LMCC review: the PHE Dr. David Ponka Assistant Professor Department of Family Medicine

Practice PHE stands for 1) plasma heat exchange 2) public health emergency 3) public health engineering 4) preventative health examination 5) all of the above

Practice PHE stands for 1) plasma heat exchange 2) public health emergency 3) public health engineering 4) preventative health examination 5) all of the above, but especially 4

PHE The ‘check up’ Quite common in Canada Feasibility and efficiency data controversial e.g. t o apply the US Preventive Health recommendations, estimated 10.6 hrs a day required (Pimlott N Who has time for family medicine? CFP 2008 (54): 14-15) But several proven manoeuvers, based on likely morbidity in a particular age group

What is… Primary prevention Secondary prevention Tertiary prevention

PHE An opportunity for: Primary prevention (screen for risky behaviour, health promotion, disease prevention), case finding, screen for undetected disease (secondary prevention) Also in practice an opportunity to: Update clinical data, consolidate a patient’s cumulative medical profile, review medications, review social context, allergies, immunization history Enhance patient-physician relationship “non-measurable” factors

What four characteristics makes a screening intervention compelling?

Burden of condition (that’s why we don’t screen for mesothelioma…) Quality of screening intervention (that’s why prostate screening is this controversial…) Effectiveness of the intervention (another reason for prostate screening…) Price (though inborn errors of metabolism recently added in Ontario…)

CTFPHC Grades of Recommendations Copyright ©2003 Canadian Medical Association or its licensors CMAJ 2003;169:

Let’s focus on 6 age categories: Infants and toddlers (<1) Toddlers and Children (1-12) Youth (13-20) Adults (21-49) Middle age (50-69) Elderly (>70)

What are the highest health risks for an infant (<1)?

Congenital Infectious SIDS/suffocation Growth and development/nutrition Abuse

So, what routine interventions are most indicated in infants?

Accessing risk of congenital abnormalities based on pregnancy history, ethnic history, family history and environment (e.g. FAS) Immunizations Advice on sleep Advice on diet Screening physical examination

What are the highest health risks for toddlers and children (1-12)?

ACCIDENTS! Trauma Fire Drowning Heart defects Abuse/neglect

So, what routine interventions are most indicated for toddlers/children?

Counselling re accident prevention: helmets smoke alarms water temperature swimming lessons Heart exam Psychosocial history taking

So according to CPS, CTF for infants, toddlers, and children: Home visits for high risk families (A) Developmental milestones (B) Dental hygiene (A) Injury prevention (bike helmets, smoke detectors) (B) Car seats (A) Sleeping position (A)

Infant, Toddlers, Children PHE: Physical Exam Ht, wt, head circumference (B) hearing, hips, eyes (Red reflex, cover/uncover) (A) visual acuity testing (B)

Infants, Toddlers, Children PHE Tests Blood lead (high risk infants) (B) Hb for High risk infants (B)

Infants, Toddlers, Children PHE Therapies Routine Immunizations (A) Hep B vaccination (A)

What are the highest health risks for youth (13-24)?

ACCIDENTS Mental health Habits including drugs Suicide STDs

HEADS interview: H (Home) "Whom do you live with?”).Don't assume what is "normal" (for example, don't assume an adolescent lives with both parents).Get an idea of the dynamics of the home situation. E (Education) "Where do you go to school?”. "What do you do with your free time?” A (Activities) "Do you have many friends?” "What do you do with your free time? D (Drugs) "Do any of your friends smoke?" (less intimidating) S (Sexuality) emphasize that you ask everyone the same questions Start with less threatening topics (eg, menstrual cycle in females). Open the door to disc of sexual orientation, kind of sexual activity (eg anal sex, oral sex, masturbation), protection used

Adults Thorough ROS, and targeted exam (+skin) FBS and cholesterol q3 years Cervical cancer screening in women STD screening if at risk Osteoporosis screening at 50 if at risk Consider cancer screening if family history Immunization boosters

Middle age (50-69) Thorough ROS, and targeted exam (+skin) Colon cancer screening (FOBT qyear or colonoscopy q5-10years for average risk adults) Mammography/paps Continue cardiovascular risk factor screening

Old age (>69) Stop cancer screening unless requested by patient or life expectancy deemed >10years Focus on ROS and cardiovascular screening, Framingham optimization Skin screening

Adult/Senior disease prevention: Discussion/Counseling Noise control and hearing protection (A) Smoking cessation counseling, nicotine repl therapy (B) Seat belt counseling (B) Dietary advice on leafy greens and veggies (B) Calcium supplements for women Folic acid for women child bearing age (A) Exercise/Mod physical activity (B) Avoid sun exposure and protective clothing (B) EtOH screening and counseling (B)

Adult/Senior disease prevention: Discussion/Counselling cont Caregiver concern of cognitive impairment (A) Multidisciplinary fall assessment (post fall) (A) Breast self examination (D)

Adult/Senior PHE Tests: TB high risk groups: Mantoux skin tests (A) Colon cancer screen: FOB adults (>50 yrs) (A) or sigmoidoscopy (Adults >50) (B); colonoscopy if HNPCC (B) BMD: if at risk Fasting lipids: Women >50 or post-menopausal, or men>40 or earlier if RFs Fasting glucose: >40 if at risk STD testing (see youth) Syphilis testing if at risk Pap tests (women 18-69) (B) Mammogram (women 50-69) (A)

Adult/Senior PHE Therapies: TB Therapy (INH prophylaxis for skin test converters) (B) Influenza high risk groups: Outreach strategies (A), amantadine prophylaxis (eg nursing homes) (A), Annual immunization (B) Immunocompetent institutionalized >55: pneumococcal vaccination (B) Varicella vaccination susceptible adolescents and adults (A) Rubella vaccination for non-pregnant susc women of child bearing age BP management (A), Osteoporosis counseling and HRT pros/cons (B)

Ethics (caveats) Informed consent Risks Labelling

Which of the following screening interventions are indicated in an apparently healthy 50 year old woman? Mammogram Pap test Vitamin B12 level FOBT BMD CXR

Which of the following screening interventions are indicated in an apparently healthy 50 year old woman? Mammogram Pap test Vitamin B12 level FOBT BMD CXR

Which of the following screening interventions are indicated in an apparently healthy 72 year old man? CXR Fall assesment Vitamin B12 level FOBT BMD PSA

Which of the following screening interventions are indicated in an apparently healthy 72 year old man? CXR Fall assesment Vitamin B12 level FOBT BMD PSA

Quiz: Should the following counseling points/physical exam maneuvers/tests/therapies be included in an evidence-based PHE? (Yes/No) Weight and height measurement of a 6 mo old baby girl Varicella vaccination of 9 mo boy who has not yet had chicken pox Counselling on sexual activity and contraception for well teenage boy Teaching 50 yo woman breast self-exam B12 and TSH tests for asymptomatic 40 yo woman

Quiz continued… Should the following counseling points/physical exam maneuvers/tests/therapies be included in an evidence-based PHE? (Yes/No) Fecal occult blood testing of 65 yo man with no complaints Urinalysis for 18 yo woman BP check for 46 yo man BMI measurement in 60 yo man Blood lead screen for 1 yo child eating painting 1950’s house

Quiz continued… List 5 examples of evidence based recommendations for accident prevention

Accident Prevention answers: Helmet use for bicycles Smoke detector use Avoid drinking and driving Seat-belt/air bag use Hot water regulators