1. Back to Basics, 2013 Population Health: Periodic Health Exam, Dr. Laura Bourns, PGY-3 PHPM University of Ottawa Department of Epidemiology & Community Medicine March 28, 2013 1

2. Periodic Health Examination

3. Overview LMCC Objectives Purpose of PHE Age group specific key conditions & risk factors Condition Specific Recommendations & Screening Management

4. 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);

5. 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.

6. 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 6

7. 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 7

8. Periodic Health Examination 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’ 8

9. PHE – Key Conditions Infant Nutrition Breast Feeding Vit D 400 IU/day Growth Growth Charts Development Rourke Baby Record Abuse & Neglect Vision & Hearing Red reflex, corneal light reflex, cover-uncover test & inquiry

10. PHE – Key Age Specific Risk Factors Infant Birth History Risk factors at conception, pregnancy, birth Incomplete immunizations Education & Advice Injury Prevention Car seat Sleep position, crib safety Removal of poisons, firearms Environment Passive smoke Familial factors Assess need for home visit Dental Health

11. PHE – Key Conditions Child Nutrition Milk intake Junk Food Healthy/choices Growth Plot on Growth Chart Development Rourke Baby Record – up to age 5 years Abuse & Neglect Other - Hearing, Vision (Amblyopia)

12. PHE – Key Age Specific Risk Factors Child Birth History Risk factors at conception, pregnancy, birth Incomplete immunizations Education & Advice Injury Prevention Car seat Bike helmets Removal of firearms Environment Passive smoke Familial factors Assess childcare/school readiness Dental Health – cleaning, fluoride, dentist No OTC cough/cold medications

13. PHE – Key Conditions Adolescence Growth Plot on Growth Chart Sexual maturity (Tanner Staging) Nutrition Healthy habits/junk food Body Image Psychosocial history & development HEADSSS

14. PHE – Key Age Specific Risk Factors Adolescence Incomplete Immunizations Sexually active Contraception STI screening for all sexually active – chlamydia, gonorrhea Alcohol/Drug use Emotional concerns Communication with parents Education & Advice Helmet Safety Vehicle Safety & seatbelts Second hand smoke Dental Care, fluoride

15. PHE – Key Conditions & Risks Young Adult Female reproductive health Pap smear (≥ 25 yrs) Folic acid STI Screening Chlamydia & gonorrhea – incidence high in <25 years Hep B & C – screening in general population not recommended HIV & syphilis – if high risk behaviour Occupational health issues Stress Exposures

16. PHE – Key Conditions Middle-aged adult Cardiovascular health risks Blood glucose Blood pressure Lipid Profile Osteoporosis Cancer Breast Colon Prostate Skin

17. PHE – Key Age Specific Risk Factors Middle-aged adult Lifestyle patterns Physical activity Smoking, alcohol Psychological, social and physical functioning Occupational health & exposures Symptoms of any illness Diet

18. PHE – Key Conditions Older adult Fracture & fall prevention Osteoporosis screening Nutrition Elder Abuse Dementia Screening Physical Exam & Investigation Follow up on caregiver concern of cognitive impairment Multidisciplinary fall assessment Visual acuity (Snellen) Hearing impairment

19. PHE – Key Age Specific Risk Factors Older adults Past illness Lifestyle factors Mental function Drug use Physical and social activity Emotional concerns Social relations and support systems

20. PHE – Special Populations Obese Adults Screen all overweight and obese patients for eating disorders, depression and psychiatric disorders Evidence to support use of behaviour modification techniques, CBT, activity enhancement & dietary counseling Reduce energy intake: 500-1000kcal/day 30 min of moderate intensity exercise 3-5 min/week Increase to at least 60 min on most days of the week *Canadian Obesity Network 2006 Clinical Practice Guidelines on the management and prevention of obesity in adults and children

21. PHE – Special Populations Smokers Education & Counseling Smoking Cessation Counseling Referral to smoking cessation programs Pharmacologic therapy Varenicline, buproprion Nicotine Replacement therapy Adjunct to smoking cessation

22. Condition Specific Recommendations & Screening

23. 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

24. Recommendations - Screening Osteoporosis screening - BMD “2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary” (CMAJ, 2010)

25. 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

26. Recommendations - Screening Cervical Cancer Incidence increases significantly after age 25, peaks in 5 th 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

27. PHE - Screening 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 Cervical Cancer – PAP Smear Recommendations (CTFPHC)

28. 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: HgbA1C (Fasting glucose, OGTT) Harms: small $, discomfort, anxiety, over-diagnosis and investigation

29. PHE Screening Type 2 Diabetes 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

30. 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

31. Recommendations - Screening 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

32. 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

33. Overall Management

34. PHE - Management 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 Encourage patient control over health Counsel about risk factor reduction, using health belief model, stages of change model, etc.

35. PHE - Management “Recommend proven prevention strategies” Smoking Cessation Regular Exercise Diet

36. Thanks