Download Periodic Health Examinations in Primary Care

Periodic Health Examinations in
Primary Care
Aim-Objectives
• At the end of this presentation the participants will be;
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Able to describe the role of PHE in primary care
Able to count three diseases with highest mortality
Able to define PHE
Able to explain the effective screening criteria used in PHE
Aware of the risks in PHE
Able to count non-evidence based check up activities of daily life
Aware of the importance of PHE and preventive medicine in
primary care.
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Iceberg phenomenon ?
1
Diseased, diagnosed & controlled
2
Diagnosed, uncontrolled
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Undiagnosed or wrongly
diagnosed disease
4
Risk factors for disease
5
Free of risk factors
Diagnosed
disease
Undiagnosed or
wrongly diagnosed
disease
3
What are PHC physicians doing?
Health Care
Health
promotion
Risk
prevention
Primary Prevention
Risk
reduction
Early
diagnosis
Secondary Prevention
Personal Preventive Medicine!
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Complication
reduction
Tertiary
Prevention
The High mortality diseases in
Saudi Arabia
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Symptoms /Signs ill defined ……
24.64%
Diseases of CVS………………... 21.82%
Injury / Poisoning………………. 18.31%
Conditions perinatal period……..
9.88%
Neoplasms………………………
4.55%
Diseases of RS………………….
4.38%
MOH- Saudi Arabia
Definition
Evaluation of apparently health
individuals in certain time periods,
using a number of standard
procedures such as counseling,
physical examination, immunization,
and laboratory investigations is called
Periodic Health Examination.
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Does it work?
• USA: Mortality from stroke has decreased by 50% since 1972
– Early diagnosis and treatment of hypertension
• Mortality from cervix cancer decreased by 80%
• Neonatal screening
– Decrease in mental retardation
• Phenylketonuria screening
• Congenital hypothyroidism
National Center for Health Statistics. http://www.cdc.gov/nchs/r&d/ndi/ndi.htm
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World Health Organization — Principles of
Screening
The Wilson-Jungner Criteria. Public Health Paper 1968,
Geneva, WHO
• The condition should be an important health problem.
• There should be a treatment for the condition.
• Facilities for diagnosis and treatment should be available.
• There should be a latent stage of the disease.
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• There should be a test or examination for the condition.
• The test should be acceptable to the population.
• The natural history of the disease should be adequately
understood.
• There should be an agreed policy on who to treat.
• The total cost of finding a case should be economically
balanced in relation to medical expenditure as a whole.
• Case-finding should be a continuous process, not just a
"once and for all" project.
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Effective screening criteria
1. Disease Has Serious Consequences
Screening should target diseases with serious consequences
such as mortality or severe or prolonged morbidity
Both pulmonary and colorectal cancer are serious
diseases, being the first and second leading causes of
cancer death in the United States , respectively. Breast
cancer is the second leading cause of cancer death in
women. Thus, all three cancers have serious
consequences.
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2. Screening Population Has High
Prevalence of Detectable Preclinical Phase
• The detectable preclinical phase of the disease
should have a high prevalence among people who
are screened
• Preclinical phase is the time from the onset of
disease to the first appearance of signs and
symptoms
• Depends on the population's awareness of the
disease and the patient's access to health care
• The preclinical phase is the interval of time when
the disease is detectable by the screening test.
2. Screening Population Has High
Prevalence of Detectable Preclinical Phase
• if the prevalence is 1% and the test's
sensitivity and specificity are both 95%, then
the probability of disease after positive test
results is only 16%.
• In contrast, if the prevalence is 5%, then the
probability of disease after positive test
results is 50%.
3. Screening Test Detects Little
Pseudodisease
Two types of pseudodisease have been described:.
-Type I pseudodisease the disease never progresses and, in
fact, may regress naturally.
-Type II pseudodisease, the disease progresses so slowly that
the patient never develops symptoms and dies from another
cause.
-Type II pseudodisease is common in diseases with long
detectable preclinical phases or among patients with short life
expectancies
-Both types undergo unnecessary tests and treatment but
derive no benefit from the treatment.
- Screening tests that detect a high frequency of
pseudodisease cannot be cost-effective.
3. Screening Test Detects Little
Pseudodisease
• With colorectal cancer, not all adenomatous polyps
progress to invasive carcinoma. Evidence shows that
many small (<1 cm) polyps regress [15]. The rate of
adenomatous polyps progressing to cancer has been
estimated at about 2.5 polyps per 1000 individuals per
year
• Not all breast ductal carcinoma in situ progresses to
invasive carcinoma
• The presence of pseudodisease in screening for both
colorectal polyps and breast cancer limits the
effectiveness of these screening programs
4. Screening Test Has High Accuracy for
Detecting the Detectable Preclinical Phase
• The screening test must have good sensitivity and
specificity
• Increasing the specificity of a screening test will
increase the cost-effectiveness of screening.
• It is not always cost-effective to increase a screening
test's sensitivity.
• An increase in sensitivity might mean an increase in
the detection of pseudodisease or an increase in the
detection of disease after the critical point in the
natural history (i.e., after the primary tumor
metastasizes).
• Both these situations are detrimental to screening.
5. Screening Test Detects Disease
Before Critical Point
• For most diseases, a critical point occurs in the
natural history of the disease; treatment is more
effective before this point and less effective after
this point .
• For most cancers, the critical point occurs when
the primary tumor metastasizes.
