The Practice of The Practice of Preventative Preventative

MedicineMedicineWhat tests should we check What tests should we check on our patients and when on our patients and when should we check them?should we check them?

OutlineOutline

What is preventative medicine and What is preventative medicine and what is it’s importancewhat is it’s importance

The definition of screening and how The definition of screening and how we decide what a good screening test we decide what a good screening test is is

Who do you look to for the current Who do you look to for the current recommendations, and how do they recommendations, and how do they formulate those recommendationsformulate those recommendations

The tests/procedures and current The tests/procedures and current recommendations recommendations

What is preventative What is preventative medicine?medicine?

Disease preventionDisease prevention Identification of disease at an early stageIdentification of disease at an early stage Definition: procedures/exams/interventions Definition: procedures/exams/interventions

performed on patients without specific performed on patients without specific complaints, to identify and modify risk complaints, to identify and modify risk factors to avoid the onset of disease, or to factors to avoid the onset of disease, or to find disease early in its course so that by find disease early in its course so that by intervening patients can remain well. intervening patients can remain well.

Synonyms: health maintenance or the Synonyms: health maintenance or the periodic health examinationperiodic health examination

What is the importance of What is the importance of reviewing this subject.reviewing this subject.

1. It has been shown to be effective at many 1. It has been shown to be effective at many levels (ex. Community wide immunizations, levels (ex. Community wide immunizations, colorectal cancer screening, cervical cancer colorectal cancer screening, cervical cancer screening, breast cancer screening, etc..)screening, breast cancer screening, etc..)

2. Your patients are going to ask you 2. Your patients are going to ask you questions about why you are checking questions about why you are checking certain tests. (ex. Pap smear, mammograms)certain tests. (ex. Pap smear, mammograms)

3. Cost considerations (if a test is not shown 3. Cost considerations (if a test is not shown to be beneficial, then by checking it to be beneficial, then by checking it routinely we are wasting resources)routinely we are wasting resources)

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3 levels of preventative 3 levels of preventative medicinemedicine

1. Primary prevention- prevents disease from 1. Primary prevention- prevents disease from occuring at all by removing it’s causes (ex. Use of occuring at all by removing it’s causes (ex. Use of folic acid to prevent neural tube defects, folic acid to prevent neural tube defects, immunizations, counseling to adopt healthy immunizations, counseling to adopt healthy lifestyles, mandating seat belt use, etc..)lifestyles, mandating seat belt use, etc..)

2. Secondary prevention- detects disease early when 2. Secondary prevention- detects disease early when it is asymptomatic and when early treatment can it is asymptomatic and when early treatment can stop it from progressing (ex. Pap smears, stop it from progressing (ex. Pap smears, mammograms, FOBT, colonoscopy, etc..)mammograms, FOBT, colonoscopy, etc..)

3. Tertiary prevention-clinical activities that prevent 3. Tertiary prevention-clinical activities that prevent further deterioration or reduce complications after a further deterioration or reduce complications after a disease has declared itself ( ex. Starting BB after MI disease has declared itself ( ex. Starting BB after MI to decrease risk of death, initiation of ACE-I in to decrease risk of death, initiation of ACE-I in diabetics to prevent nephropathy, etc.) diabetics to prevent nephropathy, etc.)

ScreeningScreening

The identification of unrecognized The identification of unrecognized disease using various modalities (H/P, lab disease using various modalities (H/P, lab tests, Xray, procedures)tests, Xray, procedures)

Sort out well appearing persons with a Sort out well appearing persons with a disease or risk factors for disease disease or risk factors for disease

Part of many primary and all secondary Part of many primary and all secondary prevention measuresprevention measures

Screening tests are typically not Screening tests are typically not diagnostic so the clinician must be willing diagnostic so the clinician must be willing to further investigate a + testto further investigate a + test

How do we decide what to How do we decide what to screen for?screen for?

1. Must consider the burden of suffering caused 1. Must consider the burden of suffering caused by the condition (discomfort, disability, death)by the condition (discomfort, disability, death)

2. Must consider how good the screening test is 2. Must consider how good the screening test is in terms of sensitivity, specificity, cost, ease of in terms of sensitivity, specificity, cost, ease of use, safety, acceptability, risk of a false positive, use, safety, acceptability, risk of a false positive, labeling of pts with conditions.labeling of pts with conditions.

