Periodic Health Examinations in Periodic Health Examinations in Primary CarePrimary Care

DR. KHALED ALDOSSARISBFM ,ABFM ,MBBS

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1 Diseased, diagnosed & controlled

2 Diagnosed, uncontrolled

3 Undiagnosed or wronglydiagnosed disease

4 Risk factors for disease

5 Free of risk factors

Diagnosed disease

Undiagnosed orwrongly diagnosed

disease

Iceberg phenomenon ?

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What are PHC physicians doing?

Health Care

Health promotion

Risk prevention Early

diagnosisComplication

reduction

Risk reduction

Personal Preventive Medicine!

Primary Prevention Secondary PreventionTertiary

Prevention

The High mortality diseases in Saudi Arabia

• Symptoms /Signs ill defined …… 24.64%• Diseases of CVS………………... 21.82%• Injury / Poisoning………………. 18.31%• Conditions perinatal period…….. 9.88%• Neoplasms……………………… 4.55%• Diseases of RS…………………. 4.38%

MOH- Saudi Arabia

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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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World Health Organization — Principles of Screening

The Wilson-Jungner Criteria. Public Health Paper 1968,

Geneva, WHO

• The condition should be an important health problem.

• There should be a treatment for the condition.

• Facilities for diagnosis and treatment should be available.

• There should be a latent stage of the disease.

• There should be a test or examination for the condition.

• The test should be acceptable to the population.

• The natural history of the disease should be adequately

understood.

• There should be an agreed policy on who to treat.

• The total cost of finding a case should be economically

balanced in relation to medical expenditure as a whole.

• Case-finding should be a continuous process, not just a

"once and for all" project.

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Types of screening

• Mass

• Targeted

• Multiple or Multiphasic

• Case-finding or opportunistic

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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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Screening / PHE programs in Saudi Arabia

• Annual periodic health examination for all diabetic and hypertensive patients registered at PHC

• Cervical screening• Breast cancer screening in some areas• Pre-marital screening (genetic dis.,

infectious dis.)• Well baby clinic

USPSTF

Grade Definitions

• Grade Definitions After July 2012

• What the Grades Mean and Suggestions for Practice ?

GradeDefinitionSuggestions for Practice

AThe USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer or provide this service.

BThe USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer or provide this service.

CThe USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

Offer or provide this service for selected patients depending on individual circumstances.

DThe USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I Statement

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Screening for High Blood Pressure in Adults

• The USPSTF recommends screening for high blood pressure in adults age 18 and older. Grade: A Recommendation.

Aspirin for the Prevention of Cardiovascular Disease

• The USPSTF recommends the use of aspirin for men ages 45 to 79 years when the potential benefit of a reduction in myocardial infarction outweighs the potential harm of an increase in gastrointestinal hemorrhage.Grade: A recommendation.

• The USPSTF recommends the use of aspirin for women ages 55 to 79 years when the potential benefit of a reduction in ischemic stroke outweighs the potential harm of an increase in gastrointestinal hemorrhage.Grade: A recommendation

• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the use of aspirin for cardiovascular disease prevention in men and women age 80 years or older.Grade: I statement.

• The USPSTF recommends against the use of aspirin for stroke prevention in women younger than age 55 years and for myocardial infarction prevention in men younger than age 45 years. Grade: D recommendation.

SCREENING OF DM

• he USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg.

• Grade: B Recommendation.• The USPSTF concludes that the current evidence is

insufficient to assess the balance of benefits and harms of screening for type 2 diabetes in asymptomatic adults with blood pressure of 135/80 mm Hg or lower.

Screening for Lipid Disorders in Adults Screening Men

• The U.S. Preventive Services Task Force (USPSTF) strongly recommends screening men aged 35 and older for lipid disorders.  Grade: A Recommendation.

• The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. Grade: B Recommendation

screening Women at Increased Risk

• The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease.  Grade: A Recommendation.

• The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. Grade: B Recommendation

Screening Young Men and All Women Not at Increased Risk

• The USPSTF makes no recommendation for or against routine screening for lipid disorders in men aged 20 to 35, or in women aged 20 and older who are not at increased risk for coronary heart disease.Grade: C Recommendation.

Screening for Thyroid Disease

• The USPSTF concludes the evidence is insufficient to recommend for or against routine screening for thyroid disease in adults. Grade: I Statement

Screening for Iron Deficiency Anemia

• The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children ages 6 to 12 months. Grade: I Statement.

• The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women.Grade: B Recommendation.

Screening for Colorectal Cancer

• The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. Grade: A Recommendation.

• The USPSTF recommends against routine screening for colorectal cancer in adults age 76 to 85 years. There may be considerations that support colorectal cancer screening in an individual patient.

Grade: C Recommendation.

• The USPSTF recommends against screening for colorectal cancer in adults older than age 85 years. Grade: D Recommendation.

• The USPSTF concludes that the evidence is insufficient to assess the benefits and harms of computed tomographic colonography and fecal DNA testing as screening modalities for colorectal cancer. Grade: I Statement.

Screening for Breast Cancer

• The USPSTF recommends biennial screening mammography for women aged 50 to 74 years. Grade: B recommendation.

• The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms. Grade: C recommendation.

• The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older. Grade: I Statement.

• The USPSTF recommends against teaching breast self-examination (BSE).Grade: D recommendation.

Screening for Cervical Cancer

• ANSWER ?

Lung Cancer Screening

• The USPSTF concludes that the evidence is insufficient to recommend for or against screening for lung cancer in asymptomatic persons with either low-dose computed tomography, chest x-ray, sputum cytology, or a combination of these tests.

Screening for Prostate Cancer

• The USPSTF recommends against

PSA-based screening for prostate cancer.Grade: D Recommendation.

Screening for Ovarian Cancer

• The USPSTF recommends against screening for ovarian cancer in women.Grade: D Recommendation

Screening for Abdominal Aortic Aneurysm

• The USPSTF recommends one-time screening for abdominal aortic aneurysm (AAA) by ultrasonography in men aged 65 to 75 who have ever smoked. Grade: B Recommendation.

• The USPSTF makes no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked. Grade: C Recommendation.

• The USPSTF recommends against routine screening for AAA in women. Grade: D Recommendation.

Screening for Depression in Adults

• The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.Grade: B recommendation.

• The USPTF recommends against routinely screening adults for depression when staff-assisted depression care supports are not in place. There may be considerations that support screening for depression in an individual patient.Grade: C recommendation

Screening for Illicit Drug Use

• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use. Grade: I Statement

Folic Acid to Prevent Neural Tube Defects

• The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid .

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PHE Suggestions AAFP 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.