PERIODIC HEALTH EXAMINATION AND SCREENING Janice Ann Paras MD 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 Aware of the importance of PHE and preventive medicine in primary care. Periodic Health Examination Evaluation of apparently healthy individuals in certain time periods, using a number of standard procedures such as history, physical examination, counseling, immunization, and laboratory investigations is called Periodic Health Examination The goal of periodic health examinations of asymptomatic adults is to reduce morbidity and mortality by identifying modifiable risk factors and early diagnosis of treatable disease. What are primary care physicians doing? Health Care Health promotion Risk prevention Primary Prevention Risk reduction Early diagnosis Secondary Prevention Personal Preventive Medicine! 5 Complication reduction Tertiary Prevention Iceberg phenomenon of disease Iceberg phenomenon of disease gives a picture of the spectrum of diseases in a community. The visible part of the iceberg denotes the clinically apparent cases of disease in the community. The part of the iceberg below the water level denoted the latent, subclinical, undiagnosed and carrier states in the community, which forms the major part Levels of health promotion and prevention Primary prevention: measures that reduces the chance that a disease will develop in a person. example vaccination against infectious diseases. • Secondary prevention: measures that lead to Identifying presymptomatic disease (or disease risk factors) before significant damage is occure e.g. screening. • Tertiary prevention: measures that limit the progress and disability from disease e.g. treatment and rehabilitation (speech therapy following CVA) Reasons of diseases (%) 50 45 40 35 30 25 20 15 10 5 0 Access 10 Genetic Environment Behaviour Insurance companies: “Mortality decreases in persons undergoing regular health checks!” 11 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) 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. 12 The natural course of diseases 13 Aggressive cancer Beginning 6 mo Symptoms 1 year DEATH Screening once a year The same cancer but less aggressive Beginning 2 year Symptoms 4 year DEATH How is PHE performed? • Healthy individuals • Counseling • Immunization • Home visit • Prophylaxis • Physical exam • Laboratory test Screening Screening is defined as identification of undiagnosed disease in an apparently healthy, asymptomatic population by means of tests, examinations or other procedures that can be applied rapidly and easily to the target population. Example of conditions that commonly screen for: breast cancer and cervical cancer in women, colorectal cancer, diabetes, dyslipidemia, osteoporosis, hypertension….etc. Criteria of screening test Wilson's criteria for screening test: > 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. > 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 whom to treat. > The total cost of finding a case should be economically balanced in relation to medical expenditure as a whole. Types of Screening • Mass Screening : Screening the whole population. e.g. Hypertension, diabetes .. .etc • Multiple or Multiphase Screening. Using multiple screening tests at the same time as in Parallel & Series. • Targeted Screening : Screening of groups with specific exposures (e.g. lead factory workers should be checked for the level of lead in blood). • Case-Finding (Opportunistic Screening): Screening of patients who consult a health facility for other purposes e.g. DM, dyslipidemia…. Components of periodic health examination Visit(RISE) • Identify the Risk factors for serious medical conditions while taking the medical history and performing the physical examination. • Provide recommended Immunizations and Chemoprophylaxis as needed. • Order the appropriate Screening tests adequate to age and gender • Educate patients about healthy lifestyle behaviors Obesity Screen all adults aged 18 or older for obesity using BMI. Body mass index (BMI) is calculated from the measured weight and height of an individual. BMI= weight (kg)/height (m2) Underweight : BMI < 18.5 Normal weight: BMI 18.5-24.9. Overweight: BMI 25-29.9. Obesity: BMI = 30 and more. BMI Based on Asia-Pacific Obesity Guidelines: Underweight Healthy Overweight Obese I Obese II < 18.5 kg/m2 18.6-22.9 23.0-24.9 25.0-29.9 > 30 Philippine Association for the Study of Overweight and Obesity (PASOO) Blood Pressure Screen all adults for high blood pressure . Hypertension is usually defined as Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥ 90 mmHg. The Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) recommends screening every 2 years those with BP <120/80 and screening every year those with SBP of 120-139 mmHg or DBP of 80-90 mmHg. AHA guidelines 2017 Immunization and chemoprophylaxis Pneumococcal Vaccine Pneumococcal vaccine