3. Then must consider in the case of primary 3. Then must consider in the case of primary prevention, how good is the intervention in prevention, how good is the intervention in preventing the disease, or in secondary preventing the disease, or in secondary prevention , how good are the treatments that prevention , how good are the treatments that are available for the disease (in terms of are available for the disease (in terms of efficacy/compliance/early treatment as a benefit efficacy/compliance/early treatment as a benefit versus late treatment)versus late treatment)

What does that mean?What does that mean? Example: Breast cancer screeningExample: Breast cancer screening Primarily occurs in women >50yrsPrimarily occurs in women >50yrs In women in their 20’s the incidence is very In women in their 20’s the incidence is very

low approx 1 in 100,000low approx 1 in 100,000 For the women that get breast CA at that For the women that get breast CA at that

age there is a substantial morbidity and age there is a substantial morbidity and mortality, but given it’s rarity in that age mortality, but given it’s rarity in that age group screening becomes impractical and group screening becomes impractical and would probably lead to more morbidity and would probably lead to more morbidity and usage of resources from further w/u of false usage of resources from further w/u of false positives (biopsies, further radiological positives (biopsies, further radiological tests, etc..)tests, etc..)

The dreaded StatisticsThe dreaded Statistics A good screening test should have a high sensitivity to A good screening test should have a high sensitivity to

limit the false negatives and a high specificity to limit limit the false negatives and a high specificity to limit the false positives (these are affected by the prevalence the false positives (these are affected by the prevalence of the disease in the population). of the disease in the population).

For many screening tests the gold standard from which For many screening tests the gold standard from which sens/spec are determined is based on long term follow sens/spec are determined is based on long term follow up with monitoring for occurrence of a disease following up with monitoring for occurrence of a disease following the screening test -detection method. The two problems the screening test -detection method. The two problems with this are knowing the length of time needed to with this are knowing the length of time needed to follow the patient to detect the disease, and the follow the patient to detect the disease, and the assumption that the abnormality detected would go on assumption that the abnormality detected would go on to cause disease if left alone (ex. Estimated that virtually to cause disease if left alone (ex. Estimated that virtually all men >90yr have foci of prostate CA). A second all men >90yr have foci of prostate CA). A second method to get around this is the incidence method which method to get around this is the incidence method which calculates sensitivity based on ratio of pts with a disease calculates sensitivity based on ratio of pts with a disease undergoing the screening test over that of the patients undergoing the screening test over that of the patients with the disease who don’t have the test (1- pts with with the disease who don’t have the test (1- pts with disease undergoing screening/ pts with disease who disease undergoing screening/ pts with disease who didn’t have screening). This limits counting benign didn’t have screening). This limits counting benign conditions found on screening but might decrease conditions found on screening but might decrease sensitivity by ignoring pts with malignancies with long sensitivity by ignoring pts with malignancies with long lead times.lead times.

Consider Simplicity and Consider Simplicity and CostCost

A good screening test should be A good screening test should be relatively simple to perform (ex. BP) relatively simple to perform (ex. BP) although that is not always the case although that is not always the case (colonoscopy)(colonoscopy)

Cost of not only the test itself, but Cost of not only the test itself, but the cost of subsequent workups of the cost of subsequent workups of positive results and the time missed positive results and the time missed from work for special visits to the from work for special visits to the physician must be consideredphysician must be considered

Acceptability, LabelingAcceptability, Labeling

Acceptability- Do the pt and physician Acceptability- Do the pt and physician find the test acceptable to perform (ex. find the test acceptable to perform (ex. Many asymptomatic pts refuse a Many asymptomatic pts refuse a colonoscopy, many women refuse pelvic colonoscopy, many women refuse pelvic exams)exams)

Labeling- Psychologically a false Labeling- Psychologically a false positive result can be devastating for a positive result can be devastating for a pt. One study showed that almost 50% pt. One study showed that almost 50% of women with false + mammograms of women with false + mammograms read as high suspicion suffered anxiety read as high suspicion suffered anxiety and worries that affected their daily and worries that affected their daily lives (1). lives (1).

Risk of False PositivesRisk of False Positives

One study showed that on average One study showed that on average internists selected 54 different tests internists selected 54 different tests during periodic health examinations during periodic health examinations (components of CBC, Chem 14 etc.) (components of CBC, Chem 14 etc.) (2).(2).

BiasesBiases Lead time bias- Period of time between detection Lead time bias- Period of time between detection

of disease by screening versus when it would of disease by screening versus when it would present with symptoms. If the period is very present with symptoms. If the period is very short then the screening test will not be very short then the screening test will not be very useful (ex. Lung cancer). If the lead time is long useful (ex. Lung cancer). If the lead time is long then the test might be useful (ex. Cervical CA).then the test might be useful (ex. Cervical CA).

