1/27/2015 To Do or Not To Do? The Annual Physical- Beyond The PAP And Breast Exam Fleur Sack, M.D., FAAFP Society of General Internal Medicine Cochrane review of 182,000 people followed for 9 years : the annual exam did not reduce overall mortality. It did consume billions of dollars. Ezekial Emanuel: New York Times January 8, 2015 From a health perspective the annual exam is basically worthless. Not having one will help reduce health care costs and save time, worry and a worthless exam. American Academy of Family Physicians Recommendations. Annual physical exam should include: Don t perform routine general health checks for asymptomatic adults- not been shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing. For a healthy male 18-65 : BP measurement For a healthy female 18-65 : BP measurement and periodic PAP smear Screening and counseling for drug, alcohol and nicotine abuse, depression and risky behaviors. Vaccinations. Screening tests. Necessary Screening USPSTF Measure blood pressure Screen for obesity Screen for depression (PHQ-9) Screen for alcohol misuse (CAGE) Screen for tobacco use Screen women of childbearing age for intimate partner violence Screening Labs Lipids: Men: older than 35 age Women: older than 45 Older than 20 if have CVD risk factors Diabetes in asymptomatic adults if BP >130/80 Hepatitis C: Persons at high risk and one-time screening for adults born between 1945-1965 Syphilis, HIV, Hep.B for those at high risk 1
Screening Tests DEXA in women older than 65 ( younger if risk factors) Colorectal cancer age 50-75 Abdominal aortic aneurysm in men 65-75 who have ever smoked Periodic Mammogram and PAP smears MEDICARE Annual Wellness Exam No co-payment or deductible Welcome to Medicare: Includes an EKG (CPT G0402) Annual wellness visit : Initial (CPT G0438) Annual wellness visit : Subsequent ( G0439) What is covered? Measurement height, weight, BP and BMI. Review medical and family history. Establish list of current providers, suppliers, medications. Personal risk assessment (Including mental health conditions) Review of functional ability and level of safety. (assessment of ADL and risk of falls) Detection of cognitive impairment FALLS One out of three older adults falls each year- less than half talk to their healthcare providers about it. Among older adults, falls are the leading cause of both fatal and nonfatal injuries. In 2013, 2.5 million nonfatal falls among older adults were treated in emergency departments and more than 734,000 of these patients were hospitalized. In 2012, the direct medical costs of falls were $30 billion. Those at risk of falls should Exercise regularly Have both prescription and OTC medications reviewed Have their eyes checked Make their homes safer by reducing tripping hazards, adding grab bars inside and outside the tub or shower and next to the toilet, adding railings on both sides of stairways, and improving the lighting in their homes. Matter of Balance Workshops Fall prevention community based program that provides the participants with a group of strategies that reduce the fear of falling and increase activity level. Contact Martha Pelaez at 305-804- 9767 or call 1-855-855-4273. 2
Hypertension Hypertension is the most common condition seen in primary care and leads to MI, stroke, renal failure and death if not properly managed. December 2013: JNC 8 Guidelines Higher blood pressure goals, less use of several antihypertensive medications 3 questions At what BP level should pharmacological agents be initiated? To what end-point is the goal of treatment? Which drugs should be used? A guide to the JNC 8 guidelines Compared with JNC 7 guidelines: Higher blood pressure goals. In patients older than 60 who do not have diabetes or CKD the goal BP is <150/90 In patients 18-59 without major comorbidities <140/90 In patients >60 with CKD, diabetes or both the goal is <140/90 JNC 8 : Limited class of drugs First and later-line treatments should be limited to the following classes thiazide diuretics, CCBs, ACEIs and ARBs. In Black population don t use ACEIs or ARBs if no CKD. Second and third line alternatives include higher dosages or combinations of above. Rest are designated as later line alternatives, including B-blockers, alpha blockers, loop diuretics. ACEIs or ARBs recommended in ALL patients with CKD. Points to consider The 140/90 definition of hypertension from JNC 7 remains reasonable The American Heart Association agrees with JNC 7. The American Diabetes Association agrees with JNC 8 The decrease in number of patients treated or treated less intensively may be as high as 5.8 million (Patients with Diabetes, CKD, older than 65 ) Remember The potential benefits of a healthy diet, weight control and regular exercise cannot be over emphasized. 3
