be presentThe safety and cost of the test should be known

- CRP: Cheap but not specific - Echocardiograpy: sensitive and specific but expensive

Effective screening criteria

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10 4

6 80

Diseased (Prevalence)

Healthy Specifity

Sensitivity

PPV NPV

(+) Test (-) Test

Basic ParametersPopulation-100 persons

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3. Morbidity and mortality of the disease should be highFactors other than the type of the disease affecting morbidity and mortality:

Effective screening criteria

- Age- Sex- Race- Geographical area- Life style (culture)

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• 0-18 months• Perinatal causes• Congenital anomalies

• 7-12 years• Accidents other than motor vehicle • Motor vehicle accidents

• 19-39 years• Motor vehicle accidents• Suicide

• 65 years and older• Heart diseases• Cerebrovascular diseases

Mortality according to age groups

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4. There should be an acceptable treatmentNo sense to screen untreatable diseases- Lung cancer (?)

5. There should be a prodromal period without complains- AIDS- Syphilis- Cervix cancer- Breast cancer

Effective screening criteria

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4 year

Beginning

Beginning

Symptoms

Symptoms

DEATH

DEATH2 year

1 year6 mo

Aggressive cancer

The same cancer but less aggressive

Screening once a year

The natural course of diseases

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Let’s come back to our example: patient with breast cancer

• It’s an important disease for women– Worldwide 719000 new cases/year. (1/1000)

• I can be recognized without symptoms– Mammography

• Curable– Surgery, Chemotherapy, Radiotherapy

• The value of treatment is more than its adverse effects

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Can periodic health examination be harmful?Asymptomatic

person

Screening

Test normal Test abnormal

True negative False negative

Reassurance Delay in diagnosis

True positive False positive

AnxietyTreatment

The average error rate of a test: %5

Ian R. McWhinney. A Textbook of Family Medicine. Oxford University Press, USA 1997.

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• Chest x-ray to screen lung diseases,

• Urinanalysis to screen urinary diseases,

• ECG,

• Microfilm to screen Tbc,

• PSA to screen prostate cancer,

• Self exam to screen breast cancer,

• CBC,

• Influenza immunization for healthy adolescents

The Check-up Chaos

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How is PHE performed?

• Healthy individuals• Counseling

• Immunization

• Home visit

• Prophylaxis

• Physical exam

• Laboratory test

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Any Guidelines for KSA?

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PHE Suggestions Bacteriuria,

Asymptomatic The AAFP recommends against the routine screening of men and nonpregnant women for asymptomatic bacteriuria.

• Breast Cancer – The AAFP recommends women age 40 years and older be screened for

breast cancer with mammography every 1-2 years after counseling by their family physician regarding the potential risks and benefits of the procedure.

• Breast Cancer – The AAFP concludes that the evidence is insufficient to recommend for

or against teaching or performing routine breast self-examination (BSE).

Cardiac Disease The AAFP recommends against the use of routine ECG as part of a

periodic health or preparticipation physical exam for cardiac disease in asymptomatic children and adults.

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PHE Suggestions

Cervical Cancer The AAFP strongly recommends that a Pap smear be completed at

least every 3 years to screen for cervical cancer for women who have ever had sex and have a cervix.

Colorectal Cancer The AAFP strongly recommends that clinicians screen men and

women 50 years of age or older for colorectal cancer. Coronary Heart Disease

The AAFP recommends against routine screening with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron-beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events.

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PHE Suggestions Diabetes, Type 2

The AAFP recommends screening for type 2 diabetes in adults with hypertension and hyperlipidemia. There is insufficient evidence to recommend for or against screening adults who are at low risk for coronary vascular disease.

Hearing difficulties The AAFP recommends screening for hearing difficulties by

questioning elderly adults about hearing impairment and counsel regarding the availability of treatment when appropriate.

Hemoglobinopathies The AAFP strongly recommends ordering screening tests for PKU,

hemoglobinopathies, and thyroid function abnormalities in neonates.• Hormone Replacement Therapy

– The AAFP recommends against the routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women.

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PHE Suggestions

• Hormone Replacement Therapy – The AAFP recommends against the routine use of unopposed estrogen

for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.

Hypertension The AAFP strongly recommends that family physicians screen adults

aged 18 and older for high blood pressure. Influenza

The AAFP recommends immunizing all persons age 50 years and older for influenza. Discuss immunization annually using AAFP recommendations.

Lipid Disorders The AAFP strongly recommends screening for lipid disorders with

either a fasting lipid profile or nonfasting total cholesterol and HDL cholesterol in males age 35 and older, and females age 45 and older.

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PHE Suggestions

Lung Cancer The AAFP recommends against the use of chest X-ray and/or sputum

cytology in asymptomatic persons for lung cancer screening. Neural tube defects

The AAFP recommends prescribing 0.4 mg folate supplementation to women not planning a pregnancy but of childbearing potential who have not previously had a baby with a neural tube defect.

Obesity The AAFP recommends screening for obesity by measuring height and

weight periodically for all patients. Osteoporosis

The AAFP recommends counseling females age 11 and older to maintain adequate calcium intake prevent osteoporosis.

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PHE Suggestions Osteoporosis

The AAFP recommends routinely screening women aged 65 and older for osteoporosis.

Prostate Cancer The AAFP concludes that there is insufficient evidence on which to

make a recommendation for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).

Second Hand Smoke The AAFP strongly recommends to counsel smoking parents with

children in the house regarding the harmful effects of smoking and children’s health.

Tobacco Use The AAFP strongly recommends that clinicians screen all adults for

tobacco use and provide tobacco cessation interventions for those who use tobacco products.

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PHE Suggestions

• Visual Impairment – The AAFP recommends screening to detect amblyopia, strabismus, and

defects in visual acuity in children younger than age 5 years.

• Visual Difficulties – The AAFP recommends screening for visual difficulties in elderly

adults by performing snellen acuity testing. Vitamin Supplementation

The AAFP concludes that the evidence is insufficient to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease.

(AAFP, August 2005) www.aafp.org

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Summary

Which is not a method for PHE?a) Counseling

b) Immunization

c) Physical exam

d) Prescription

e) Home visit

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Which is not a criteria for PHE?a) The disease having a asymptomatic period

b) The disease having an acceptable treatment

c) The disease having low morbidity and mortality

d) The prevalence of the disease is high

e) There are risk factors or tests for early diagnosis

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Which one is a correct PHE according to AAFP?

a) ECG to screen heart diseases

b) CBC to sreen blood diseases

c) Chest x-ray for screening purposes

d) Weight and height measurement for children

e) Performing a check-up every year to healthy individuals

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Persons above 65 y. Should have influenza immunizations every year

a) True b) False

The adverse effects of passive smoking to children should be explained to smoking parents at every visit

a) True b) False

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