1. Back to Basics, 2016 Preventive medicine: Periodic Health Exam Dr. Trevor Arnason, MSc, MD, CCFP, PGY-5 PHPM University of Ottawa School of Epidemiology, Public Health and Preventive Medicine March 22, 2016 1

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

3. Preventive Medicine “Preventive Medicine is the specialty of medical practice that focuses on the health of individuals, communities, and defined populations. Its goal is to protect, promote, and maintain health and well- being and to prevent disease, disability, and death.” -American Board of Preventive Medicine 3

4. Why prevention? 4

5. MCC Objectives - Prevention General Objectives: Health Promotion And Maintenance Formulate preventive measures into their management strategies. Communicate with the patient, the patient's family and concerned others with regard to risk factors and their modification where appropriate. Describe programs for the promotion of health including screening for, and the prevention of, illness.

6. MCC Objectives - Prevention (Pop. Health; 78-3) Key Objective Understand the three levels of prevention (primary, secondary and tertiary). Appreciate the role that physicians can play in promoting health and preventing diseases at the individual and community level (e.g. prevention of low birth weight, immunization, obesity prevention, smoking cessation, cancer screening, etc.). Enabling Objectives: Be able to both define the concept of levels of prevention at the individual (clinical) and population levels, as well as formulate preventive measures into their clinical management strategies. Be able to describe the health impact of community-level interventions to promote health and prevent disease.

7. Levels of prevention Primary prevention—a condition is prevented before it develops by addressing its risk or protective factors. Secondary prevention—early detection or intervention to identify a disease and delay the progression of an early or preclinical disease and minimize disability. Tertiary prevention—interventions that lessen the impact of disability from fully developed disease through eliminating, reducing or managing impairments.

8. 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 8

9. 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);

10. 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.

11. 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

12. WARNING! - screening 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

13. WARNING! - screening Benefits of screening are often overestimated The harms of screening practices are often ignored or minimized Screening 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

14. Approach to ‘screening’ or ‘case finding’ 1) What is the population ? 2) What outcomes are common in this population? 3) What interventions are available to prevent the outcomes? 4) What is the available evidence to support the intervention in this population to prevent the outcome(s)

15. Periodic Health Examination The period health examination (PHE) represents an opportunity for the prevention or early detection of health- related problems. The nature of the examination will vary depending on the age, sex, occupation, and cultural background of the patient. 15

16. Populations usually defined by age and sex Infant and child Nutrition, growth, development Abuse/neglect Other (e.g., hearing, amblyopia) Adolescence Substance abuse Sexual activity (e.g., contraception, sexually transmitted infections [STI]) Young adult Female reproductive health (e.g., Papanicolaou smear, STI screening, folic acid) Occupational health issues (e.g., stress, exposures) 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

17. Populations usually defined by age and sex Middle-aged adult Cardiovascular health risks (e.g., blood glucose, blood pressure, lipid profile) Cancer screening (e.g., breast, colon, prostate, skin) Osteoporosis Occupational health issues (e.g., stress, exposures) Older adult Fracture and fall prevention (e.g., osteoporosis screening) Nutrition Elder abuse Dementia screening 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

18. For the MCCQE Focus on the simple stuff (eg: things that apply to everyone) Controversial topics are less likely to be emphasized Exam is Canada-wide, so Provincial recommendations are not as important “Recommend proven prevention strategies” Smoking Cessation Regular Exercise Nutrition Alcohol moderation

19. Some things are good for almost everybody! All ages Injury prevention (e.g., noise control, seat belts, bicycle helmets) Lifestyle modification (e.g., physical activity, smoking prevention/cessation, sun exposure) Immunization

20. 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’ 20

21. PHE Resources National Advisory Committee on Immunizations (NACI) http://www.phac-aspc.gc.ca/publicat/cig- gci/index-eng.php 21

22. PHE Resources CFPC Preventative Care Checklist 22

23. PHE Resources Rourke Record http://www.rourkebabyrecord.ca/national.asp 23

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. Ah…what if I can’t remember all this on exam day? “Recommend proven prevention strategies” Smoking Cessation Regular Exercise Nutrition Alcohol moderation Stress reduction

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

34. Condition Specific Screening Recommendations

35. Osteoporosis Intervention: Bone Mineral Density “2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary” (CMAJ, 2010)

36. 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

37. 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 Type 2 Diabetes

38. CategoryLow to Moderate Risk High RiskVery high risk Level of Risk (10 year risk of diabetes) Low: 1-4% Moderate: 17% 33%50% Routine Screening Recommended? NOq3-5 yearsannually RationaleNo evidence of improved outcomes Evidence for  MI rates  Cost vs. annual screening Evidence for  DM complications & death

39. Cancer screening There are really only 3 cancer screening programs that you should think about: Cervical Colorectal Breast Slightly different programs in each province, so follow CTFPHC wherever possible Other screening tests may be done in specific circumstances, but are generally not clearly beneficial as “population wide” screening programs (eg: prostate, lung)

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

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

42. Breast Cancer Incidence & Case-fatality rate increase with age Intervention: Mammography Population for routine screening: Age 50-74 No personal or Family Hx of Breast CA No known BRCA1 or 2 mutation No previous chest wall radiation

43. Breast Cancer Mammography Age40-4950-6970-74 Routine Screening Recommended? NOq 2-3 years RationaleLower 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

44. Breast Cancer 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

45. Colorectal Cancer CTFPHC (2016) recommends: Screening adults aged 50 to 74 for CRC with FOBT (either gFOBT or FIT) every two years OR flexible sigmoidoscopy every 10 years. NOT screening adults aged 75 years and over for CRC. NOT using colonoscopy as a screening test for CRC.

46. A primary care physician recommends an exercise rehabilitation program to a patient who recently suffered a myocardial infarction. This is meant to prevent worsening of the patients ischemic heart disease. What level of prevention does this represent?  Primordial prevention  Primary prevention  Secondary prevention  Tertiary prevention  There is no more prevention to do, this person already has disease.

47. A 20 year-old female patient visits your family medicine clinic for a “check-up” because her mother told her she needed to get a Pap test annually once she became an adult and she never did. She has been sexually active for approximately 2 years. What are two important prevention issues with respect to this patient’s sexual health that you should discuss at this visit.

48. A 55 year-old asymptomatic, male patient comes to your office because he is concerned about developing a chronic disease. His golfing buddies all have to take a bunch of pills – he thinks he should probably be doing the same. He has not seen a healthcare provider in 20 years. a) List two items on the physical exam that you would do to assess this individual’s risk of a chronic disease AND name the disease for each. b) List two laboratory-based screening tests that you will order.

49. Thanks Acknowledgements: This was developed based on a previous presentation by Dr. Laura Bourns.