1. April 20111 Back to Basics, 2012 POPULATION HEALTH: Periodic Health Exam, Immunization, & Special Populations Epidemiology & Community Medicine Based on slides prepared by Dr. R. Spasoff

2. April 20112 MCC Objectives: Periodic Health Exam Objectives Through efficient, focused, data gathering: In an infant, toddler, or child elicit information about risk factors at conception, pregnancy, and birth, familial factors, and existing signs of illness or environmental risk factors (missed immunization, diet, passive smoke inhalation, skin protection). Determine height, weight, head circumference, medical status, and developmental milestones. For a youth, elicit information about nutrition, physical activity, drug use, sexual/social/peer activities, emotional concerns, and communication with parents. In adults, elicit information about lifestyle patterns, psychological, social, and physical functioning, symptoms of any illness, and situational factors affecting mood. In seniors, elicit information about past illness, lifestyle factors, mental function, drug use, physical and social activity, emotional concerns, social relations, and support systems. List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: Select investigation specific to age and gender concerns (e.g., VDRL for youth, chlamydia screen for high-risk youths, cholesterol for>35 year, fecal occult blood for middle age, tuberculin testing, HIV serology for high-risk group, mammography for>50 year, pap smear for adult women, rubella serology for young women).

3. April 20113 MCC Objectives: Periodic Health Exam Conduct an effective plan of management for a patient who is well and without disease, well and with disease, not well and with disease, not well and without disease: Communicate and make recommendations regarding disease prevention (e.g., healthy diet, calcium supplements for women, folic acid for women planning pregnancy, exercise, breast self-exam, avoidance of high-risk sexual behavior, barrier contraceptives, flossing, fluoride toothpaste, balance training and home-based prevention program for elderly). Communicate and make recommendations regarding accident prevention (e.g., recommend helmet use for bicycle injury, smoke detector use, avoid drinking/drugs and driving, seat- belt/air bag use). Encourage patient control over health (e.g., hepatitis immunization for high-risk travel, influenza and pneumococcal immunization for elderly or chronic disease patients, measles/mumps/rubella for youth). Outline intervention(s) that would reduce risk for an existing condition detected (e.g., Amantadine/Rimantadine if high-risk for influenza, sun avoidance/protective clothing, smoking cessation, reduce alcohol, regular condom use for STD). For a frequently encountered risk factor (e.g., colon cancer), outline one intervention that would reduce the risk for the condition.

4. April 20114 077 PERIODIC HEALTH EXAMINATION (1) “Determine patient’s risks for common gender/age specific conditions” This would involve knowing something about prevalence of condition, as well as patient’s risk factors for it. Objectives identify certain common conditions for each age group Use periodic health exam for health promotion/disease prevention interventions. Case-finding and screening for disease & risky behaviours

5. April 20115 Key conditions (1) Infant/Toddler <3 years –Delayed growth & development –Abuse/neglect Child 3-12 years –Vision/hearing defect –“Accidents” –Delayed development –Abuse/neglect

6. April 20116 Key conditions (2) Youth 13-24 years –MVA –Substance abuse –STDs –Contraception –Sedentary lifestyle –Female: rubella/HPV immunization –Eating disorders (don’t know why not included)

7. April 20117 Key conditions (3) Adult 25-44 years –Substance abuse –Eating disorders –Family violence –Hypertension –Female: cervical cancer –Male: elevated cholesterol, MVA

8. April 20118 Key conditions (4) Middle age 45-64 years –Lung cancer –Colon cancer –Skin cancer –Obesity –Female: osteoporosis, breast cancer –Male: IHD, prostate cancer (55 and up)

9. April 20119 Key conditions (5) Seniors >64 yrs –Elder abuse –Falls –Drug-related morbidity –Nutrition –Cancer –Dementia (Should be on MCC list)

10. April 201110 077 PERIODIC HEALTH EXAMINATION (2) “ Elicit information about ethnic, family, socio-economic, occupational, and lifestyle characteristics that are known to be at high risk for a particular condition.” Presumably means “…known to convey a high risk…” MCC provides a list for each age group

11. April 201111 Key Age-specific Risk factors (1) Infant, Toddler, Child: –Risk factors at conception, pregnancy, birth –Familial factors –Existing signs of illness –Environment (missed immunization, diet, passive smoke inhalation, skin protection) –Height, weight, head circumference, medical status, developmental milestones

12. April 201112 Key Age-specific Risk factors (2) Youth –Nutrition –Physical activity –Drug use –Sexual/social/peer activities –Emotional concerns –Communication with parents

13. April 201113 Key Age-specific Risk factors (3) Adults: –Lifestyle patterns –Psychological, social and physical functioning –Symptoms of any illness –Situational factors affecting mood

14. April 201114 Key Age-specific Risk factors (4) Seniors: –Past illness –Lifestyle factors –Mental function –Drug use –Physical and social activity –Emotional concerns –Social relations and support systems

15. April 201115 Periodic Health Exam (2A) General: –Use lab tests only for specific to age and sex concerns. Do not use the same battery of tests in all patients. –Interpret results taking into account age/gender, etc.