Length time bias- more slow growing cancers Length time bias- more slow growing cancers are diagnosed during screening than during are diagnosed during screening than during usual medical care when pts are more likely usual medical care when pts are more likely diagnosed with a rapid growing tumor causing diagnosed with a rapid growing tumor causing symptoms, so screening may be catching more symptoms, so screening may be catching more malignancies with a better prognosis and malignancies with a better prognosis and therefore might appear more beneficial than it therefore might appear more beneficial than it truly is.truly is.

Where do you look for the Where do you look for the current recommendations?current recommendations?

The U.S. Preventative Services Task The U.S. Preventative Services Task Force (USPSTF) was first convened by Force (USPSTF) was first convened by the U.S. Public Health Service in 1984 the U.S. Public Health Service in 1984 and it’s recommendations are and it’s recommendations are considered the gold standard for clinical considered the gold standard for clinical preventative services. They review the preventative services. They review the current available literature/information current available literature/information and make recommendations based on and make recommendations based on the available data.the available data.

They have released two print editions They have released two print editions and portions of the 3and portions of the 3rdrd edition are now edition are now available online.available online.

The tests that I will The tests that I will reviewreview

H/P and LabsH/P and Labs H&P H&P CBCCBC CHEM 8CHEM 8 LFT’sLFT’s Fasting LipidsFasting Lipids TSHTSH PSAPSA UAUA PAP SmearPAP Smear HIV SerologyHIV Serology FOBTFOBT

Radiological/Radiological/ProceduralProcedural ColonoscopyColonoscopy MammogramMammogram EKG/Stress EKG/Stress

testing/Calcium testing/Calcium scoresscores

CXRCXR DEXADEXA Ankle/Brachial Ankle/Brachial

Index (PAD)Index (PAD) Carotid DopplerCarotid Doppler

How do they rate these How do they rate these tests?tests? First they rate the evidenceFirst they rate the evidence

Prior to the 3Prior to the 3rdrd edition edition Grade I-at least one properly randomized controlled trial Grade I-at least one properly randomized controlled trial Grade II-obtained from other controlled trials or analytic studies, or Grade II-obtained from other controlled trials or analytic studies, or

from multiple time series with dramatic results in uncontrolled from multiple time series with dramatic results in uncontrolled experiments, has 3 subcategories based on the type of study experiments, has 3 subcategories based on the type of study

Grade III-Opinions of respected authorities based upon clinical Grade III-Opinions of respected authorities based upon clinical experience, descriptive studies and case reports, or reports of expert experience, descriptive studies and case reports, or reports of expert committees.committees.

With the 3With the 3rdrd edition they tried to simplify edition they tried to simplify itit Good- consistent results obtained from well designed, well Good- consistent results obtained from well designed, well

conducted studies in the representative population that directly conducted studies in the representative population that directly assess effects on health outcomesassess effects on health outcomes

Fair- evidence sufficient to determine effects on health Fair- evidence sufficient to determine effects on health outcomes but the strength of evidence is limited by the number, outcomes but the strength of evidence is limited by the number, quality, or consistency of individual studies, generalizability to quality, or consistency of individual studies, generalizability to routine practice, or indirect nature of the evidence on health routine practice, or indirect nature of the evidence on health outcomes.outcomes.

Poor-evidence is insufficient to assess the effects on health Poor-evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, outcomes because of limited number or power of studies, important flaws in design or concept of studies, gaps in the important flaws in design or concept of studies, gaps in the chain of evidence, or lack of information on important health chain of evidence, or lack of information on important health outcomes.outcomes.

Next they give a recommendation Next they give a recommendation and grade the recommendation and grade the recommendation

based on that evidencebased on that evidence Prior to 3Prior to 3rdrd edition there were 5 grades edition there were 5 grades

A-There is good evidence to support the recommendation for inclusion of the A-There is good evidence to support the recommendation for inclusion of the service for the periodic health evaluation.service for the periodic health evaluation.

B-There is fair evidence to support the recommendation for inclusion of the B-There is fair evidence to support the recommendation for inclusion of the service for the periodic health evaluation.service for the periodic health evaluation.

C-There is insufficient evidence for or against the recommendation for C-There is insufficient evidence for or against the recommendation for inclusion of the service for the periodic health evaluation.inclusion of the service for the periodic health evaluation.

D-There is fair evidence to support the recommendation to exclude the service D-There is fair evidence to support the recommendation to exclude the service for the periodic health evaluation.for the periodic health evaluation.