2013 ACC/AHA Guidelines:Cholesterol Treatment to Reduce ASCVD Risk in Adults THEN NOW Statin therapy to achieve LDC-C and Non-HDL C targets Statin therapy for all individuals at increased ASCVD risk who are likely to benefit 4 Statin Benefit Groups Clinical ASCVD. Primary elevation of LDL-C greater than 190. Age 40-75 with diabetes and LDL-C of 70-189. Age 40-75 with LDL-C of 70-189 and estimated 10 year ASCVD risk > 7.5 %. Recommendations: Lifestyle modification before, during statin therapy. High to moderate intensity statin therapy for all who will benefit. HIGH INTENSITY Lowers LDL-C by 50% Atorvastatin (Lipitor) 40-80mg Rosuvastatin (Crestor) 20-40mg Which Statin? MODERATE INTENSITY Lowers LDL-C by 30-50% Atorvastatin 10-20mg Rosuvastatin 5-10mg Simvastatin 20-40mg Pravastatin 40-80mg Lovastain 40mg Fluvastatin XL 80 or Fluvastatin 40 bid Pitavastatin 2-4mg Group 1: Secondary Prevention Age < 75 high intensity statin Age>75 or not a candidate for highintensity, moderate intensity statin Group 2: Adults with LDL-C>190 High intensity statin Moderate intensity statin if cannot tolerate. 4
Group 3 :Adults 40-75 with diabetes and LDL-C 70-189 Moderate intensity statin or if estimated 10 year risk is >7.5, high intensity statin Group 4: Adults aged 40-75 with LDL-C of 70-189 and estimated 10 year ASCVD risk > 7.5% Moderate to high intensity statin. ASCVD risk Role of biomarkers and imaging tests May consider other factors Primary LDL-C >160 or other genetic Hyperlipidemias Family history of premature ASCVD Hs-CRP > 2 CAC score > 300 Agatston units ( or 75 th percentile for age, sex, ethnicity ) ABI<0.9 Calcium CT score A non-invasive way of obtaining information about the presence, location and extent of calcified plaque in the coronary arteries. Most useful for people who are at moderate risk for heart disease. Low risk don t warrant imaging, high risk need risk factor modification regardless of score. Zoster vaccine FDA approved after age 50 Recommended after age 60 Does not matter if had shingles in the past Does not matter if states no prior history of chickenpox. 5
Pneumococcal Vaccine PCV13 (Prevnar) to adults 65 or older who have not previously received pneumococcal vaccine or whose history is unknown. PPSV23 (Pneumovax) 6-12 months after Prevnar. If received Pneumovax in the past- Prevnar at least one year later. HPV9 Vaccine Licensed in December 2014 9 serotypes instead of 4 Estimated that will prevent an additional 4,000 cancers Will be recommended to the CDC by the Advisory Committee on Immunization Practiced at the end of February 2015. Choosing Wisely Campaign choosingwisely.org An initiative of the ABIM Foundation- right care at the right time Evidence-based Not duplicative Free from harm Truly necessary Recognized the importance of conversations to improve care and eliminate unnecessary tests and procedures Consumer Reports created resources for consumers and providers Examples on the DO NOT list Order EKG or other cardiac screening tests for low risk patients without symptoms. Order Preoperative chest X-rays in the absence of a clinical suspicion for intra-thoracic pathology. Order Baseline lab studies in patients without significant systemic disease undergoing lowrisk surgery specifically CBC, BMP or CMP, coagulation studies. Screen for carotid artery stenosis in asymptomatic patients. Routinely screen for prostate cancer (PSA or digital exam). DO NOT EXAMPLES CONTINUED: Routinely measure 1,25 dihydroxyvitamin D. Serum 25- hydroxyvitamin D levels are overused but is correct test. Order free T3 when assessing levothyroxine dose in hypothyroid patient TSH only. Routinely use topical antibiotics on a surgical wound AND THE DO NOT LIST GOES ON Order CT screening for lung cancer among patients at low risk. May be useful in high risk patients (individuals 55-74 with at least a 30-pack year history who are either still smoking or quit in the past 15 years). Routinely repeat DEXA scans more often than once every two years. Healthy women >67 with normal bone mass may not need additional testing for 10 years unless risk factors change. 6