Periodic Health Examinations in Primary Care

1. Periodic Health Examinations in Primary Care

2. 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 count non-evidence based check up activities of daily life • Aware of the importance of PHE and preventive medicine in primary care. / 35

3. 1 Diseased, diagnosed & controlled 2 Diagnosed, uncontrolled 3 Undiagnosed or wrongly diagnosed disease 4 Risk factors for disease 5 Free of risk factors Diagnosed disease Undiagnosed or wrongly diagnosed disease Iceberg phenomenon ?

4. What are PHC physicians doing? Tertiary Prevention Primary Prevention Secondary Prevention Personal Preventive Medicine! / 36

5. The High mortality diseases in Saudi Arabia • 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

6. 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. / 35

7. 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 / 35

8. 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.

9. 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.

10. Effective screening criteria 1. Disease Has Serious Consequences Screening should target diseases with serious consequences suchas mortality or severe or prolonged morbidity Both pulmonary and colorectal cancer are serious diseases, beingthe first and second leading causes of cancer death in the UnitedStates , respectively. Breast cancer is the second leadingcause of cancer death in women. Thus, all three cancers haveserious consequences. / 35

11. 2. Screening Population Has High Prevalence of Detectable Preclinical Phase • The detectable preclinicalphase of the disease should have a high prevalence among peoplewho are screened • Preclinical phase is the time from the onset of diseaseto the first appearance of signs and symptoms • Dependson the population's awareness of the disease and the patient'saccess to health care • The preclinical phase is the intervalof time when the disease is detectable by the screening test.

12. 2. Screening Population Has High Prevalence of Detectable Preclinical Phase • if the prevalence is 1% and the test's sensitivityand specificity are both 95%, then the probability of disease afterpositive test results is only 16%. • In contrast, if the prevalenceis 5%, then the probability of disease after positive test resultsis 50%.

13. 3. Screening Test Detects Little Pseudodisease Two types of pseudodiseasehave been described:. -TypeI pseudodisease the disease never progressesand, in fact, may regress naturally. -Type II pseudodisease,the disease progresses so slowly that the patient never developssymptoms and dies from another cause. -Type II pseudodiseaseis common in diseases with long detectable preclinical phasesor among patients with short life expectancies -Both types undergo unnecessary tests and treatmentbut derive no benefit from the treatment. - Screening tests that detecta high frequency of pseudodisease cannot be cost-effective.

14. 3. Screening Test Detects Little Pseudodisease • With colorectal cancer, not all adenomatous polyps progressto invasive carcinoma. Evidence shows that many small (<1cm) polyps regress [15]. The rate of adenomatous polyps progressingto cancer has been estimated at about 2.5 polyps per 1000 individualsper year • Not all breast ductal carcinoma in situ progressesto invasive carcinoma • The presenceof pseudodisease in screening for both colorectal polyps andbreast cancer limits the effectiveness of these screening programs

15. 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 increasethe cost-effectiveness of screening. • It is not alwayscost-effective to increase a screening test's sensitivity. • An increase in sensitivity might mean an increase in the detectionof pseudodisease or an increase in the detection of diseaseafter the critical point in the natural history (i.e., afterthe primary tumor metastasizes). • Both these situations are detrimental toscreening.

16. 5. Screening Test Detects Disease Before Critical Point • For most diseases, a critical point occurs in the natural historyof the disease; treatment is more effective before this pointand 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 preclinicalphase, then screening cannot be effective. • CT can detect stageI pulmonary cancer is asymptomatic people.

17. 6. Screening Test Causes Little Morbidity • The screening test must not inflict mortality or significantmorbidity on those screened. • For pulmonary cancer screening, the CT study is performed withoutIV contrast material, so short-term toxicity is not a problem. • For breast cancer screening, the short-term effect is patientdiscomfort.

18. 7. Screening Test Is Affordable and Available • The diagnostic test must be affordable and available to thetarget population.

19. 8. Treatment Exists • An effective treatment for the disease must exist for screeningto improve patient outcomes. • Detection of disease alone is notcost-effective. This may seem a trite criterion for screening,but it is important because many common diseases (e.g., Parkinson'sdisease, 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

20. 9. Treatment Is More Effective When Applied Before Symptoms Begin • For screening to be cost-effective, treatment must be more effectiveor less toxic when applied during the detectable preclinicalphase, as compared with treatment applied after symptoms begin

21. 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 casesor many cases of pseudodisease undergo treatment; • these patientsderive no benefit from treatment, only its side effects.

22. Types of screening • Mass • Targeted • Multiple or Multiphasic • Case-finding or opportunistic

23. How is PHE performed? • Healthy individuals • Counseling • Immunization • Home visit • Prophylaxis • Physical exam • Laboratory test / 35

24. Any Guidelines for KSA? / 35

25. 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

26. 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. / 35

27. 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 electron-beam 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. / 35

28. 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. / 35

29. 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. / 35

30. 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. / 35

31. Thank you