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Back to Basics 2017

Preventive Medicine and


the
Periodic Health
Examination
Dr. Jennifer LeMessurier, MPH, MD
PGY-4 Public Health and Preventive Medicine Resident
School of Epidemiology and Public Health
University of Ottawa
Acknowledgements
This material was developed based
on previous presentations by Dr.
Laura Bourns and Dr. Trevor Arnason
Overview
MCC Objectives
Preventive Medicine
The Periodic Health Examination
Resources for the PHE
Population approach to the PHE
Selected conditions recommendations for
screening

Quick practice questions


Preventive Medicine
Preventive Medicine is the specialty of medical
practice that focuses on the health of individuals,
communities, and defined populations. Its goal is
to protect, promote, and maintain health and
well-being and to prevent disease, disability, and
death.

-American Board of Preventive Medicine

4
Source: Statistics Canada, 2012. CIHI infographics available from:
https://yourhealthsystem.cihi.ca/hsp/inbrief?lang=en#!/indicators/012/avoidable-deaths/;mapC1;mapLevel2;/
MCC Objectives -
Prevention
General Objectives:

Health Promotion And Maintenance

Formulate preventive measures into management


strategies.

Communicate with the patient, the patient's family and


concerned others with regard to risk factors and their
modification where appropriate.

Describe programs for the promotion of health


including screening for, and the prevention of, illness.
MCC Objectives Prevention
(Population Health: 78-3)
Key Objectives
Understand the three levels of prevention (primary, secondary and tertiary).
Appreciate the role that physicians can play in promoting health and
preventing diseases at the individual and community level (e.g. prevention of
low birth weight, immunization, obesity prevention, smoking cessation, cancer
screening, etc.).

Enabling Objectives
Be able to both define the concept of levels of prevention at the individual
(clinical) and population levels, as well as formulatepreventivemeasures
into their clinical management strategies.
Be able to describe the health impact of community-level interventions to
promote health and prevent disease.
Apply the principles of screening and be able to evaluate the utility of a
proposed screening intervention, including being able to discuss the potential
for lead-time bias and length-prevalence bias.
Levels of prevention
Primary preventiona condition is prevented
before it develops by addressing its risk or
protective factors.
Secondary preventionearly detection or
intervention to identify a disease and delay the
progression of an early or preclinical disease and
minimize disability.
Tertiary preventioninterventions that lessen the
impact of disability from fully developed disease
through eliminating, reducing or managing
impairments.
Periodic Health
Examination
History, risk assessment, and a tailored
physical examination that could lead to
delivery of preventive services
Review a patients ongoing medical issues
Counsel for preventive health issues
Improve physician patient relationship

9
MCC Objectives
Periodic Health Exam (74)
Key Objectives
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
Perform an appropriate history and physical examination based on the
patient's age, sex, and background;
List and interpret appropriate investigations, including:
o 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);
Construct an effective initial management plan, including:
o Communicate effectively with the patient to reach common ground
regarding goals related to disease prevention and risk reduction;
o Recommend proven prevention strategies (e.g., smoking
cessation, regular exercise);
o Incorporate the periodic health examination principles in the care of
a patient with a chronic disease.
Structure of the PHE
Get diagnostic problems out of the way!

History
Physical Exam
Lab tests, diagnostic imaging (screening tests)
Immunizations
Counselling
Other medications/interventions
Approach screening cautiously
Screening seems easy, but is a controversial area
of medicine with an ever-evolving evidence-base

No single source of recommendations multiple


organizations produce guidelines, sometimes on
same topics (even in Canada)

Recommendations frequently changing with new


information, research and innovation

Industry and government funding may influence


screening and other prevention practices
Approach screening cautiously
Benefits of screening practices may be over-
estimated

Harms of screening practices may be under-


appreciated

Screening benefits at a population level may not


translate to benefits for different sub-populations or
individuals

Not always clear when patients are asymptomatic


Need to consider competing risks, which can be
challenging to navigate
Approach to screening or
case finding
1. What is the population?
2. What outcomes are common in this
population?
3. What interventions are available to
prevent the outcomes?
4. What is the available evidence to
support the intervention in this
population to prevent the outcome(s)?
Periodic Health
Examination
The periodic health examination
(PHE) represents an opportunity
for the prevention or early
detection of health-related
problems.
The nature of the examination will
vary depending on the age, sex,
occupation, and cultural
background of the patient.

