1. Periodic Health Examinations in Primary Care

2. / 352 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.

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

4. / 36 4 What are PHC physicians doing? Health Care Health promotion Risk prevention Risk reduction Early diagnosis Complication reduction Personal Preventive Medicine! Primary Prevention Secondary Prevention Tertiary Prevention

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. / 356 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.

7. / 357 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

8. 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. 9

10. / 3510 Effective screening criteria 1. Disease Has Serious Consequences Screening should target diseases with serious consequences such as mortality or severe or prolonged morbidity Both pulmonary and colorectal cancer are serious diseases, being the first and second leading causes of cancer death in the United States, respectively. Breast cancer is the second leading cause of cancer death in women. Thus, all three cancers have serious consequences.

11. 2. Screening Population Has High Prevalence of Detectable Preclinical Phase The detectable preclinical phase of the disease should have a high prevalence among people who are screened Preclinical phase is the time from the onset of disease to the first appearance of signs and symptoms Depends on the population's awareness of the disease and the patient's access to health care The preclinical phase is the interval of 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 sensitivity and specificity are both 95%, then the probability of disease after positive test results is only 16%. In contrast, if the prevalence is 5%, then the probability of disease after positive test results is 50%.

13. 3. Screening Test Detects Little Pseudodisease Two types of pseudodisease have been described:. -Type I pseudodisease the disease never progresses and, in fact, may regress naturally. -Type II pseudodisease, the disease progresses so slowly that the patient never develops symptoms and dies from another cause. -Type II pseudodisease is common in diseases with long detectable preclinical phases or among patients with short life expectancies -Both types undergo unnecessary tests and treatment but derive no benefit from the treatment. - Screening tests that detect a high frequency of pseudodisease cannot be cost-effective.

14. 3. Screening Test Detects Little Pseudodisease With colorectal cancer, not all adenomatous polyps progress to invasive carcinoma. Evidence shows that many small (<1 cm) polyps regress [15]. The rate of adenomatous polyps progressing to cancer has been estimated at about 2.5 polyps per 1000 individuals per year15 Not all breast ductal carcinoma in situ progresses to invasive carcinoma The presence of pseudodisease in screening for both colorectal polyps and breast 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 increase the cost-effectiveness of screening. It is not always cost-effective to increase a screening test's sensitivity. An increase in sensitivity might mean an increase in the detection of pseudodisease or an increase in the detection of disease after the critical point in the natural history (i.e., after the primary tumor metastasizes). Both these situations are detrimental to screening.

16. 5. Screening Test Detects Disease Before Critical Point For most diseases, a critical point occurs in the natural history of the disease; treatment is more effective before this point and 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 preclinical phase, then screening cannot be effective. CT can detect stage I pulmonary cancer is asymptomatic people.

17. 6. Screening Test Causes Little Morbidity The screening test must not inflict mortality or significant morbidity on those screened. For pulmonary cancer screening, the CT study is performed without IV contrast material, so short-term toxicity is not a problem. For breast cancer screening, the short-term effect is patient discomfort.

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

19. 8. Treatment Exists An effective treatment for the disease must exist for screening to improve patient outcomes. Detection of disease alone is not cost-effective. This may seem a trite criterion for screening, but it is important because many common diseases (e.g., Parkinson's disease, 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 effective or less toxic when applied during the detectable preclinical phase, 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 cases or many cases of pseudodisease undergo treatment; these patients derive no benefit from treatment, only its side effects.

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

23. / 3523 How is PHE performed? Healthy individuals Counseling Immunization Home visit Prophylaxis Physical exam Laboratory test

24. / 3524 Any Guidelines for KSA?

25. 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. / 3526 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.

27. / 3527 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.

28. / 3528 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.

29. / 3529 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.

30. / 3530 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.

31. Thank you