Back to Basics, 2014 Population Health: Periodic Health Exam, Dr. Trevor Arnason, MD, CCFP, PGY-3 PHPM University of Ottawa Department of Epidemiology & Community Medicine March 28, 2013

Periodic Health Examination

Overview The Periodic Health Examination LMCC Objectives Resources for the PHE Population approach to the PHE Selected conditions – recommendations for screening

Periodic Health Examination “History, risk assessment, and a tailored physical examination that could lead to delivery of preventive services” Review a patient’s ongoing medical issues Counsel for preventive health issues Improve physician patient relationship Objectives identify certain common conditions for each age group Definition from: “Annual adult health check up” (Canadian Family physician – January 2012)

Periodic Health Examination Use periodic health exam for health promotion disease prevention interventions E.g. Smoking cessation, exercise, immunization Case-finding and screening for disease & risky behaviours E.g. substance abuse Chance to detect characteristics that are known to place patients at high risk for particular conditions E.g. Family, socioeconomic, occupational and lifestyle characteristics Objectives identify certain common conditions for each age group Definition from: “Annual adult health check up” (Canadian Family physician – January 2012)

Structure of the PHE Get diagnostic problems out of the way, first! History Physical Exam Lab tests, diagnostic imaging (“screening” tests) Immunizations Counselling Other medications/interventions

Objectives – Periodic Health Examination (74) Key Objective Given a patient presenting for a PHE, the candidate will determine the patient's risks for age and sex-specific conditions to guide the history, physical examination, and laboratory screening Enabling Objectives: Given a patient presenting for a PHE, the candidate will: Perform an appropriate history and physical examination based on the patient's age, sex, and background List and interpret appropriate investigations, including evidence- based screening investigations specific to age and sex concerns (e.g., fasting glucose for greater than 40 years, mammography for greater than 50 years);

Objectives - Periodic Health Examination (74) Enabling Objectives: Construct an effective initial management plan, including communicate effectively with the patient to reach common ground regarding goals related to disease prevention and risk reduction Recommend proven prevention strategies (e.g., smoking cessation, regular exercise) Incorporate the periodic health examination principles in the care of a patient with a chronic disease.

WARNING! about prevention/screening Prevention and screening seems easy, but is actually one of the most difficult areas of medicine No single source of recommendations – multiple organizations produce guidelines sometimes on same topics Recommendations constantly changing with new information, research and innovation Industry and government funding greatly influence screening/prevention practices

WARNING! about prevention/screening Benefits of screening are often overestimated The harms of screening/prevention practices are often ignored or minimized Screening/prevention benefits at a population level do not necessarily apply to different sub-populations, individuals Not always clear when patients are ‘asymptomatic’ Need to consider competing risks, a concept that is difficult for human beings to comprehend

Approach to ‘screening’ or ‘case finding’ 1) Define the population 2) Define the outcomes you need to consider 3) Consider what interventions are available to prevent the outcomes 4) Consider the available evidence to support the intervention in this population to prevent the outcome(s)

For the MCCQE Focus on the simple stuff (eg: health promotion, things that apply to everyone) Controversial topics are less likely to be emphasized Exam is Canada-wide, so Provincial recommendations are not as important

PHE Resources Canadian Task Force On Preventive Health Care: Clinical Guidelines Targeted and evidence based Clinician Summary of guidelines for common conditions Grading of recommendation and evidence as ‘strong’, ‘moderate’ or ‘weak’ Objectives identify certain common conditions for each age group

PHE Resources National Advisory Committee on Immunizations (NACI) http://www.phac-aspc.gc.ca/publicat/cig- gci/index-eng.php Objectives identify certain common conditions for each age group

PHE Resources CFPC Preventative Care Checklist Objectives identify certain common conditions for each age group

PHE Resources Rourke Record http://www.rourkebabyrecord.ca/national.asp Objectives identify certain common conditions for each age group

Populations - Infant Get diagnostic problems out of the way, first! History – pregnancy, birth, breastfeeding, vision, hearing, development, abuse/neglect Physical Exam – growth charts, developmental milestones, eyes (eg: cover/uncover), hips Lab tests, diagnostic imaging (“screening” tests) - ?hemoglobin Immunizations – lots, annual flu (>6mos) Counselling – car seat, sleep position, crib, poisons, firearms, smoke/CO alarms, dental health, nutrition, passive smoke Other meds/interventions – Vitamin D 400 IU/day, home visit