15
Conditions to consider based
on patient age
Some things are good for
almost everybody!
All ages
Injury prevention (e.g., noise control,
seat belts, bicycle helmets)
Lifestyle modification (e.g., physical
activity, smoking prevention/cessation,
sun exposure)
Immunization
For the MCCQE
Focus on the simple stuff i.e. things that apply to
everyone

Controversial topics are less likely to be emphasized


MCCQE is a national exam, so provincial
recommendations are not the focus

Recommend proven prevention strategies


Smoking Cessation
Regular Exercise
Nutrition
Alcohol moderation
PHE Resources

http://canadiantaskforce.ca/
Targeted and evidence based
Summary of recommendations for
clinicians and policy-makers
Grading of recommendation and evidence
as strong, moderate or weak

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PHE Resources
National Advisory Committee on
Immunizations (NACI)
http://www.phac-aspc.gc.ca/naci-ccni/
Advisory committee of experts in the fields of
pediatrics, infectious diseases, immunology,
medical microbiology, internal medicine and
public health.
Makes recommendations for the use of vaccines
currently or newly approved for use in humans in
Canada, including the identification of groups at
risk for vaccine-preventable diseases for whom
vaccination should be targeted.

20
PHE Resources
CFPC Preventative Care Checklist Forms
(last updated in February 2015)
http://www.cfpc.ca/projectassets/templates/reso
urce.aspx?id=1184&langType=4105

21
PHE Resources

http://www.rourkebabyrecord.ca/
The Rourke Baby Record is a system that many Canadian
doctors and other healthcare professionals use for well-baby
and well-child visits for infants and children from 1 week to 5
years of age.
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PHE Resources
Greig Health Record
http://www.cps.ca/tools-outils/greig-health-record
The Greig Health Record, published in 2010 and
updated in 2016, is an evidence-based health
promotion guide for clinicians caring for children and
adolescents aged 6 to 17 years.
Checklist templates include sections for growth and
weight; psychosocial history and development;
nutrition; physical activity and sedentary behaviour;
sleep; injury prevention; abuse; the physical exam;
immunization; and other specific concerns.
Population Infants
Get diagnostic problems out of the way!
History pregnancy, birth, breastfeeding, vision,
hearing, development, abuse/neglect
Physical Exam growth charts, developmental
milestones, eyes (e.g., cover/uncover), hips
Lab tests, diagnostic imaging (screening tests)
hemoglobin if at risk for hemoglobinopathy
Immunizations lots, annual flu (>6mos)
Counselling car seat, sleep position, crib, poisons,
firearms, smoke/CO alarms, dental health, nutrition,
passive smoke
Other meds/interventions Vitamin D 400 IU/day,
home visit
Populations Children
Get diagnostic problems out of the way!
History pregnancy, birth, vision, hearing,
development, abuse/neglect, school readiness
Physical Exam growth charts, developmental
milestones, eyes
Lab tests, diagnostic imaging (screening
tests) - none
Immunizations lots, annual flu (>6mos)
Counselling car seat/ seatbelts, bike helmets,
hearing protection, poisons, firearms, smoke/CO
alarms, dental health, nutrition, passive smoke, no
OTC cough cold/medicines
Other meds/interventions dentist
Populations Adolescents
Get diagnostic problems out of the way!
History HEADSS, diet
Physical Exam growth charts, sexual maturity
Lab tests, diagnostic imaging (screening tests) sexually
transmitted infections
Immunizations DTaP, missed childhood, HPV, Hep B,
annual flu
Counselling seatbelts, bike helmets, hearing protection,
dental health, nutrition, alcohol, smoking, other drugs,
occupational exposures, sun exposure
Other meds/interventions Vitamin D, dentist