E-There is good evidence to support the recommendation to exclude the E-There is good evidence to support the recommendation to exclude the service for the periodic health evaluation.service for the periodic health evaluation.

For the 3For the 3rdrd edition USPSTF changed grading to include recommendations edition USPSTF changed grading to include recommendations A-USPSTF strongly recommends the clinician provide the service to eligible A-USPSTF strongly recommends the clinician provide the service to eligible

pts, because there is good evidence it was found to improve important health pts, because there is good evidence it was found to improve important health outcomes and concludes that benfits outweigh the harmsoutcomes and concludes that benfits outweigh the harms

B-USPSTF recommends the clinician provide the service to eligible pts, B-USPSTF recommends the clinician provide the service to eligible pts, because there is fair evidence it was found to improve important health because there is fair evidence it was found to improve important health outcomes and concludes that benfits outweigh the harmsoutcomes and concludes that benfits outweigh the harms

C-USPSTF makes no recommendation for or against the service, because there C-USPSTF makes no recommendation for or against the service, because there is fair evidence it can improve health outcomes but balance of benfits and is fair evidence it can improve health outcomes but balance of benfits and harms is too close for a general recommendationharms is too close for a general recommendation

D-USPSTF recommends against the service for asymptomatic pts, because D-USPSTF recommends against the service for asymptomatic pts, because there is fair evidence it is ineffective or that harms outweigh benefitsthere is fair evidence it is ineffective or that harms outweigh benefits

I-The evidence is insufficient to recommend for or against the serviceI-The evidence is insufficient to recommend for or against the service

History and PhysicalHistory and Physical

No general recommendation for or No general recommendation for or against general H/P and the only thing it against general H/P and the only thing it costs is timecosts is time

Obviously a thorough H/P on initial Obviously a thorough H/P on initial consultation and then periodically is the consultation and then periodically is the best screening tool that we have since best screening tool that we have since the majority of our diagnoses are made the majority of our diagnoses are made through H/Pthrough H/P

Certain aspects that do have Certain aspects that do have recommendationsrecommendations

Blood PressureBlood Pressure

For pts age ≥18: Grade A with good For pts age ≥18: Grade A with good evidence for regular screening for evidence for regular screening for HTN (at least every one to two HTN (at least every one to two years)years)

Clinical Breast ExamClinical Breast Exam

Grade-I :no study comparing CBE to no Grade-I :no study comparing CBE to no exam, and studies show that breast exam, and studies show that breast cancer mortality is similar in groups cancer mortality is similar in groups screened with mammography +/- CBE, screened with mammography +/- CBE, most organizations including the AMA most organizations including the AMA recommend to begin yearly exams recommend to begin yearly exams starting at age 40 (if not earlier based starting at age 40 (if not earlier based on family history)on family history)

Digital Rectal ExamDigital Rectal Exam

Grade I: Although DRE has some utility as a Grade I: Although DRE has some utility as a screening tool for prostate CA (although screening tool for prostate CA (although sensitivity is still quite low) it is inconclusive sensitivity is still quite low) it is inconclusive whether early detection improves outcomes and whether early detection improves outcomes and screening is associated with important harms screening is associated with important harms (frequent false +, anxiety, biopsies etc.). None (frequent false +, anxiety, biopsies etc.). None of the major medical societies endorses of the major medical societies endorses universal or mass screening of any particular universal or mass screening of any particular group, but they conclude that men most likely group, but they conclude that men most likely to benefit are ≥age 50 (or younger if they have to benefit are ≥age 50 (or younger if they have a strong family history) and have a life a strong family history) and have a life expectancy of >10yrs.expectancy of >10yrs.

CBCCBC

No general recommendation on a No general recommendation on a complete blood countcomplete blood count

For H/H- Grade C (2For H/H- Grade C (2ndnd edition) with edition) with level I/II evidence which is level I/II evidence which is inconclusive, so no rec. for or inconclusive, so no rec. for or against general use as screening against general use as screening tool. For Pregnant women – Grade A tool. For Pregnant women – Grade A with level I/II evidence for screeningwith level I/II evidence for screening

Chemistry PanelChemistry Panel No general recommendation on total chem No general recommendation on total chem

panelpanel Glucose-Glucose-

In general population-Grade I, not enough In general population-Grade I, not enough evidence available to recommend for or evidence available to recommend for or against screeningagainst screening

