1. Choosing Wisely in Adult Health Maintenance
Jauch Symposium Oct 14, 2016
Anthony Day, MD, FAAFP

2. Objectives Identify sources of high value preventive care
Discuss ways to inform patients on why many tests are not routinely recommended
List common tests/procedures that have not been shown to be of high value
Describe the potential for inadvertent patient harm with over utilization of tests

3. Illustrative Case 1 19 female presenting for pre-college physical
Volleyball scholarship to D3 school
Sexually active only on two occasions with former boyfriend
No medical problems or concerns

4. History
Sports related – FH early CAD, activity sxs, injuries, eating disorders, menstrual cycles
Immunizations
Illness/risk behaviors
Medical problems when applicable
Key FH, SH, PMHx

5. Exam Low yield in asymptomatic individuals
Sports focused (BMI, Heart, Marfan’s, joints)
Don’t screen for scoliosis (D, Fam Med)
Don’t do pelvic exam/pap smear (D, Fam Med) – discuss preg prevention
Don’t do ECG (D, Fam Med, *sports)
Males – don’t do testicular screening (D)

6. USPTXF A Recommendations
Folic acid supplementation (A)
HIV screening (A)
BP screening (A)
Tobacco screening (A)
Immunizations – Tdap (21), HPV, MMR, Flu, Meningoccocal, others based on imm hx

7. USPTXF B Recommendations
Depression screening (B)
GC/Chlamydia screen– sexually active (B)
STD Counseling (B)
BRCA risk assessment (B)
Obesity screening (B)/ Diet/exercise counseling (B)
Intimate partner violence (B)
Skin cancer counseling (B)
Etoh screen/intervention (B)

8. Tips
Patients expect to be touched but you can explain that the exam is minimal when people don’t have symptoms
Most women won’t be upset at not having to have a pelvic exam/pap smear/ men not having a testicular exam
Asking what patients know about health and filling in gaps is more meaningful than a spiel

9. Illustrative Case 2 66 yo F for annual health maintenance
No major medical problems
Last pap smear at age 60 was normal
Overweight, but active, still working
No complaints

10. Approach
Society of General Internal Medicine Choosing Wisely – don’t do routine health checks in asymptomatic adults
Risk of unnecessary testing and potential patient harm
Should deliver evidence-based preventive care
Most insurers/societies recommend annual preventive visit

11. Evidence-based Prevention
No pap after age 65 (FM/USPTFX)
Don’t listen carotids/order us (FM and Vascular)
No routine EKG (FM)
No routine 25-OH Vit D – only high risk, use OTC supplement (Clinical Path)
Aspirin 81 mg if greater than 10% 10 year ASCVD risk

12. USPTFX Colorectal Ca screen (A) HTN screen (A)
Hyperlipid screen (A) – if increased risk
Diabetes screen (B) – if overweight
Mammogram (B) – FH for BRCA risk
Etoh, Depression, Fall risk, Obesity, Osteoporosis screen (B)
Exercise/diet counseling (B)
Consider Vit D supplementation (B)

13. USPTFX Ds AAA screen – only male smoking hx
UA – never treat asymptomatic bacteriuria
COPD screen (CT for Lung ca only in current/recent smokers)
Menopausal hormones for prevention
Ovarian, pancreatic ca screening
Vitamins for CVD prevention

14. Immunizations
Tdap/Td – CMS only pays if injury, try to get before age 65
Influenza annually – don’t avoid in egg-allergic patients (Allergy) – give and observe 30”, no study with anaphylaxis
Zoster (age 60) – easier before age 65
PCV13 (Prevnar), followed by PPSV23 (Pneumovax) 1 year later

15. Tips
Again, most women ok with not doing pap smears, other intimate exams
Self-breast exam and clinical breast exam not recommended if getting mammograms
Males – no routine PSA or DRE
Focus on education, health, activity and preventive testing
Minimize exam/labs when asymptomatic

16. Illustrative Case 3
80 year male with HTN, CAD, mild dementia, CKD stage 3, T2DM, COPD, recent CVA, Prostate Cancer
Routine F/u of medical problems
Still smokes, A1C 7.9, on appropriate meds
Stable angina limits activity, mod dyspnea with exertion
What prevention should we consider?

17. Recommendations
Avoid breast, colorectal, prostate or lung cancer screening without considering life expectancy, risk of testing/treatments (Surg, Gen Surg, Long-term care, Gen Internal Med)
Etoh, Depression, Obesity screen (B)
Fall prevention – Vit D supplementation and Activity/Strength training (B, Phys Therapy)
Manage his chronic disease/risks avoid aggressive hosp/interventions if frail unless clear goals (Long-term care)

18. Tips
Exercise/activity one of few interventions that prolong life, if fall risk utilize PT to match with individual abilities/goals
Establish patient-centered goals for care
Many interventions untested in advanced elderly
Geriatric pts on 5 or more meds have 58% likelihood of adverse drug reaction

19. Comments/ Questions