Choosing Wisely in Adult Health Maintenance Jauch Symposium Oct 14, 2016 Anthony Day, MD, FAAFP

Objectives Identify sources of high value preventive care Discuss ways to inform patients on why many tests are not routinely recommended List common tests/procedures that have not been shown to be of high value Describe the potential for inadvertent patient harm with over utilization of tests

Illustrative Case 1 19 female presenting for pre-college physical Volleyball scholarship to D3 school Sexually active only on two occasions with former boyfriend No medical problems or concerns

History Sports related – FH early CAD, activity sxs, injuries, eating disorders, menstrual cycles Immunizations Illness/risk behaviors Medical problems when applicable Key FH, SH, PMHx

Exam Low yield in asymptomatic individuals Sports focused (BMI, Heart, Marfan’s, joints) Don’t screen for scoliosis (D, Fam Med) Don’t do pelvic exam/pap smear (D, Fam Med) – discuss preg prevention Don’t do ECG (D, Fam Med, *sports) Males – don’t do testicular screening (D)

USPTXF A Recommendations Folic acid supplementation (A) HIV screening (A) BP screening (A) Tobacco screening (A) Immunizations – Tdap (21), HPV, MMR, Flu, Meningoccocal, others based on imm hx

USPTXF B Recommendations Depression screening (B) GC/Chlamydia screen– sexually active (B) STD Counseling (B) BRCA risk assessment (B) Obesity screening (B)/ Diet/exercise counseling (B) Intimate partner violence (B) Skin cancer counseling (B) Etoh screen/intervention (B)

Tips Patients expect to be touched but you can explain that the exam is minimal when people don’t have symptoms Most women won’t be upset at not having to have a pelvic exam/pap smear/ men not having a testicular exam Asking what patients know about health and filling in gaps is more meaningful than a spiel

Illustrative Case 2 66 yo F for annual health maintenance No major medical problems Last pap smear at age 60 was normal Overweight, but active, still working No complaints

Approach Society of General Internal Medicine Choosing Wisely – don’t do routine health checks in asymptomatic adults Risk of unnecessary testing and potential patient harm Should deliver evidence-based preventive care Most insurers/societies recommend annual preventive visit

Evidence-based Prevention No pap after age 65 (FM/USPTFX) Don’t listen carotids/order us (FM and Vascular) No routine EKG (FM) No routine 25-OH Vit D – only high risk, use OTC supplement (Clinical Path) Aspirin 81 mg if greater than 10% 10 year ASCVD risk

USPTFX Colorectal Ca screen (A) HTN screen (A) Hyperlipid screen (A) – if increased risk Diabetes screen (B) – if overweight Mammogram (B) – FH for BRCA risk Etoh, Depression, Fall risk, Obesity, Osteoporosis screen (B) Exercise/diet counseling (B) Consider Vit D supplementation (B)

USPTFX Ds AAA screen – only male smoking hx UA – never treat asymptomatic bacteriuria COPD screen (CT for Lung ca only in current/recent smokers) Menopausal hormones for prevention Ovarian, pancreatic ca screening Vitamins for CVD prevention

Immunizations Tdap/Td – CMS only pays if injury, try to get before age 65 Influenza annually – don’t avoid in egg-allergic patients (Allergy) – give and observe 30”, no study with anaphylaxis Zoster (age 60) – easier before age 65 PCV13 (Prevnar), followed by PPSV23 (Pneumovax) 1 year later

Tips Again, most women ok with not doing pap smears, other intimate exams Self-breast exam and clinical breast exam not recommended if getting mammograms Males – no routine PSA or DRE Focus on education, health, activity and preventive testing Minimize exam/labs when asymptomatic

Illustrative Case 3 80 year male with HTN, CAD, mild dementia, CKD stage 3, T2DM, COPD, recent CVA, Prostate Cancer Routine F/u of medical problems Still smokes, A1C 7.9, on appropriate meds Stable angina limits activity, mod dyspnea with exertion What prevention should we consider?

Recommendations Avoid breast, colorectal, prostate or lung cancer screening without considering life expectancy, risk of testing/treatments (Surg, Gen Surg, Long-term care, Gen Internal Med) Etoh, Depression, Obesity screen (B) Fall prevention – Vit D supplementation and Activity/Strength training (B, Phys Therapy) Manage his chronic disease/risks avoid aggressive hosp/interventions if frail unless clear goals (Long-term care)

Tips Exercise/activity one of few interventions that prolong life, if fall risk utilize PT to match with individual abilities/goals Establish patient-centered goals for care Many interventions untested in advanced elderly Geriatric pts on 5 or more meds have 58% likelihood of adverse drug reaction

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