In patients with HTN or hyperlipidemia- Grade In patients with HTN or hyperlipidemia- Grade B with good evidence for annual screening B with good evidence for annual screening since in pts with HTN and hyperlipidemia since in pts with HTN and hyperlipidemia there is a higher level of DM II and that those there is a higher level of DM II and that those pts benefit from more aggressive treatment of pts benefit from more aggressive treatment of their HTN/hyperlipidemiatheir HTN/hyperlipidemia

Liver Function TestsLiver Function Tests No general recommendations to use as a No general recommendations to use as a

screening toolscreening tool There are recommendation for Hep viral There are recommendation for Hep viral

screeningscreening Hep B surface antigenHep B surface antigen

In pregnant women at first prenatal visit- Grade A with good In pregnant women at first prenatal visit- Grade A with good evidence for screening all pregnant womenevidence for screening all pregnant women

In general asymptomatic pts- Grade D with no evidence of In general asymptomatic pts- Grade D with no evidence of benefit and possible harms (cost, labeling, etc.)benefit and possible harms (cost, labeling, etc.)

In high risk pts- Grade C, no recommendation for or against, In high risk pts- Grade C, no recommendation for or against, might be beneficial to identify pts that might benefit from might be beneficial to identify pts that might benefit from vaccinationvaccination

Hep C serologyHep C serology In general population- Grade D, with no evidence of benefit In general population- Grade D, with no evidence of benefit

and possible harms and possible harms In high risk pts- Grade I, In high risk pts screening would In high risk pts- Grade I, In high risk pts screening would

have higher yield and tx with current therapies appear have higher yield and tx with current therapies appear beneficial but no data as to whether early tx improves beneficial but no data as to whether early tx improves mortality (although older therapies are suggestive that it mortality (although older therapies are suggestive that it does) so they were unable to give a general recommendation does) so they were unable to give a general recommendation for or against, but other groups including the NIH/CDC do for or against, but other groups including the NIH/CDC do recommend screening high risk groupsrecommend screening high risk groups

LipidsLipids

For Men age ≥35 and Women age ≥45- For Men age ≥35 and Women age ≥45- Grade A with good evidence for screening Grade A with good evidence for screening every 5 yearsevery 5 years

For men/women less than those ages with For men/women less than those ages with other risk factors for CAD- Grade B with good other risk factors for CAD- Grade B with good evidence for screening every 5 yearsevidence for screening every 5 years

For men/women less than those ages without For men/women less than those ages without risk factors for CAD- Grade C with no good risk factors for CAD- Grade C with no good evidence for or against screening although evidence for or against screening although potential benefit in this pt population is likely potential benefit in this pt population is likely lessless

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TSHTSH

In Asymptomatic pts- Grade I, no In Asymptomatic pts- Grade I, no recommendation for or against recommendation for or against regular screening since there is no regular screening since there is no substantial data showing benefit to substantial data showing benefit to treating subclinical screening treating subclinical screening detected thyroid disorderdetected thyroid disorder

PSAPSA

Pts of any age- Grade I, no Pts of any age- Grade I, no recommendation for or against use recommendation for or against use as a regular screening test for as a regular screening test for similar reasons to DRE. Must similar reasons to DRE. Must discuss risks/benefits of the test with discuss risks/benefits of the test with pt and decide together whether to pt and decide together whether to proceed.proceed.

UAUA For Asymptomatic men/women (not For Asymptomatic men/women (not

pregnant)- Grade D with fair evidence that pregnant)- Grade D with fair evidence that there is no benefit to routine screening there is no benefit to routine screening

Pregnant women- Grade A, recommends Pregnant women- Grade A, recommends routine UA/Culture at 12-15 wks to r/o routine UA/Culture at 12-15 wks to r/o asymptomatic bacteruriaasymptomatic bacteruria

As a screen for bladder CA- Grade D with As a screen for bladder CA- Grade D with fair evidence that screening is not fair evidence that screening is not beneficial due to the low prevelance of beneficial due to the low prevelance of asymptomatic disease that progresses to asymptomatic disease that progresses to clinically significant diseaseclinically significant disease

PAP Smear/PelvicPAP Smear/Pelvic Women who are sexually active and have a cervix- Grade Women who are sexually active and have a cervix- Grade

A with good evidence for beginning screening pap A with good evidence for beginning screening pap smears at least every 3 yrs within 3yrs of onset of sexual smears at least every 3 yrs within 3yrs of onset of sexual activity or by age 21. There is no direct evidence that activity or by age 21. There is no direct evidence that yearly screening is more effective, but several yearly screening is more effective, but several organizations have made recs. regarding yearly organizations have made recs. regarding yearly screening till 2 to 3 normals followed by screening every screening till 2 to 3 normals followed by screening every 3 yrs, or yearly testing in pts with higher risk sexual 3 yrs, or yearly testing in pts with higher risk sexual activity, although there is no data to support either of activity, although there is no data to support either of these recs..these recs..

