Periodic Health Examinations in Primary Care

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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 PHC physicians doing?

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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Effective screening criteria1. Disease Has Serious Consequences

Screening should target diseases with serious consequences such as mortality or severe or prolonged morbidity

Both pulmonary and colorectal cancer are serious diseases, being the first and second leading causes of cancer death in the United States , respectively. Breast cancer is the second leading cause of cancer death in women. Thus, all three cancers have serious consequences.

2. Screening Population Has High Prevalence of Detectable Preclinical Phase

• The detectable preclinical phase of the disease should have a high prevalence among people who are screened

• Preclinical phase is the time from the onset of disease

to the first appearance of signs and symptoms• Depends on the population's awareness of the

disease and the patient's access to health care• The preclinical phase is the interval of time when the

disease is detectable by the screening test.

2. Screening Population Has High Prevalence of Detectable Preclinical Phase

• if the prevalence is 1% and the test's sensitivity and specificity are both 95%, then the probability of disease after positive test results is only 16%.

• In contrast, if the prevalence is 5%, then the probability of disease after positive test results

is 50%.

3. Screening Test Detects Little Pseudodisease

Two types of pseudodisease have been described:.-Type I pseudodisease the disease never progresses and, in fact, may regress naturally. -Type II pseudodisease, the disease progresses so slowly that the patient never develops symptoms and dies from another cause. -Type II pseudodisease is common in diseases with long detectable preclinical phases or among patients with short life expectancies -Both types undergo unnecessary tests and treatment but derive no benefit from the treatment.- Screening tests that detect a high frequency of pseudodisease cannot be cost-effective.

3. Screening Test Detects Little Pseudodisease

• With colorectal cancer, not all adenomatous polyps progress to invasive carcinoma. Evidence shows that many small (<1 cm) polyps regress [15]. The rate of adenomatous polyps progressing to cancer has been estimated at about 2.5 polyps per 1000 individuals per year

• Not all breast ductal carcinoma in situ progresses to invasive carcinoma

• The presence of pseudodisease in screening for both colorectal polyps and breast cancer limits the effectiveness of these screening programs

4. Screening Test Has High Accuracy for Detecting the Detectable Preclinical Phase

• The screening test must have good sensitivity and specificity• Increasing the specificity of a screening test will increase the

cost-effectiveness of screening. • It is not always cost-effective to increase a screening test's

sensitivity.• An increase in sensitivity might mean an increase in the

detection of pseudodisease or an increase in the detection of disease after the critical point in the natural history (i.e., after the primary tumor metastasizes).

• Both these situations are detrimental to screening.

5. Screening Test Detects Disease Before Critical Point

• For most diseases, a critical point occurs in the natural history of the disease; treatment is more effective before this point and less effective after this point .

• For most cancers, the critical point occurs when the primary tumor metastasizes.

• If the critical point occurs before the detectable preclinical phase, then screening cannot be effective.

• CT can detect stage I pulmonary cancer is asymptomatic people.

6. Screening Test Causes Little Morbidity

• The screening test must not inflict mortality or significant morbidity on those screened.

• For pulmonary cancer screening, the CT study is performed without IV contrast material, so short-term toxicity is not a problem.

• For breast cancer screening, the short-term effect is patient discomfort.

7. Screening Test Is Affordable and Available

• The diagnostic test must be affordable and available to the target population.

8. Treatment Exists

• An effective treatment for the disease must exist for screening to improve patient outcomes.

• Detection of disease alone is not cost-effective. This may seem a trite criterion for screening, but it is important because many common diseases (e.g., Parkinson's disease, multiple sclerosis, Alzheimer's) have no treatment. Although it may be possible to detect these conditions preclinically, screening cannot be cost-effective if no treatment exists

9. Treatment Is More Effective When Applied Before Symptoms Begin

• For screening to be cost-effective, treatment must be more effective or less toxic when applied during the detectable preclinical

phase, as compared with treatment applied after symptoms begin

10. Treatment Is Not Too Risky or Toxic

• Treatment cannot be so risky or toxic that it offsets its long-term benefits.

• This is particularly important when many false-positive cases or many cases of pseudodisease undergo treatment;

• these patients derive no benefit from treatment, only its side effects.

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Can periodic health examination be harmful?

The average error rate of a test: %5Ian R. McWhinney. A Textbook of Family Medicine. Oxford University Press, USA 1997.

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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.

•Thank you