*HEADSS - Home, Education, Employment, Activities, Drugs, Sexuality,


Suicide/Depression
Populations Young Adult
History HEADDS, diet
Physical Exam Wt (BMI), BP, eyes, ears
Lab tests, diagnostic imaging (screening tests)
STBBI screening
(Chlamydia/Gonorrhea/Syphilis/HCV/HBV/HIV), Pap
smear, HbA1c if at risk
Immunizations DTaP, HPV, Hep B, annual flu
Counselling seatbelts, bike helmets, hearing
protection, dental health, nutrition, alcohol, smoking,
other drugs, occupational exposures, sun exposure
Other meds/interventions folic acid, Vitamin D,
dentist
Populations Middle Aged
Adult
History Psychological, social and physical
functioning, nutrition, physical activity, alcohol,
smoking,
Physical Exam Wt (BMI), BP, eyes, ears
Lab tests, diagnostic imaging (screening tests)
Blood glucose, lipid profile, osteoporosis, breast
cancer, lung cancer (smokers), colon cancer
Immunizations DTaP, annual flu
Counselling seatbelts, bike helmets, hearing
protection, dental health, nutrition, alcohol, smoking,
other drugs, occupational exposures, sun exposure
Other meds/interventions Vitamin D, dentist
Populations Older Adult
History Psychological, social and physical functioning,
nutrition, physical activity, alcohol, smoking, fracture
and fall prevention, dementia screening, elder abuse
Physical Exam Wt (BMI), BP, eyes (Snellen), ears
Lab tests, diagnostic imaging (screening tests)
Blood glucose, lipid profile, osteoporosis, breast,
cervical, colon, lung, AAA
Immunizations DTaP, annual flu, pneumococcal, HZV
Counselling seatbelts, bike helmets, hearing
protection, dental health, nutrition, alcohol, smoking,
other drugs, occupational exposures, sun exposure
Other meds/interventions Vitamin D, dentist
Common themes
History nutrition, physical activity, substances
(smoking/EtOH)

Physical Exam Wt (BMI), BP, eyes, ears

Lab tests, diagnostic imaging (screening tests)


nothing

Immunizations routine and annual flu

Counselling injury prevention (e.g. seatbelts, bike helmets),


dental health, nutrition, substances, sun exposure

Other meds/interventions Vitamin D, dentist


Ahwhat if I cant remember
all this on exam day?
Recommend proven prevention
strategies
Smoking Cessation
Regular Exercise
Nutrition
Alcohol moderation
Stress reduction
Generally not used for
screening (asymptomatic)
TSH
CBC
Electrolytes, Cr
Vitamin B12, Vitamin D
ALP
ECG
CXR
Urinalysis
Choosing Wisely Canada
Eleven Things Physicians and Patients
Should Question
1. Dont do imaging for lower-back pain unless red flags are present.
2. Dont use antibiotics for upper respiratory infections that are likely viral in origin,
such as influenza-like illness, or self-limiting, such as sinus infections of less than
seven days of duration.
3. Dont order screening chest X-rays and ECGs for asymptomatic or low risk
outpatients.
4. Dont screen women with Pap smears if under 21 years of age or over 69
years of age.
5. Dont do annual screening blood tests unless directly indicated by the risk
profile of the patient.
6. Dont routinely measure Vitamin D in low risk adults.
7. Dont routinely do screening mammography for average risk women aged
40 49. Individual assessment of each womans preferences and risk should guide
the discussion and decision regarding mammography screening in this age group.
8. Dont do annual physical exams on asymptomatic adults with no significant
risk factors.
9. Dont order DEXA (Dual-Energy X-ray Absorptiometry) screening for
osteoporosis on low risk patients.
10.Dont advise non-insulin requiring diabetics to routinely self-monitor blood sugars
between office visits.
11.Dont order thyroid function tests in asymptomatic patients.

http://www.choosingwiselycanada.org/recommendations/family-medicine/
Condition Specific
Screening
Recommendations
Osteoporosis

Quick Reference Guide: 2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in
Canada. Available from: http://www.osteoporosis.ca/multimedia/pdf/Quick_Reference_Guide_October_2010.pdf
Hypertension
Prevalence: HTN in 19% of Canadian adults; prevalence
increases with age, comorbidities

Population: Adults 18+ without previous diagnosis of HTN


Intervention: Blood pressure measurement
Recommendation:
Assess blood pressure in adults at all appropriate visits
Measure BP according to Canadian Hypertension
Education Program (CHEP) recommendations, updated
annually
Apply CHEP criteria for assessment and diagnosis of
hypertension
Type II Diabetes
Prevalence: Diabetes in those aged 20+ years is 9.6%
(CCDSS, 2010-2011)

Population: Adults 40 years of age if at risk (earlier with


additional risk factors)

Intervention: HbA1C (or fasting plasma glucose)


Recommendation (Diabetes Canada, 2013 CPG):
Screenevery 3 yearsin individuals 40 years of age if at
risk
Screenevery 3 years in individuals at high risk according to
the CANRISK calculator
Screenearlier and/or more frequentlyin people with
additional risk factors for diabetes
Type II Diabetes
Category Low to High Risk Very high risk
Moderate Risk
Level of Risk Low: 1-4% 33% 50%
(10 year risk of Moderate: 17%
diabetes)
Routine No q3-5 years Annually
Screening
Recommended?