Women ≥65 with adequate normal pap smears recently Women ≥65 with adequate normal pap smears recently and at not at high risk- Grade D with limited evidence and at not at high risk- Grade D with limited evidence for benefit with cont screening in this populationfor benefit with cont screening in this population

Women who had hysterectomy for benign disease- Women who had hysterectomy for benign disease- Grade D with fair evidence that there is little benefit to Grade D with fair evidence that there is little benefit to cont screening in the populationcont screening in the population

HPV testing- Grade I with poor evidence to determine HPV testing- Grade I with poor evidence to determine the risks/benefits of HPV testing in conjunction with pap the risks/benefits of HPV testing in conjunction with pap smear as a screening tool. Trials are ongoing looking at smear as a screening tool. Trials are ongoing looking at question, but currently no recommendation for or question, but currently no recommendation for or against it’s use.against it’s use.

HIV SerologyHIV Serology

History is very important on deciding History is very important on deciding this issue this issue In non high risk groups- Grade C In non high risk groups- Grade C

recommendation with fair evidence , no recommendation with fair evidence , no recommendation for or against screeningrecommendation for or against screening

In high risk groups (IVDU, homosexual In high risk groups (IVDU, homosexual men)- Grade A with good evidence for men)- Grade A with good evidence for periodic screening periodic screening

For Pregnant women- Grade A with good For Pregnant women- Grade A with good evidence for routine screeningevidence for routine screening

FOBT/ColonoscopyFOBT/Colonoscopy Recommends screening for CRC in general with Recommends screening for CRC in general with

Grade A, good evidence that screening Grade A, good evidence that screening beginning at age 50 for average risk individuals beginning at age 50 for average risk individuals is beneficial. They do not make direct is beneficial. They do not make direct recommendations on which screening modality recommendations on which screening modality to use although they suggest multiple to use although they suggest multiple possibilities including yearly FOBT + flexible possibilities including yearly FOBT + flexible sigmoidoscopy every 5 yrs, or colonoscopy every sigmoidoscopy every 5 yrs, or colonoscopy every 10 yrs (considered the gold standard) that vary 10 yrs (considered the gold standard) that vary in their cost, complications, availability, in their cost, complications, availability, sensitivity/specificity etc..sensitivity/specificity etc..

For pts with a FH of colon CA before age 60 it is For pts with a FH of colon CA before age 60 it is reasonable to begin screening at an earlier agereasonable to begin screening at an earlier age

MammogramMammogram

For women age ≥40- Grade B For women age ≥40- Grade B recommendation with fair evidence recommendation with fair evidence of benefit for screening with of benefit for screening with mammogram every 1-2 yrs with or mammogram every 1-2 yrs with or without CBE/SBEwithout CBE/SBE

EKG/Stress testing/Calcium EKG/Stress testing/Calcium ScoresScores

In pts at low risk for CHD events- Grade D In pts at low risk for CHD events- Grade D recommendation with fair evidence that although recommendation with fair evidence that although testing will detect a small percentage of pts with testing will detect a small percentage of pts with disease, the harm from screening the population disease, the harm from screening the population including unnecessary procedures/over including unnecessary procedures/over treatment/labeling outweigh any benefitstreatment/labeling outweigh any benefits

In pts at increased risk for CHD- Grade I with In pts at increased risk for CHD- Grade I with insufficient evidence to recommend for or against insufficient evidence to recommend for or against screening in this population. It is unclear in a screening in this population. It is unclear in a asymptomatic pt in this population whether these asymptomatic pt in this population whether these tests add more information than risk stratification tests add more information than risk stratification based on conventional CHD risk factors, and whether based on conventional CHD risk factors, and whether the benefits outweigh the harms. (the AHA suggests the benefits outweigh the harms. (the AHA suggests stress testing might be beneficial for diabetic pts if stress testing might be beneficial for diabetic pts if they are going to start a vigorous exercise program).they are going to start a vigorous exercise program).

CXRCXR

To screen for Lung CA- Grade I with To screen for Lung CA- Grade I with insufficient evidence to recommend for insufficient evidence to recommend for or against routine screening (there is or against routine screening (there is no good study designed to look at no good study designed to look at screening versus not screening, but screening versus not screening, but observational studies suggest that CXR observational studies suggest that CXR screening does not decrease mortality screening does not decrease mortality from lung CA which makes since from lung CA which makes since because by the time it is visible on a because by the time it is visible on a CXR it has usually metastasized on a CXR it has usually metastasized on a cellular level and we have essentially no cellular level and we have essentially no effective treatment options for effective treatment options for metastatic disease).metastatic disease).