Populations - Child History –pregnancy, birth, vision, hearing, development, abuse/neglect, school readiness Physical Exam – growth charts, developmental milestones, eyes Lab tests, diagnostic imaging (“screening” tests) - none Immunizations – lots, annual flu (>6mos) Counselling – car seat/ seatbelts, bike helmets, hearing protection, poisons, firearms, smoke/CO alarms, dental health, nutrition, passive smoke, no OTC cough cold/medicines Other meds/interventions – dentist

Populations - Adolescent History – HEADDS, diet Physical Exam – growth charts, sexual maturity Lab tests, diagnostic imaging (“screening” tests) – STI screening Immunizations – DTaP (pertussis), missed childhood, HPV, Hep B, annual flu Counselling – seatbelts, bike helmets, hearing protection, dental health, nutrition, alcohol, smoking, other drugs, occupational exposures, sun exposure Other meds/interventions – Vitamin D, dentist

Populations – Young Adult History – HEADDS, diet Physical Exam – Wt (BMI), BP, eyes, ears Lab tests, diagnostic imaging (“screening” tests) – STI screening (Chlamydia/Gonorrhea), Pap smear, Hep B and C, HIV, HbA1c, fasting lipid profile Immunizations – DTaP (pertussis), HPV, Hep B, annual flu Counselling – seatbelts, bike helmets, hearing protection, dental health, nutrition, alcohol, smoking, other drugs, occupational exposures, sun exposure Other meds/interventions – folic acid, Vit D, dentist

Populations – Middle Aged Adult History – Psychological, social and physical functioning, nutrition, physical activity, alcohol, smoking, Physical Exam – Wt (BMI), BP, eyes, ears Lab tests, diagnostic imaging (“screening” tests) – Blood glucose, lipid profile, osteoporosis, Cancer – breast, prostate, colon Immunizations – DTaP (pertussis), annual flu Counselling – seatbelts, bike helmets, hearing protection, dental health, nutrition, alcohol, smoking, other drugs, occupational exposures, sun exposure Other meds/interventions – Vitamin D, dentist

Populations – Older Adult History – Psychological, social and physical functioning, nutrition, physical activity, alcohol, smoking, fracture and fall prevention, dementia screening, elder abuse Physical Exam – Wt (BMI), BP, eyes (Snellen), ears Lab tests, diagnostic imaging (“screening” tests) – Blood glucose, lipid profile, osteoporosis, Cancer – breast, cervical, colon (prostate), AAA Immunizations – DTaP (pertussis), annual flu, pneumococcal, HZV Counselling – seatbelts, bike helmets, hearing protection, dental health, nutrition, alcohol, smoking, other drugs, occupational exposures, sun exposure Other meds/interventions – Vitamin D, dentist

Populations – Common themes History – nutrition, physical activity, substances (smoking/EtOH) Physical Exam – Wt (BMI), BP, eyes, ears Lab tests, diagnostic imaging (“screening” tests) – nothing Immunizations – routine and annual flu Counselling – injury prevention (eg: seatbelts, bike helmets), dental health, nutrition, substances, sun exposure Other meds/interventions – Vitamin D, dentist

Management “Recommend proven prevention strategies” Smoking Cessation Regular Exercise Nutrition Alcohol reduction Smoking cessation Regular exercise

Generally not used for screening (asymptomatic) TSH CBC Electrolytes, Cr Vitamin B12 ALP ECG Urinalysis

Condition Specific Recommendations & Screening

Recommendations Osteoporosis Prevention <50 years old Consume 100-1500 mg elemental Ca/day 400-1000 IU per day (if low risk for deficiency) >50 years old Dose of 1200mg elemental Ca/day Supplement if not achievable by diet 800-1000 IU /day (50 + or moderate risk of deficiency) *Osteoporosis Society of Canada 2010 SOGC: 1500 mg of total calcium intake and 800IU of vitamin D supplementation per day in post-menopausal women **OSC provides list of indications for measuring bone density in those > 50 and those > 50