16. April 201116 077 PERIODIC HEALTH EXAMINATION (3) “Conduct an effective plan of management” All patients: –Encourage patient control over health –Follow recommendations of CTFPHC (http://www.ctfphc.org/ )http://www.ctfphc.org/ Patient with risk factors: –Counsel about risk factor reduction, using health belief model, stages of change model, etc.

17. April 201117 078-3 PERIODIC HEALTH EXAMINATION (1) Clinical Guidelines for primary and preventive care Targeted and Evidence based Objectives target common conditions for each age group Use periodic health exam for health promotion/disease prevention interventions. Case-finding and screening for disease & risky behaviours

18. April 201118 Classification of Recommendations A Good evidence to recommend B Fair evidence to recommend C Existing evidence is conflicting and does not allow to make a recommendation for or against D Fair evidence to recommend against E Good evidence to recommend against I insufficient evidence to recommend

19. April 201119 Elements Discussion Physical exam Tests Therapy

20. April 201120 Gen Pop- Discussion Dental Hygiene (community fluoridation, brushing, flossing) (A) Noise control, hearing protection (A) Seatbelt use (B) Injury prevention (bicycle helmets, smoke detectors) (B) Moderate physical activity (B)

21. April 201121 Gen Pop- Discussion Avoid sun exposure and wear protective clothing (B) Problem drinking screening, counselling (B) Counselling to protect against STI’s (B) Nutritional counselling on fat and cholesterol (B)

22. April 201122 Gen Pop- Physical Exam Clinical breast exam women age 50-69 (A) Blood pressure measurement (B) BMI measurement in obese adults (B)

23. April 201123 Gen Pop- Tests Mutiphase screening with FOB test adults>50 q1-2 yrs (A) Sigmoidoscopy adults > 50 freq not established (B) Bone Mineral Density (1 major or 2 minor criteria)

24. April 201124

25. April 201125 The Canadian Task Force on Preventive Health Care concludes that there is fair evidence to recommend screening postmenopausal women to prevent fragility fractures (no or low trauma fractures) (grade B recommendation). Although there is no direct evidence that screening reduces fractures, there is good evidence that screening is effective in identifying postmenopausal women with low bone mineral density and that treating osteoporosis can reduce the risk of fractures in this population (grade A recommendation).

26. April 201126 Gen Pop- Tests Fasting lipid profile Controversial Fasting glucose- hypertension and hyperlipidemia (B) Mammography women 50-69 q1-2 yrs (A) Sexually active women Pap Smear q1y x2, then q3y if both normal

27. Gen Pop- Tests not Recommended PSA still has insufficient evidence to justify screening Syphilis tests should not be done routinely Breast self exam (D)- fair evidence of no benefit and good evidence of harm April 201127

28. April 201128 Gen Pop- Therapy Folic Acid supplementation women of child bearing age (A) Pharmacologic treatment of hypertension with diastolic BP>90 mm Hg

29. April 201129 Special Pops- Smokers Counsel on smoking cessation Nicotine replacement therapy (A) Referral to smoking cessation program (B) Dietary advice on leafy green vegetables and fruits (B)

30. April 201130 Special Pops- Pediatric Discussion –Home visits to high risk families (A) –Inquiry into developmental milestones (B) Physical –Repeated examination of hips hearing and eyes (A) –Serial heights weights and head circumference (B) –Visual acuity testing (>2 yrs) (B)

31. April 201131 Special Pops- Pediatric Tests –Routine hemoglobin fir high risk populations (sickle cell and thalassemia) (B) –Blood lead screening for high risk infants (B) Therapy –Immunization

32. April 201132 Special Pops- Adolescents Counsel on sexual activity and contraceptive methods (B) Counsel to prevent smoking initiation (B)

33. April 201133 Perimenopausal Women Counsel on osteoporosis Counsel on risks and benefits of hormone replacement therapy (B)

34. Special Pops- adults>65 Follow up on caregiver concern of cognitive impairment (A) Multidisciplinary post-fall assessment (B) Visual acuity (Snellen) (B) Hearing impairment (B)

35. Special Pops- Familial First degree relative with melanoma –Full body skin exam (B) Familial Adenomatous Polyposis –Sigmoidoscopy and genetic testing (B) Hereditary non-polyposis colorectal cancer –Colonoscopy (B) April 201135

36. Special Pops- Other Tb high risk –Mantoux testing (A) –INH chemoprophylaxis for close contacts and recent convertors (B) STI high risk –Voluntary HIV antibody screening (A) –Gonorrhea screening (A) –Chlamydia screening (B) April 201136