Rationale No evidence of Evidence for Evidence for


improved MI rates DM
outcomes complications &
Cost vs. death
annual
screening
Cancer screening
There are really only 3 cancer screening programs
that you should think about:
Cervical
Colorectal
Breast
Slightly different programs in each province, so follow
CTFPHC wherever possible
Other screening tests may be done in specific
circumstances, but are generally not clearly beneficial
as population wide screening programs (e.g. lung)
Cervical Cancer
Incidence increases significantly after age 25
peaking in 5th decade
Population: Asymptomatic women; have been
or are sexually active
Intervention: Screening with cervical cytology
(pap smear)
Recommendation: Screen women 25 with a
pap test q3years until age 70
Cervical Cancer
Recommendations for cervical cancer screening
(CTFPHC, 2013)
Age Recommendation Rationale
(yrs)
Very low incidence/mortality
<20 No routine screening
Evidence of harm
Uncertain benefit of
20-24 No routine screening
screening, high false positives
Small benefit of screening,
25-29 Routine screening q3years increasing cancer incidence
and mortality in age group
Evidence of effectiveness of
30-69 Routine screening q3years
screening
If not adequately screened,
No screening if 3
recommend screening every
70 successive negative Pap
3 years until 3 successive
tests in last 10 years
Breast Cancer
1 in 9 females will develop breast cancer in their lifetime
(incidence and case-fatality rates increase with age)

Population for routine screening:


Age 50-74
No personal or family history of breast cancer
No known BRCA1 or 2 mutation
No previous chest wall radiation
Intervention: Mammography
Recommendation: Screen women 50 with a mammogram
q2-3years until age 74.
*Clinical Breast Exam remains appropriate when women present with, or physicians have
concerns about, abnormal breast changes (i.e. not used for routine screening).
Breast Cancer
Recommendations for breast cancer screening (CTFPHC,
2011)
Age 40-49 50-69 70-74
Routine No q2-3years q2-3years
Screening
Recommended?
Rationale Lower likelihood 720 women 450 women
of breast cancer would need to would need to
be screened q2- be screened q2-
Greater 3 yrs to save 1 3 yrs to save 1
likelihood of life life
Certain ethnic groups
falsehave higher (Ashkenazi Jews) and lower rates (East
positive
Asians)
Benefit of screening uncertain for those with life expectancy shortened
by comorbid conditions
CTFPHC offers patient FAQs and guides to benefits and risks of screening
Colorectal cancer
Second most common cause of cancer mortality in men and the third
most common in women; incidence and mortality low until middle
age, rising thereafter.

Population for routine screening:


Adults aged 50-74
If no previous CRC or polyps, inflammatory bowel disease, signs
or symptoms of CRC, history of CRC in one or more first degree
relatives, or adults with hereditary syndromes predisposing to
CRC (e.g. familial adenomatous polyposis, Lynch Syndrome).

Interventions: guaiac fecal occult blood test, fecal immunochemical


test, flexible sigmoidoscopy (but not colonoscopy)

Recommendation: Screen adults aged 50 with FOBT (either gFOBT


or FIT) q2years OR flexible sigmoidoscopy q10years until age 74.
Practice Questions
Remember youll have multiple choice AND fill in the blank!
A primary care physician recommends an
exercise rehabilitation program to a patient
who recently suffered a myocardial infarction. This
is meant to prevent worsening of the patients
ischemic heartprevention
a) Primordial disease. What level of prevention
does this represent?
b) Primary prevention
c) Secondary prevention
d) Tertiary prevention
e) There is no more prevention to do, this person
already has disease.
A 20 year-old female patient visits your family
medicine clinic for a check-up because her
mother told her she needed to get a Pap test
annually once she became an adult and she never
did. She has been sexually active for
approximately 2 years.

List two important prevention issues with respect


to this patients sexual health that you should
A 55 year-old asymptomatic, male patient comes
to your office because he is concerned about
developing chronic disease. His golfing buddies all
have to take a bunch of pills he thinks he should
probably be doing the same. He has not seen a
healthcare provider in 20 years.

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