The Annual Exam in Asymptomatic Adults Elizabeth “Ellie” Richardson, MSIII UNMSOM

45 year old woman with an insignificant past medical history and A family history significant for hypertension presents to clinic for her annual exam. Last PaP smear was 3 years ago with no significant findings and Negative for HPV. What should be done during her annual physical exam appointment if she has no complaints or concerns? Clinical Case

PICO Patient- Asymptomatic Adults Intervention- review Annual physical exam components and associated frequencies. Create an EB recommendation for providers. Comparison- Standard Annual PE exams. Outcome- Reduced healthcare costs such as unnecessary visits and possible unneeded diagnostic tests; improve patient outcomes PICO

MeSH terms: Adult; Diagnostic tests, Routine; Humans; Middle aged; Physical Examination Key words: Body temperature, respiratory rate, heart rate, auscultation [abdomen, peripheral pulse, lymph node, spleen, liver], digital rectal examination, pulse, hearing tests, breast examination, lung percussion, muscle stretch reflex, and terms for routine Physical Examination MESH Terms

1940’s Routine annual comprehensive physical examinations became a part of American medical practice 1980’s AMA, ACP, USPSTF, and Canadian task force recommended a focused annual physical examination on preventative clinical health outcomes Tremendous support from physicians and patients of an annual physical exam` Physicians endorse the annual pe for reasons such as building rapport with patients, satisfy patients’ expectations, fear of malpractice litigation, and compensation. (Frame 1995, Prochazka 2005) American Adults showed a 90% endorsement for the annual physical exam according to a 2002 study. (Oboler 2002) Background

Purpose- ”Determine whether the routine annual physical examination results in improved outcomes for asymptomatic adults.” Objective- Primary: to evaluate the Value of Routine annual PE. Secondary: If a specific visit increases the likelihood that patients will receive preventive services. Study design- primary: Reviewed USPTF recommendations; Systematic reviews, computerized literature review- MEDLINE, and JAMA articles Purpose: Objective: Do not include screening and preventive interventions, PE to further explore pt’s concerns, or PE to meet insurance, disability, employment or sports requirements. Primary- What components are recommended by high quality EB guidelines or reports. Study Design: Primary: “USPSTF to recommend a service the benefits of the service must outweigh the harms.” USPTF focuses on clinical preventive services not just the identification of the disease. Systematic review- Obler and LaForce reviewed medical literature from 1966-1988; 1988 to current literature search Medline, Reviewed 53 chapters of The Rational Clinical Examination, compilation of articles from JAMA. Secondary: Boulware 2007, Update to current Medline Description of Study

Population studied-English speaking, Asymptomatic adult patients Study Questions-Frequency of physical exams, Efficacy of physical exam components Conclusion- 1. Comprehensive routine annual pE are not recommended for the asymptomatic adult. Components of PE for the asymptomatic adult include: BP screening every 1-2 years, Periodic measurement of BMI, Pap smears (USPTF criteria) 2. Some evidence indicating a specific visit for preventive services may increase the likelihood of PAP smears, cholesterol screening, and FOBT Purpose: Objective: Do not include screening and preventive interventions, PE to further explore pt’s concerns, or PE to meet insurance, disability, employment or sports requirements. Primary- What components are recommended by high quality EB guidelines or reports. Study Design: Primary: “USPSTF to recommend a service the benefits of the service must outweigh the harms.” USPTF focuses on clinical preventive services not just the identification of the disease. Systematic review- Obler and LaForce reviewed medical literature from 1966-1988; 1988 to current literature search Medline, Reviewed 53 chapters of The Rational Clinical Examination, compilation of articles from JAMA. Secondary: Boulware 2007, Update to current Medline Description of Study

The review addresses a sensible question because annual Physical exams are routinely scheduled Search for studies appeared to be exhaustive Primary objective included 11 references Secondary Objective included a robust Systematic review Comprehensively assessed risk of bias in primary studieS. Bias of primary studies carries over; did not directly evaluate specialty society recommendations, however, Each component of the PE was linked to a specific purpose Results were clinically applicable and the authors provided a recommendation to providers - Secondary Critical Appraisal

Discussion The study design was appropriate for the clinical question Cons: Selective inclusion of English speaking adults. Did not assess other groups in the united states such as immigrants, refugees, Asylees, and non- english speakers Pros: Large Diverse sample size Pros of intervention- improve patients outcomes, EB recommendation of an annual physical exam Cons of intervention- ‘Intangible’ benefits of the pE or ‘laying on of hands’ in the strengthening Rapport with patients I found this to be clinically relevant because of the frequency of annual physical exam appointments Before implementing this intervention I would like additional EB information of the frequency of patients that are lost to follow-up because of the decreased frequency of annual check-ins and hospitalization rates in patients with this implemented intervention   Discussion

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