1 Periodic Health Examinations Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM PO Box – Riyadh Tel: – Fax:

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3 Aim-Objectives At the end of this presentation the participants will be; –Able to describe the role of PHE in primary care –Able to count three diseases with highest mortality –Able to define PHE –Able to explain the effective screening criteria used in PHE –Aware of the risks in PHE –Able to count non-evidence based check up activities of daily life –Aware of the importance of PHE and preventive medicine in primary care.

4 What are primary care physicians doing? Health Care Health promotion Risk prevention Risk reduction Early diagnosis Complication reduction Personal Preventive Medicine! Primary Prevention Secondary Prevention Tertiary Prevention

5 Prevention of what?

6 Reasons of diseases (%)

7 Insurance companies: “Mortality decreases in persons undergoing regular health checks!” CHECK-UP (1921) PERIODIC HEALTH EXAM was introduced. (1970) Some diseases don’t have enough clues at the beginning, and when able to diagnose there was no time for treatment: check-up gone. Changing by personal factors such as age, exposure, sex, and risk

8 Definition Evaluation of apparently health individuals in certain time periods, using a number of standard procedures such as counseling, physical examination, immunization, and laboratory investigations is called Periodic Health Examination.

9 Does it work? USA: Mortality from stroke has decreased by 50% since 1972 –Early diagnosis and treatment of hypertension Mortality from cervix cancer decreased by 80% Neonatal screening –Decrease in mental retardation Phenylketonuria screening Congenital hypothyroidism National Center for Health Statistics.

10 Immunization and Polio Polio figures in KSA

11 Think of your daily life A 30-year old woman applies to your office. She has no history of disease but afraid of becoming breast cancer. –Should you perform a breast exam? –Should you teach her breast self exam? –Should you order a mammography? How do you decide?

12 1.Prevalence of the disease should be high No sense to screen diseases with low prevalance. - Osteogenesis imperfecta: incidence 1/10 000/year Effective screening criteria Medline Plus. Medical Encyclopedia. Osteogenesis imperfecta.

13 2. Predictive risk factors or tests should be present The safety and cost of the test should be known - CRP: Cheap but not specific - Echocardiograpy: sensitive and specific but expensive Effective screening criteria

Diseased (Prevalence) Healthy Specifity Sensitivity PPVNPV (+) Test(-) Test Basic Parameters Population-100 persons

15 3. Morbidity and mortality of the disease should be high Factors other than the type of the disease affecting morbidity and mortality: Effective screening criteria - Age - Sex - Race - Geographical area - Life style (culture)

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months Perinatal causes Congenital anomalies 7-12 years Accidents other than motor vehicle Motor vehicle accidents years Motor vehicle accidents Suicide 65 years and older Heart diseases Cerebrovascular diseases Mortality according to age groups

18 4.There should be an acceptable treatment No sense to screen untreatable diseases - Lung cancer (?) 5.There should be a prodromal period without complains - AIDS - Syphilis - Cervix cancer - Breast cancer Effective screening criteria

19 4 year Beginning Symptoms DEATH 2 year 1 year6 mo Aggressive cancer The same cancer but less aggressive Screening once a year The natural course of diseases

20 Let’s come back to our example: patient with breast cancer It’s an important disease for women –Worldwide new cases/year. (1/1000) I can be recognized without symptoms –Mammography Curable –Surgery, Chemotherapy, Radiotherapy The value of treatment is more than its adverse effects

21 Can periodic health examination be harmful? Asymptomatic person Screening Test normal True negative Reassurance False negative Delay in diagnosis Test abnormal True positive Treatment False positive Anxiety The average error rate of a test: %5 Ian R. McWhinney. A Textbook of Family Medicine. Oxford University Press, USA 1997.

22 Chest x-ray to screen lung diseases, Urinanalysis to screen urinary diseases, ECG, Microfilm to screen Tbc, PSA to screen prostate cancer, Self exam to screen breast cancer, CBC, Influenza immunization for healthy adolescents The Check-up Chaos

23 How is PHE performed? Healthy individuals Counseling Immunization Home visit Prophylaxis Physical exam Laboratory test

24 Any Guidelines for KSA?

25 PHE Suggestions  Bacteriuria,  Asymptomatic The AAFP recommends against the routine screening of men and nonpregnant women for asymptomatic bacteriuria. Breast Cancer –The AAFP recommends women age 40 years and older be screened for breast cancer with mammography every 1-2 years after counseling by their family physician regarding the potential risks and benefits of the procedure. Breast Cancer –The AAFP concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (BSE).  Cardiac Disease  The AAFP recommends against the use of routine ECG as part of a periodic health or preparticipation physical exam for cardiac disease in asymptomatic children and adults.