Recommendations - Screening Osteoporosis screening - BMD SOGC: 1500 mg of total calcium intake and 800IU of vitamin D supplementation per day in post-menopausal women **OSC provides list of indications for measuring bone density in those > 50 and those > 50 “2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary” (CMAJ, 2010)

Recommendations - Screening Blood pressure Population: Adults 18+ without previous Dx of HTN Prevalence: HTN in 19% of Canadian adults; prevalence increases with age, comorbidites Intervention: Screening by BP measurement At all appropriate health care visits Measured according to Canadian Hypertension Education Program (CHEP) recommendations Apply CHEP criteria for assessment and diagnosis of hypertension DM or CRF: target < 130/80 BP Targets – CHEP 2009 Source: CTFPHC

Recommendations - Screening Cervical Cancer Incidence increases significantly after age 25, peaks in 5th decade Intervention: Screening with cervical cytology Population: asymptomatic women; have been or are sexually active Recommendation: Screen women ≥ 25 with a pap test q3 years

PHE - Screening Cervical Cancer – PAP Smear Recommendations (CTFPHC) Age (yrs) Recommendation Rationale <20 No routine screening Very low incidence/mortality Evidence of harm 20-24 Uncertain benefit of screening, high false + 25-29 Routine screening, every 3 years Small benefit of screening, ing Cervical CA incidence and mortality in age group 30-69 Evidence of effectiveness of screening ≥70 No screening if 3 successive neg Paps in last 10 yrs If not adequately screened, recommend screening every 3 years until 3 success negative Paps Source: CTFPHC

Recommendations - Screening Type 2 Diabetes Prevalence: 6.8% of Canadians Type 1 or 2 Diabetes (2008/2009) ~50% of new cases diagnosed in adults age 45-64 Population for screening: asymptomatic adults Risk level: FINDRISC tool Intervention: HbA1C (Fasting glucose, OGTT) Harms: small $, discomfort, anxiety, over-diagnosis and investigation Source: CTFPHC FINDRISC – chosen because of internal and external validation HGA1a & BG – perform similarly in predicting type 2 diabetes and reltaed microvascular complications. HGBa1c chosen for patient covenience

PHE Screening Type 2 Diabetes Category Low to Moderate Risk High Risk Very high risk Level of Risk (10 year risk of diabetes) Low: 1-4% Moderate: 17% 33% 50% Routine Screening Recommended? NO q3-5 years annually Rationale No evidence of improved outcomes Evidence for  MI rates  Cost vs. annual screening Evidence for  DM complications & death Source: CTFPHC

Recommendations - Screening Breast Cancer 22,700 new cases, 5400 deaths annually (2009) Incidence & Case-fatality rate increase with age Intervention: Mammography Population considered for screening: Age 40-74 No personal or Family Hx of Breast CA No known BRCA1 or 2 mutation No previous chest wall radiation Source: CTFPHC

Recommendations - Screening Breast Cancer - Mammography Age 40-49 50-69 70-74 Routine Screening Recommended? NO q 2-3 years Rationale Lower likelihood of breast cancer Greater likelihood of false + in age group 720 women would need to be screened q2-3 yrs to save 1 life 450 women would need to be screened q2-3 yrs to save 1 life Source: CTFPHC

PHE - Screening Breast Cancer – Special Considerations Certain ethnic groups have higher (Ashkenzai Jews) or lower rates (East Asians) Benefit of screening uncertain for those with life expectancy shortened by comorbid conditions Can provide “ Decision Aid for Breast Cancer Screening in Canada” available from PHAC Source: CTFPHC

Key points - Structure of the PHE Get diagnostic problems out of the way, first! History Physical Exam Lab tests, diagnostic imaging (“screening” tests) Immunizations Counselling Other medications/interventions

Key points - Approach to ‘screening’ or ‘case finding’ 1) Define the population 2) Define the outcomes you need to consider 3) Consider what interventions are available to prevent the outcomes 4) Consider the available evidence to support the intervention in this population to prevent the outcome(s)

Key point - Management: “Recommend proven prevention strategies” Smoking Cessation Regular Exercise Nutrition Alcohol reduction Smoking cessation Regular exercise

Thanks Acknowledgements: This was developed based on a previous presentation by Dr. Laura Bourns Thanks to Dr. Cleo Mavriplis for providing content on screening/prevention.