Transcript Aktif Dinleme - İletişim Kursu, Kırıkkale

Preventive Medicine and
Periodic Health Examinations in Primary Care
Dr. Zekeriya Aktürk
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Saudi Diploma in Family Medicine
Aim-Objectives
• At the end of this presentation the participants will be;
–
–
–
–
–
–
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 describe current clinical preventive service
recommendations for family practice
– Aware of the importance of PHE and preventive medicine in
primary care.
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What are primary care physicians
doing?
Health Care
Health
promotion
Risk
prevention
Primary Prevention
Risk
reduction
Early
diagnosis
Complication
reduction
Secondary Prevention
Personal Preventive Medicine!
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Tertiary
Prevention
Prevention of what?
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Reasons of diseases (%)
50
45
40
35
30
25
20
15
10
5
0
Access
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Genetic
Environment
Saudi Diploma in Family Medicine
Behaviour
Insurance companies:
“Mortality decreases in persons undergoing regular health checks!”
CHECK-UP
(1921)
Some diseases don’t have enough clues at the beginning, and
when able to diagnose there was no time for treatment: check-up
gone.
Changing by personal factors such as age, exposure, sex, and risk
PERIODIC HEALTH EXAM was introduced.
(1970)
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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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Immunization and Polio
• Polio eradication in Turkey
• Every year 6.5 million children are immunized
• Last case seen in 1998
Morbidite
hızı(1/100.000)
Mortalite
hızı(1/1.000.000)
1,8
0,7
1,6
0,6
1,4
0,5
1,2
1
0,4
0,8
0,3
0,6
0,2
0,4
0,1
0,2
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
1973
0
1971
0
Turkish MoH, polio morbidity and mortality rates. http://www.saglik.gov.tr/extras/istatistikler/temel2000/97.htm
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Think of your daily life
• A 30-year old woman applies to your office. She has no
history of disease but afraid of becoming breast cancer.
– Should you perform a breast exam?
– Should you teach her breast self exam?
– Should you order a mammography?
• How do you decide?
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Effective screening criteria
1. Prevalence of the disease should be high
No sense to screen diseases with low prevalance.
- Osteogenesis imperfecta: incidence 1/10 000/year
Medline Plus. Medical Encyclopedia. Osteogenesis imperfecta.
http://www.nlm.nih.gov/medlineplus/ency/article/001573.htm
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Effective screening criteria
2. Predictive risk factors or tests should be present
The safety and cost of the test should be known
- CRP: Cheap but not specific
- Echocardiograpy: sensitive and specific but expensive
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Basic Parameters
Population-100 persons
(+) Test
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(-) Test
Diseased
(Prevalence)
10
Healthy
6
80
PPV
NPV
4
Saudi Diploma in Family Medicine
Sensitivity
Specifity
Effective screening criteria
3. Morbidity and mortality should be high
Factors related with morbidity and mortality (beyond the
disease itself) :
- Age
- Sex
- Race
- Gegraphical area
- Life style (culture)
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Mortality according to age groups
•
•
•
•
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0-18 months
• Perinatal causes
• Congenital anomalies
7-12 years
• Accidents other than motor vehicle
• Motor vehicle accidents
19-39 years
• Motor vehicle accidents
• Suicide
65 years and older
• Heart diseases
• Cerebrovascular diseases
Saudi Diploma in Family Medicine
Effective screening criteria
4. There should be an acceptable treatment
No sense to srean untreatable diseases
- Lung cancer (?)
5. There should be a prodromal period without complains
- AIDS
- Syphilis
- Cervix cancer
- Breast cancer
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The natural course of diseases
Aggressive cancer
Beginning
6 mo
Symptoms 1 year
DEATH
Screening once
a year
Beginning
2 year
Symptoms
The same cancer but less aggressive
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4 year
DEATH
Let’s come back to our example:
patient with breast cancer
• It’s an important disease for women
– Worldwide 719000 new cases/year. (1/1000)
• Morbidity/mortality
• It can be recognized without symptoms
– Mammography
• Curable
– Surgery, Chemotherapy, Radiotherapy
• The value of treatment is more than its adverse effects
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Can periodic health examination be
harmful?
Asymptomatic
person
Screening
Test normal
Test abnormal
True negative
False negative
True positive
False positive
Reassurance
Delay in diagnosis
Treatment
Anxiety
The average error rate of a test: %5
Ian R. McWhinney. A Textbook of Family Medicine. Oxford University Press, USA 1997.
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The Check-up Chaos
• Chest x-ray to screen lung diseases,
• Urinanalysis to screen urinary diseases,
• ECG,
• Microfilm to screen Tbc,
• PSA to screen prostate cancer,
• Self exam to screen breast cancer,
• CBC,
• Influenza immunization for healthy adolescents
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How is PHE performed?
• Healthy individuals
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•
Counseling
•
Immunization
•
Home visit
•
Prophylaxis
•
Physical exam
•
Laboratory test
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Any Guidelines for KSA?
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