• If the critical point occurs before the detectable
preclinical phase, then screening cannot be
effective.
• CT can detect stage I pulmonary cancer is
asymptomatic people.
6. Screening Test Causes Little
Morbidity
• The screening test must not inflict mortality or
significant morbidity on those screened.
• For pulmonary cancer screening, the CT study
is performed without IV contrast material, so
short-term toxicity is not a problem.
• For breast cancer screening, the short-term
effect is patient discomfort.
7. Screening Test Is Affordable and
Available
• The diagnostic test must be affordable and
available to the target population.
8. Treatment Exists
• An effective treatment for the disease must exist
for screening to improve patient outcomes.
• Detection of disease alone is not cost-effective.
This may seem a trite criterion for screening, but
it is important because many common diseases
(e.g., Parkinson's disease, multiple sclerosis,
Alzheimer's) have no treatment. Although it may
be possible to detect these conditions
preclinically, screening cannot be cost-effective if
no treatment exists
9. Treatment Is More Effective When
Applied Before Symptoms Begin
• For screening to be cost-effective, treatment
must be more effective or less toxic when
applied during the detectable preclinical
phase, as compared with treatment applied
after symptoms begin
10. Treatment Is Not Too Risky or Toxic
• Treatment cannot be so risky or toxic that it
offsets its long-term benefits.
• This is particularly important when many
false-positive cases or many cases of
pseudodisease undergo treatment;
• these patients derive no benefit from
treatment, only its side effects.
Types of screening
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Mass
Targeted
Multiple or Multiphasic
Case-finding or opportunistic
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How is PHE performed?
• Healthy individuals
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Counseling
•
Immunization
•
Home visit
•
Prophylaxis
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Physical exam
•
Laboratory test
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Any Guidelines for KSA?
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Screening / PHE programs in
Saudi Arabia
• Annual periodic health examination for all
diabetic and hypertensive patients
registered at PHC
• Cervical screening
• Breast cancer screening in some areas
• Pre-marital screening (genetic dis.,
infectious dis.)
• Well baby clinic
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PHE Suggestions
 Bacteriuria,
 Asymptomatic The AAFP recommends against the routine screening of
men and nonpregnant women for asymptomatic bacteriuria.
• Breast Cancer
– The AAFP recommends women age 40 years and older be screened for
breast cancer with mammography every 1-2 years after counseling by
their family physician regarding the potential risks and benefits of the
procedure.
• Breast Cancer
– The AAFP concludes that the evidence is insufficient to recommend for
or against teaching or performing routine breast self-examination
(BSE).
 Cardiac Disease
 The AAFP recommends against the use of routine ECG as part of a
periodic health or preparticipation physical exam for cardiac disease in
asymptomatic children and adults.
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PHE Suggestions
 Cervical Cancer
 The AAFP strongly recommends that a Pap smear be completed at
least every 3 years to screen for cervical cancer for women who have
ever had sex and have a cervix.
 Colorectal Cancer
 The AAFP strongly recommends that clinicians screen men and women
50 years of age or older for colorectal cancer.
 Coronary Heart Disease
 The AAFP recommends against routine screening with resting
electrocardiography (ECG), exercise treadmill test (ETT), or electronbeam computerized tomography (EBCT) scanning for coronary calcium
for either the presence of severe coronary artery stenosis (CAS) or the
prediction of coronary heart disease (CHD) events in adults at low risk
for CHD events.
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PHE Suggestions
 Diabetes, Type 2
 The AAFP recommends screening for type 2 diabetes in adults with
hypertension and hyperlipidemia. There is insufficient evidence to
recommend for or against screening adults who are at low risk for
coronary vascular disease.
 Hearing difficulties
 The AAFP recommends screening for hearing difficulties by
questioning elderly adults about hearing impairment and counsel
regarding the availability of treatment when appropriate.
 Hemoglobinopathies
 The AAFP strongly recommends ordering screening tests for PKU,
hemoglobinopathies, and thyroid function abnormalities in neonates.
• Hormone Replacement Therapy
– The AAFP recommends against the routine use of combined estrogen
and progestin for the prevention of chronic conditions in
postmenopausal women.
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PHE Suggestions
• Hormone Replacement Therapy
– The AAFP recommends against the routine use of unopposed estrogen
for the prevention of chronic conditions in postmenopausal women
who have had a hysterectomy.
 Hypertension
 The AAFP strongly recommends that family physicians screen adults
aged 18 and older for high blood pressure.
 Influenza
 The AAFP recommends immunizing all persons age 50 years and older
for influenza. Discuss immunization annually using AAFP
recommendations.
 Lipid Disorders
 The AAFP strongly recommends screening for lipid disorders with
either a fasting lipid profile or nonfasting total cholesterol and HDL
cholesterol in males age 35 and older, and females age 45 and older.
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PHE Suggestions
 Lung Cancer
 The AAFP recommends against the use of chest X-ray and/or sputum
cytology in asymptomatic persons for lung cancer screening.
 Neural tube defects
 The AAFP recommends prescribing 0.4 mg folate supplementation to
women not planning a pregnancy but of childbearing potential who
have not previously had a baby with a neural tube defect.
 Obesity
 The AAFP recommends screening for obesity by measuring height and
weight periodically for all patients.
 Osteoporosis
 The AAFP recommends counseling females age 11 and older to
maintain adequate calcium intake prevent osteoporosis.
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• Thank you