Back to Basics, 2013Population Health:

Periodic Health Exam,

Dr. Laura Bourns, PGY-3 PHPM University of OttawaDepartment of Epidemiology & Community Medicine

March 28, 20131

Periodic Health Examination

OverviewLMCC Objectives

Purpose of PHE

Age group specific key conditions & risk factors

Condition Specific Recommendations & Screening

Management

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.

Periodic Health Examination

“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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Periodic Health Examination

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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Periodic Health Examination

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 – Key ConditionsInfant

NutritionBreast FeedingVit D 400 IU/day

GrowthGrowth Charts

DevelopmentRourke Baby Record

Abuse & NeglectVision & Hearing

Red reflex, corneal light reflex, cover-uncover test & inquiry

PHE – Key Age Specific Risk Factors

Infant Birth History

Risk factors at conception, pregnancy, birth Incomplete immunizations

Education & Advice Injury Prevention

Car seatSleep position, crib safetyRemoval of poisons, firearms

EnvironmentPassive smoke

Familial factorsAssess need for home visit

Dental Health

PHE – Key ConditionsChild

NutritionMilk intakeJunk Food Healthy/choices

GrowthPlot on Growth Chart

DevelopmentRourke Baby Record – up to age 5 years

Abuse & NeglectOther - Hearing, Vision (Amblyopia)

PHE – Key Age Specific Risk Factors

Child Birth History

Risk factors at conception, pregnancy, birth Incomplete immunizations

Education & Advice Injury Prevention

Car seat Bike helmets Removal of firearms

Environment Passive smoke

Familial factors Assess childcare/school readiness

Dental Health – cleaning, fluoride, dentist No OTC cough/cold medications

PHE – Key ConditionsAdolescence

GrowthPlot on Growth ChartSexual maturity (Tanner Staging)

NutritionHealthy habits/junk foodBody Image

Psychosocial history & developmentHEADSSS

PHE – Key Age Specific Risk Factors

Adolescence Incomplete Immunizations Sexually active

ContraceptionSTI screening for all sexually active – chlamydia,

gonorrhea Alcohol/Drug use Emotional concerns Communication with parents

Education & Advice Helmet Safety Vehicle Safety & seatbelts Second hand smoke Dental Care, fluoride

PHE – Key Conditions & Risks

Young Adult Female reproductive health

Pap smear (≥ 25 yrs)Folic acid

STI ScreeningChlamydia & gonorrhea – incidence high in <25 yearsHep B & C – screening in general population not

recommendedHIV & syphilis – if high risk behaviour

Occupational health issuesStressExposures

PHE – Key ConditionsMiddle-aged adult

Cardiovascular health risksBlood glucoseBlood pressureLipid Profile

OsteoporosisCancer

BreastColonProstateSkin

PHE – Key Age Specific Risk Factors

Middle-aged adultLifestyle patterns

Physical activitySmoking, alcohol

Psychological, social and physical functioningOccupational health & exposuresSymptoms of any illnessDiet

PHE – Key ConditionsOlder adult

Fracture & fall preventionOsteoporosis screening

NutritionElder AbuseDementia Screening

Physical Exam & InvestigationFollow up on caregiver concern of cognitive

impairment Multidisciplinary fall assessmentVisual acuity (Snellen)Hearing impairment

PHE – Key Age Specific Risk Factors

Older adultsPast illnessLifestyle factorsMental functionDrug usePhysical and social activityEmotional concernsSocial relations and support systems

PHE – Special PopulationsObese Adults

Screen all overweight and obese patients for eating disorders, depression and psychiatric disorders

Evidence to support use of behaviour modification techniques, CBT, activity enhancement & dietary counselingReduce energy intake: 500-1000kcal/day30 min of moderate intensity exercise 3-5 min/week

Increase to at least 60 min on most days of the week

*Canadian Obesity Network2006 Clinical Practice Guidelines on the management and prevention of obesity in adults and children

PHE – Special PopulationsSmokers

Education & CounselingSmoking Cessation

Counseling Referral to smoking cessation programs

Pharmacologic therapy Varenicline, buproprion

Nicotine Replacement therapy Adjunct to smoking cessation

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)

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 measurementAt all appropriate health care visitsMeasured according to Canadian Hypertension

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

hypertension

Recommendations - Screening

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: HgbA1C (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

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

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

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

Overall Management

PHE - ManagementConstruct an effective initial

management plan, including: Communicate effectively with the patient to

reach common ground regarding goals related to disease prevention and risk reduction

Encourage patient control over healthCounsel about risk factor reduction, using

health belief model, stages of change model, etc.

PHE - Management“Recommend proven

prevention strategies”

Smoking Cessation

Regular Exercise

Diet

Thanks