DEXA (Dual-energy x-ray DEXA (Dual-energy x-ray absorptiometry )absorptiometry )

Women age ≥65 or women between 60-64 who are at Women age ≥65 or women between 60-64 who are at increased risk (low wt, postmenopausal not on estrogen increased risk (low wt, postmenopausal not on estrogen replacement)- Grade B recommendation with good replacement)- Grade B recommendation with good evidence that screening is beneficial in these groups of evidence that screening is beneficial in these groups of women. There is no specific recommendation on the women. There is no specific recommendation on the screening interval, but it is thought that 2 yrs might be screening interval, but it is thought that 2 yrs might be needed to see a substantial difference in BMD.needed to see a substantial difference in BMD.

Women age 60-64 who are not at increased risk or Women age 60-64 who are not at increased risk or women younger than 60- Grade C with fair evidence women younger than 60- Grade C with fair evidence that it would prevent a small number of fractures but that it would prevent a small number of fractures but the benefits and harms were similar so no the benefits and harms were similar so no recommendation for or against screening in this recommendation for or against screening in this population population

Women/Men on long term corticosteroids- Not Women/Men on long term corticosteroids- Not specifically reviewed. A summary statement by the specifically reviewed. A summary statement by the Amer College of Rheum in 2001 recommended that for Amer College of Rheum in 2001 recommended that for Pt on Prednisone≥ 5mg daily for time of ≥3months that Pt on Prednisone≥ 5mg daily for time of ≥3months that they be screened annually to biannually (and tx they be screened annually to biannually (and tx preventatively)(3).preventatively)(3).

Screening in Men- has not been reviewed to dateScreening in Men- has not been reviewed to date

Ankle/Brachial IndexAnkle/Brachial Index

In Asymptomatic Individuals- Grade In Asymptomatic Individuals- Grade D with fair evidence that pts in this D with fair evidence that pts in this category would not benefit from category would not benefit from screening/treatmentscreening/treatment

Carotid DopplerCarotid Doppler

In Asymptomatic Individuals- Grade In Asymptomatic Individuals- Grade I with insufficient evidence for I with insufficient evidence for screening with carotid doppler in screening with carotid doppler in this populationthis population

Summary: What you should Summary: What you should definitely dodefinitely do

MenMen Annual H&P starting at age 18 Annual H&P starting at age 18

including BP measurementincluding BP measurement Fasting Lipids every 5 yrs starting Fasting Lipids every 5 yrs starting

at age 35 for average risk pts and at age 35 for average risk pts and younger if pt has significant risk younger if pt has significant risk factorsfactors

CRC screening starting at age 50 CRC screening starting at age 50 with either annual FOBT with flex with either annual FOBT with flex sig every 5 yrs or colonoscopy sig every 5 yrs or colonoscopy every 10 yrs. If Pt has FH of early every 10 yrs. If Pt has FH of early CRC then it is acceptable to begin CRC then it is acceptable to begin screening at a younger age screening at a younger age (dictated by their history)(dictated by their history)

If pt has HTN or Hyperlipidemia If pt has HTN or Hyperlipidemia then check annual fasting glucosethen check annual fasting glucose

HIV Serology annually in high risk HIV Serology annually in high risk populationspopulations

WomenWomen Annual H&P starting at age 18 Annual H&P starting at age 18

including BP measurementincluding BP measurement Fasting Lipids every 5 yrs starting at Fasting Lipids every 5 yrs starting at

age age 4545 for average risk pts and for average risk pts and younger if pt has significant risk younger if pt has significant risk factorsfactors

CRC screening starting at age 50 CRC screening starting at age 50 with either annual FOBT with flex sig with either annual FOBT with flex sig every 5 yrs or colonoscopy every 10 every 5 yrs or colonoscopy every 10 yrs. If Pt has FH of early CRC then it yrs. If Pt has FH of early CRC then it is acceptable to begin screening at a is acceptable to begin screening at a younger age (dictated by their younger age (dictated by their history)history)

If pt has HTN or Hyperlipidemia then If pt has HTN or Hyperlipidemia then check annual fasting glucosecheck annual fasting glucose

HIV Serology annually in high risk HIV Serology annually in high risk populationspopulations

Pap Smear every 1-3 yrs (no good Pap Smear every 1-3 yrs (no good evidence to support one way over evidence to support one way over another) starting within 3 yrs of another) starting within 3 yrs of initiation of sexual activity or by age initiation of sexual activity or by age 21.21.

