1. 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

2. Periodic Health Examination

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

4. 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)

5. 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)

6. 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

7. 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);

8. 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.

9. 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

10. 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

11. 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)

12. 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

13. 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

14. PHE Resources National Advisory Committee on Immunizations (NACI)
gci/index-eng.php
Objectives identify certain common conditions for each age group

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

16. PHE Resources Rourke Record
Objectives identify certain common conditions for each age group

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

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

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

26. Condition Specific Recommendations & Screening

27. Recommendations Osteoporosis Prevention <50 years old
Consume mg elemental Ca/day
IU per day (if low risk for deficiency)
>50 years old
Dose of 1200mg elemental Ca/day
Supplement if not achievable by diet
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

28. 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)

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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)

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

40. 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.