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Back to Basics, 2014 Population Health: Periodic Health Exam,

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

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Title: Back to Basics, 2014 Population Health: Periodic Health Exam,


1
Back to Basics, 2014Population HealthPeriodic
Health Exam,
  • Dr. Trevor Arnason, MD, CCFP,
  • PGY-3 PHPM University of Ottawa
  • Department of Epidemiology Community Medicine

2
Periodic Health Examination
3
Overview
  • The Periodic Health Examination
  • LMCC Objectives
  • Resources for the PHE
  • Population approach to the PHE
  • Selected conditions recommendations for
    screening

4
Periodic Health Examination
  • History, risk assessment, and a tailored
    physical examination that could lead to delivery
    of preventive services
  • Review a patients ongoing medical issues
  • Counsel for preventive health issues
  • Improve physician patient relationship

5
Periodic Health Examination
  • Use periodic health exam for health promotion
    disease prevention interventions
  • E.g. Smoking cessation, exercise, immunization
  • Case-finding and screening for disease risky
    behaviours
  • E.g. substance abuse
  • Chance to detect characteristics that are known
    to place patients at high risk for particular
    conditions
  • E.g. Family, socioeconomic, occupational and
    lifestyle characteristics

6
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

7
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)

8
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.

9
WARNING! about prevention/screening
  • Prevention 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

10
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

11
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)

12
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

13
PHE Resources
  • Canadian Task Force On Preventive Health Care
    Clinical Guidelines
  • Targeted and evidence based
  • Clinician Summary of guidelines for common
    conditions
  • Grading of recommendation and evidence as
    strong, moderate or weak

14
PHE Resources
  • National Advisory Committee on Immunizations
    (NACI)
  • http//www.phac-aspc.gc.ca/publicat/cig-gci/index-
    eng.php

15
PHE Resources
  • CFPC Preventative Care Checklist

16
PHE Resources
  • Rourke Record
  • http//www.rourkebabyrecord.ca/national.asp

17
Populations - Infant
  • Get 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 (gt6mos)
  • 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

18
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 (gt6mos)
  • 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

19
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

20
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
  • Counselling seatbelts, bike helmets, hearing
    protection, dental health, nutrition, alcohol,
    smoking, other drugs, occupational exposures, sun
    exposure
  • Other meds/interventions folic acid, Vit D,
    dentist

21
Populations Middle Aged Adult
  • History Psychological, social and physical
    functioning, nutrition, physical activity,
    alcohol, smoking,
  • Physical Exam Wt (BMI), BP, eyes, ears
  • Lab tests, diagnostic imaging (screening tests)
    Blood glucose, lipid profile, osteoporosis,
    Cancer breast, prostate, colon
  • Immunizations DTaP (pertussis), 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

22
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
  • Counselling seatbelts, bike helmets, hearing
    protection, dental health, nutrition, alcohol,
    smoking, other drugs, occupational exposures, sun
    exposure
  • Other meds/interventions Vitamin D, dentist

23
Populations Common themes
  • History nutrition, physical activity,
    substances (smoking/EtOH)
  • Physical Exam Wt (BMI), BP, eyes, ears
  • 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
  • Other meds/interventions Vitamin D, dentist

24
Management
  • Recommend proven prevention strategies
  • Smoking Cessation
  • Regular Exercise
  • Nutrition
  • Alcohol reduction

25
Generally not used for screening (asymptomatic)
  • TSH
  • CBC
  • Electrolytes, Cr
  • Vitamin B12
  • ALP
  • ECG
  • Urinalysis

26
Condition Specific Recommendations Screening
27
Recommendations
  • Osteoporosis
  • Prevention
  • lt50 years old
  • Consume 100-1500 mg elemental Ca/day
  • 400-1000 IU per day (if low risk for deficiency)
  • gt50 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

28
Recommendations - Screening
  • Osteoporosis screening - BMD

2010 clinical practice guidelines for the
diagnosis and management of osteoporosis in
Canada summary (CMAJ, 2010)
29
Recommendations - Screening
  • 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 measurement
  • At all appropriate health care visits
  • Measured according to Canadian Hypertension
    Education Program (CHEP) recommendations
  • Apply CHEP criteria for assessment and diagnosis
    of hypertension

30
Recommendations - Screening
  • Cervical Cancer
  • Incidence increases significantly after age 25,
    peaks in 5th decade
  • Intervention Screening with cervical cytology
  • Population asymptomatic women have been or are
    sexually active
  • Recommendation Screen women 25 with a pap test
    q3 years

31
PHE - Screening
  • Cervical Cancer PAP Smear Recommendations
    (CTFPHC)

Age (yrs) Recommendation Rationale
lt20 No routine screening Very low incidence/mortality Evidence 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
32
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

33
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
34
Recommendations - Screening
  • 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

35
Recommendations - Screening
  • 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
36
PHE - Screening
  • Breast 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

37
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

38
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)

39
Key point - Management
  • Recommend proven prevention strategies
  • Smoking Cessation
  • Regular Exercise
  • Nutrition
  • Alcohol reduction

40
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.
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