is recommended once for all adults aged 65 years or older. Pneumococcal vaccine is also recommended to adults aged 19-64 years who: • Have chronic heart disease • Have chronic lung disease • Are alcoholic • Have chronic liver disease • Have DM • Are smokers Tetanus & FLU Vaccine For all adults more than 19 years, tetanus toxoid and reduced diphtheria toxoid (Td) should be administered every 10 years. Flu Vaccine Annual influenza vaccination is strongly encouraged for all adults. Vaccination is particularly important for people who are at high risk for serious flu complications from influenza: • Adults 65 years old and more. • Chronic diseases (IHD, heart failure, stroke, chronic liver diseases, chronic kidney disease, asthma etc….). • HIV • Cancer patients. • Pregnant women Folic Acid Supplementation Give (400 to 800 μg) of folic acid to all Women planning a pregnancy or capable of becoming pregnant. Start supplementation at least 1 month before conception continue through first 2-3 months of pregnancy. Women with risk factors are advise to take higher dose of folic acid. These risk factors include personal or family history of a pregnancy affected by a neural tube defect, the use of certain anti-seizure medications, mutations in folate related enzymes, maternal diabetes, and maternal obesity. Screening tests Screening for Dyslipidemia Us Preventive Service Task Forces (USPSTF) recommendations Screen all men age 35 years and older , and men age 2035 years who are at increased risk for CHD Screen women age 45 years and women age 20-45 years who are at increased risk for CHD Risk factors for CHD include • DM • Previous CHD or atherosclerosis • Family history of cardiovascular disease • Smoking • HTN • Obesity (body mass index ≥30 kg/m2) Screening for Diabetes Mellitus The American Diabetes Association (ADA) recommends screening all adults for diabetes every three years starting at 45 years of age using fasting plasma glucose (FPG), 2-hour post prandial plasma, or Hb A1C. Adults of any age who are overweight or obese (BMI 25 kg/m2) and who have one or more additional risk factors for diabetes should also be screened. Additional risk factors for DM includes: • Family history diabetes mellitus in a first-degree relative • Physical inactivity Additional risk factors for DM • History of delivering a baby weighing >4.1 kg (9 lb) or of gestational diabetes mellitus • Hypertension (blood pressure ≥140/90 mmHg) • Dyslipidemia defined as a HDL cholesterol ≤35 mg/dL(0.9 mmol/L) and/or a serum triglyceride (TG) concentration ≥250 mg/dL (2.8 mmol/L) • Previously identified HbA1C ≥5.7 percent, impaired glucose tolerance or impaired fasting glucose (IFG) • Polycystic ovary syndrome • History of vascular disease Screening for Abdominal Aortic Aneurysm Screen all men aged 65 to 75 years who have ever smoker (life-time of 100 cigarettes) for abdominal aortic aneurysm Screen using abdominal ultrasound One-time screening is sufficient Screening for Osteoporosis USPSTF Recommendations Women 65 years and older should be screened for osteoporosis. Screening test DEXA scan Screening for Colorectal Cancer Screen all patients aging between 50-75 years for colon cancer using colonoscopy, rigid sigmoidoscopy or highly sensitive fecal occult blood testing FOBT Screening intervals • Annual screening with high-sensitivity fecal occult blood testing (FOB) Screening for Colorectal Cancer • Sigmoidoscopy every 5 years. • Screening colonoscopy every 10 years Patients who have family history of colorectal cancer before the age of 60 years are advised to start screening at age of 40, or 10 years before the youngest case in the immediate family; which one is earlier . Repeat colonoscopy every 5 years. Screening for Breast Cancer USPSTF recommendations • Screen using mammography • The USPSTF recommends screening females aged 50-79 years every two years. • The decision to start screening mammography in women prior to age 50 years should be an individual one. Women who place a higher value on the potential benefit than the potential harms may choose to begin biennial (every two years) screening between the ages of 40 and 49 years Screening for Cervical Cancer USPSTF recommends screening for cervical cancer every 3 years with cervical cytology alone in women aged 21 to 29 years. For women aged 30 to 65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (cotesting).. Risk Factors for Cervical Cancer: • HPV (the major risk factor) • HIV infection • Immune deficiency • Smoking • Previous treatment of a high-grade precancerous lesion or cervical cancer Screening for Prostate Cancer The USPSTF recommends against using prostatespecific antigen (PSA) for prostate cancer screening. For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)– based screening for prostate cancer should be an individual one. DRE (Digital Rectal Examination) Thank you!