26 PHE Suggestions  Cervical Cancer  The AAFP strongly recommends that a Pap smear be completed at least every 3 years to screen for cervical cancer for women who have ever had sex and have a cervix.  Colorectal Cancer  The AAFP strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer.  Coronary Heart Disease  The AAFP recommends against routine screening with resting electrocardiography (ECG), exercise treadmill test (ETT), or electron- beam computerized tomography (EBCT) scanning for coronary calcium for either the presence of severe coronary artery stenosis (CAS) or the prediction of coronary heart disease (CHD) events in adults at low risk for CHD events.

27 PHE Suggestions  Diabetes, Type 2  The AAFP recommends screening for type 2 diabetes in adults with hypertension and hyperlipidemia. There is insufficient evidence to recommend for or against screening adults who are at low risk for coronary vascular disease.  Hearing difficulties  The AAFP recommends screening for hearing difficulties by questioning elderly adults about hearing impairment and counsel regarding the availability of treatment when appropriate.  Hemoglobinopathies  The AAFP strongly recommends ordering screening tests for PKU, hemoglobinopathies, and thyroid function abnormalities in neonates. Hormone Replacement Therapy –The AAFP recommends against the routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women.

28 PHE Suggestions Hormone Replacement Therapy –The AAFP recommends against the routine use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.  Hypertension  The AAFP strongly recommends that family physicians screen adults aged 18 and older for high blood pressure.  Influenza  The AAFP recommends immunizing all persons age 50 years and older for influenza. Discuss immunization annually using AAFP recommendations.  Lipid Disorders  The AAFP strongly recommends screening for lipid disorders with either a fasting lipid profile or nonfasting total cholesterol and HDL cholesterol in males age 35 and older, and females age 45 and older.

29 PHE Suggestions  Lung Cancer  The AAFP recommends against the use of chest X-ray and/or sputum cytology in asymptomatic persons for lung cancer screening.  Neural tube defects  The AAFP recommends prescribing 0.4 mg folate supplementation to women not planning a pregnancy but of childbearing potential who have not previously had a baby with a neural tube defect.  Obesity  The AAFP recommends screening for obesity by measuring height and weight periodically for all patients.  Osteoporosis  The AAFP recommends counseling females age 11 and older to maintain adequate calcium intake prevent osteoporosis.

30 PHE Suggestions  Osteoporosis  The AAFP recommends routinely screening women aged 65 and older for osteoporosis.  Prostate Cancer  The AAFP concludes that there is insufficient evidence on which to make a recommendation for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).  Second Hand Smoke  The AAFP strongly recommends to counsel smoking parents with children in the house regarding the harmful effects of smoking and children’s health.  Tobacco Use  The AAFP strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products.

31 PHE Suggestions Visual Impairment –The AAFP recommends screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years. Visual Difficulties –The AAFP recommends screening for visual difficulties in elderly adults by performing snellen acuity testing.  Vitamin Supplementation  The AAFP concludes that the evidence is insufficient to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease. (AAFP, August 2005)

32 Summary Which is not a method for PHE? a)Counseling b)Immunization c)Physical exam d)Prescription e)Home visit

33 Which is not a criteria for PHE? a)The disease having a asymptomatic period b) The disease having an acceptable treatment c) The disease having low morbidity and mortality d) The prevalence of the disease is high e) There are risk factors or tests for early diagnosis

34 Which one is a correct PHE according to AAFP? a) ECG to screen heart diseases b) CBC to sreen blood diseases c) Chest x-ray for screening purposes d) Weight and height measurement for children e) Performing a check-up every year to healthy individuals

35 Persons above 65 y. Should have influenza immunizations every year a) True b) False The adverse effects of passive smoking to children should be explained to smoking parents at every visit a) True b) False

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