Mammogram annually starting at age Mammogram annually starting at age 40 40

DEXA biannually starting at age 65 DEXA biannually starting at age 65 for normal risk pts or age 60 for for normal risk pts or age 60 for higher risk ptshigher risk pts

H/H, Glucose, Hep B sur Ag, H/H, Glucose, Hep B sur Ag, UA/Culture, and HIV serology all UA/Culture, and HIV serology all recommended in pregnant womenrecommended in pregnant women

Screening tests that the Screening tests that the evidence is inconclusive or evidence is inconclusive or

not availablenot available MenMen

DRE +/- PSA annually DRE +/- PSA annually starting at age 50 in men with starting at age 50 in men with a 10 yr life expectancya 10 yr life expectancy

Annual fasting glucose in pts Annual fasting glucose in pts without risk factorswithout risk factors

Lipids in pt less than 35 yrs Lipids in pt less than 35 yrs old without CAD risk factorsold without CAD risk factors

TSHTSH HIV screening in low risk HIV screening in low risk

individualsindividuals Hep B/C screening in high Hep B/C screening in high

risk individualsrisk individuals CXR in long term smokers to CXR in long term smokers to

screen for lung CA screen for lung CA DEXA (no recommendation to DEXA (no recommendation to

date)date) EKG +/- Stress testing for EKG +/- Stress testing for

asymptomatic pts with asymptomatic pts with multiple risk factors for CAD multiple risk factors for CAD (including DM)(including DM)

WomenWomen Annual fasting glucose in pts Annual fasting glucose in pts

without risk factorswithout risk factors Lipids in pt less than Lipids in pt less than 45 45 yrs yrs

old without CAD risk factorsold without CAD risk factors TSHTSH HIV screening in low risk HIV screening in low risk

individualsindividuals Hep B/C screening in high Hep B/C screening in high

risk individualsrisk individuals CXR in long term smokers to CXR in long term smokers to

screen for lung CA screen for lung CA DEXA in pts less than 60 yrs DEXA in pts less than 60 yrs

oldold EKG +/- Stress testing for EKG +/- Stress testing for

asymptomatic pts with asymptomatic pts with multiple risk factors for CAD multiple risk factors for CAD (including DM)(including DM)

HPV testing in addition to HPV testing in addition to PAP SmearPAP Smear

Tests Not recommended for Tests Not recommended for screeningscreening

CBC/CHEM8/LFT’sCBC/CHEM8/LFT’s ABIABI PAP/Pelvic for pts who had hysterectomy PAP/Pelvic for pts who had hysterectomy

secondary to benign disease, or for secondary to benign disease, or for women 65yrs or older who have had women 65yrs or older who have had negative pap smears on regular routine negative pap smears on regular routine screeningscreening

Carotid DopplersCarotid Dopplers Hep B/C serologiesHep B/C serologies UA (for bladder CA or other etiologies)UA (for bladder CA or other etiologies)

BibliographyBibliography 1. Lerman, C, Trock, B, Rimer, BK, et al. Psychological 1. Lerman, C, Trock, B, Rimer, BK, et al. Psychological

and behavioral implications of abnormal and behavioral implications of abnormal mammograms. Ann Intern Med 1991; 114:657. mammograms. Ann Intern Med 1991; 114:657.

2. Romm, FJ, Fletcher, SW, Hulka, BS. The periodic 2. Romm, FJ, Fletcher, SW, Hulka, BS. The periodic health examination: Comparison of recommendations health examination: Comparison of recommendations and internists' performance. South Med J 1981; and internists' performance. South Med J 1981; 74:265. 74:265.

3. Recommendations for the prevention and treatment 3. Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. of glucocorticoid-induced osteoporosis: 2001 update. American College of Rheumatology Ad Hoc Committee American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis. Arthritis on Glucocorticoid-Induced Osteoporosis. Arthritis Rheum 2001 Jul;44(7):1496-503. [54 references] Rheum 2001 Jul;44(7):1496-503. [54 references]

4. 4. www.ahrq.gov/clinic/prevnew.htmwww.ahrq.gov/clinic/prevnew.htm. . 5. 5. www.uptodate.comwww.uptodate.com, Preventive services , Preventive services

recommendations for periodic health evaluation, F. recommendations for periodic health evaluation, F. Daniel Duffy, MDDaniel Duffy, MD