Transcript Back to Basics, 2013 Population Health: Periodic Health Exam

Back to Basics, 2013
Population Health:
Periodic Health Exam,
Dr. Laura Bourns, PGY-3 PHPM University of Ottawa
Department of Epidemiology & Community Medicine
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March 28, 2013
Periodic Health Examination
Overview
 LMCC Objectives
 Purpose of PHE
 Age group specific key conditions & risk factors
 Condition Specific Recommendations & Screening
 Management
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);
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.
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
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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
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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’
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PHE – Key Conditions
Infant
 Nutrition
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 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
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
PHE – Key Conditions
Child
 Nutrition
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 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)
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
PHE – Key Conditions
 Adolescence
 Growth
 Plot on Growth Chart
 Sexual maturity (Tanner Staging)
 Nutrition
 Healthy habits/junk food
 Body Image
 Psychosocial history & development
 HEADSSS
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
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
PHE – Key Conditions
Middle-aged adult
 Cardiovascular health risks
 Blood glucose
 Blood pressure
 Lipid Profile
 Osteoporosis
 Cancer
 Breast
 Colon
 Prostate
 Skin
PHE – Key Age Specific Risk Factors
Middle-aged adult
 Lifestyle patterns
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 Physical activity
 Smoking, alcohol
Psychological, social and physical functioning
Occupational health & exposures
Symptoms of any illness
Diet
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
PHE – Key Age Specific Risk Factors
 Older adults
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Past illness
Lifestyle factors
Mental function
Drug use
Physical and social activity
Emotional concerns
Social relations and support systems
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
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
Condition Specific
Recommendations &
Screening
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
Recommendations Screening
 Osteoporosis screening - BMD
“2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary” (CMAJ, 2010)
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
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
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
No routine screening
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
Routine screening, every 3
years
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
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
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 NO
Recommended?
q3-5 years
annually
Rationale
Evidence for  MI
rates
Evidence for 
DM complications
& death
No evidence of
improved
outcomes
 Cost vs. annual
screening
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
Recommendations Screening
Breast Cancer - Mammography
Age
40-49
50-69
70-74
Routine
Screening
Recommended?
NO
q 2-3 years
q 2-3 years
Rationale
Lower likelihood
of breast cancer
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
Greater likelihood
of false + in age
group
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
Overall Management
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.
PHE - Management
 “Recommend proven prevention
strategies”
 Smoking Cessation
 Regular Exercise
 Diet
Thanks