Transcript Aktif Dinleme - İletişim Kursu, Kırıkkale

Periodic Health Examinations
Introduction to Primary Care:
a course of the Center of Post Graduate Studies in FM
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
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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.
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
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 figures in KSA
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2,5
2
1,5
-
1
0,5
0
198
199
200 200 200
81 82 83 84 85 86 87 88 89
91 92 93 94 95 96 97 98 99
0
0
0 1 2
Incidence 2,6 1,8 1,1 1,2 1,2 0,3 0,1
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0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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)
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Healthy
6
80
PPV
NPV
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Sensitivity
Specifity
Effective screening criteria
3. Morbidity and mortality of the disease should be high
Factors other than the type of the disease affecting
morbidity and mortality:
- Age
- Sex
- Race
- Geographical area
- Life style (culture)
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Mortality according to age groups
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•
•
•
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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
Effective screening criteria
4. There should be an acceptable treatment
No sense to screen 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
The same cancer but less aggressive
Beginning
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2 year
Symptoms
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)
• I 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
Any Guidelines for KSA?
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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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PHE Suggestions
 Osteoporosis
 The AAFP recommends routinely screening women aged 65 and older
for osteoporosis.
 Prostate Cancer
 The AAFP concludes that there is insufficient evidence on which to
make a recommendation for or against routine screening for prostate
cancer using prostate specific antigen (PSA) testing or digital rectal
examination (DRE).
 Second Hand Smoke
 The AAFP strongly recommends to counsel smoking parents with
children in the house regarding the harmful effects of smoking and
children’s health.
 Tobacco Use
 The AAFP strongly recommends that clinicians screen all adults for
tobacco use and provide tobacco cessation interventions for those who
use tobacco products.
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PHE Suggestions
• Visual Impairment
– The AAFP recommends screening to detect amblyopia, strabismus, and
defects in visual acuity in children younger than age 5 years.
• Visual Difficulties
– The AAFP recommends screening for visual difficulties in elderly
adults by performing snellen acuity testing.
 Vitamin Supplementation
 The AAFP concludes that the evidence is insufficient to recommend for
or against the use of supplements of vitamins A, C, or E; multivitamins
with folic acid; or antioxidant combinations for the prevention of
cancer or cardiovascular disease.
(AAFP, August 2005) www.aafp.org
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Summary
Which is not a method for PHE?
a) Counseling
b) Immunization
c) Physical exam
d) Prescription
e) Home visit
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Which is not a criteria for PHE?
a) The disease having a asymptomatic period
b) The disease having an acceptable treatment
c) The disease having low morbidity and mortality
d) The prevalence of the disease is high
e) There are risk factors or tests for early diagnosis
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Which one is a correct PHE according to
AAFP?
a) ECG to screen heart diseases
b) CBC to sreen blood diseases
c) Chest x-ray for screening purposes
d) Weight and height measurement for children
e) Performing a check-up every year to healthy
individuals
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Persons above 65 y. Should have influenza immunizations every year
a) True b) False
The adverse effects of passive smoking to children should be explained
to smoking parents at every visit
a) True b) False
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