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Evidence-Based Periodic Health Examination

Bagian Ilmu Kesehatan Masyarakat (IKM) Bag. Epidemiology Fakultas Kedokteran Umum UMY

dr. Titiek Hidayati M. Kes.

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Pemeriksaan kesehatan berkala yang berdasarkan pada bukti bukti kesehatan (Evidence Based) Tentang berbagai tes kesehatan yang tepat guna sesuai waktu dan kegunaannya
Task Forces on Prevention Health Screening as a Strategy for Preventive Medicine
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Periodic health examination (PHE)


Periodically, patients visit physicians office not because they are unwell, but because they want a check-up. Such visits are referred to as health maintenance or the PHE. The PHE is an opportunity to relate to an asymptomatic patient for the purpose of case finding and screening for undetected disease and risky behavior. It is also an opportunity for health promotion and disease prevention. The decision to include or exclude a medical condition in the PHE should be based on the burden of suffering caused by the condition, the quality of the screening, and effectiveness of the intervention.
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Pencegahan lebih baik dari pada pengobatan


An ounce of Prevention equals to pounds of Cure

Task Forces on Prevention


The US Preventive Services Task Force

(1984, 1996, 2002) The Canadian Task Force on Periodic Health Examination (1997) The Task Force on Philippine Guidelines Periodic Health Examination (2004) - Sie Promosi kesehatan, Sie P2M dan PTM (Puskesmas, Dinkes kabupaten, Dinkes propinsi dan Depkes)

(Task Force on Philippines Guidelines on PHEX, 2004)

Health Screening as a Strategy for Preventive Medicine

In the last half century, health care has seen a major shift in philosophy from curative medicine to preventive medicine Four major strategies used in the rapidly growing field of Preventive Medicine:
1. Health Screening (doing tests for early detection of disease or risk factors for disease) 2. Lifestyle change (avoidance of unhealthy habits) 3. Risk factor control (treatment of factors that predispose to disease) 4. Vaccination programs (immunization against infectious diseases)

Screening (WHO, 1994): The use of presumptive methods to detect unrecognized health risks or asymptomatic disease in apparently healthy individuals in order to permit prevention & . timely prevention

Screening (WHO, 1994): Penggunaan metode-metode yang dianggap bisa mendeteksi risiko kesehatan yang tidak dikenal atau penyakit yang asimptomatik pada individu-individu yang tampak sehat dalam rangka membolehkan dilakukannya pencegahan atau pencegahan yang tepat pada waktunya

Screening (executive medical check up) is performed to categorize members of the general public into:

Higher probability of disease

This group is urged to seek further medical attention for definitive diagnosis & treatment

Lower probability of disease

Pitfalls of Screening & Other Preventive Medicine Strategies: Things that ought to work do not always so

Lifestyle changes such as salt restriction: have failed to lead to appreciable changes in the incidence of stroke & coronary disease in the general population
Most dietary maneuvers, like high fiber diet, have not been proven effective in cancer prevention Risk factor control has failed as well, and in some instances has even led to an increase in deaths: The cholesterol lowering drug clofibrate, was removed from the market because a trial by WHO showed more deaths among patients who received treatment

Many screening tests, such as ECG: have been found to be inaccurate for detection of early coronary disease

Consequently, many asymptomatic patients are wrongly labeled as being ill (false labeling) Instead of improving the quality of life of people, false labeling has been found to wreak havoc on the social, psychological, physical & even financial stability of unfortunate individuals Productive people have been denied insurance or employment or have resigned from work because of depression Many times, the side effects of screening have been far worse than the effects of the diseases which we were trying to prevent in the first place

Although treating early disease may be cheaper & easier, the savings are often offset by the costs of having to do the screening tests on large numbers of apparently healthy individuals

Curative surgery for a case of coronary artery disease (CAD) may cost half a million pesos (Rp 100juta) in the Philippines
In contrast, primary prevention of a single death from cardiovascular disease may entail treating at least 143 patients For high cholesterol with a statin for 5 years. depending on the statin used , this may costs as much as 20 million pesos (Rp 4 milyar) Indeed, sometimes, pounds of prevention translates to just an ounce of cure

Criteria for the use of screening test


(Blueprints Family medice, Martin S. Lipsky)

Criteria for the use of screening tests include the following : - The disease is common and significantly affects individuals and society - Effective treatments for the disease are available - The screening tests or procedures are accurate and reasonable in terms of cost, comfort and complications - Characteristics that measure the accuracy of screening tests include sensitivity, speciticity, positive and negative predictive values
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(Task Force on Philippines Guidelines on PHEX, 2004)

Criteria for Screening

Because health screening carries the potential for harm & because it can lead to huge increments, criteria need to be set on when screening for early disease should be done Four criteria

1. Treatment for the asymptomatic condition must have been evaluated using well-designed randomized controlled trials (RCTs) that observed effects on clinical outcomes

. 2. The burden of illness from asymptomatic condition must have


3. Accuracy of the screening test for the asymptomatic

been measured accurately in locally-conducted community-based studies (disease prevalence or its impact on peoples lives)

condition must have been evaluated in validation studies done in the community (false positive & false negative errors)

4. Cost-effectiveness of the screening test, as well as

treatment for the disease, should have been evaluated locally in properly conducted economic analysis (studies that evaluate costs, risks & benefits of treatment)

Communitybased VS Studies

Hospitalbased Studies:
Hospitalized patients tend to have more advanced illness (easier to detect): Exaggerate the prevalence of the condition

(Task Force on Philippines Guidelines on PHEX, 2004)

Recommendation Scale

Level 1: Recommendation satisfies all the above criteria


Level 2: Recommendation satisfies no. 1, but not all no.2, no.3 & no.4 Level 3: Recommendation satisfies no.2, no.3 & no.4, but not no.1

Level 4: Recommendation satisfies none of the criteria

(Task Force on Philippines Guidelines on PHEX, 2004)

Executive Summary of Various Screening Recommendation

Screening Tests for Adults:


Table A-1 for Adults: Screening tests recommended for the general population Table A-2 for Adults: Screening tests recommended for selected populations Table A-3 for Adults: Screening tests cannot be recommended routinely Table A-4 for Adults: Screening tests not recommended

Screening Tests for Children:


Table B-1 for Children: . Screening tests recommended for the general population Table B-2 for Children: Screening tests recommended for selected populations Table B-3 for Children: Screening tests cannot be recommended routinely Table B-4 for Children: Screening tests not recommended

Screening Tests for Pregnant Women:


Table C-1 for Pregnant Women: Screening tests recommended for the general population Table C-2 for Pregnant Women: Screening tests recommended for selected populations Table C-3 for Pregnant Women: Screening tests cannot be recommended routinely Table C-4 for Pregnant Women: Screening tests not recommended

Immunizations for Adults:


Table D-1 for Adults: . Immunizations recommended for the general population Table D-2 for Adults: Immunizations recommended for selected populations Table D-3 for Adults: Immunizations cannot be recommended routinely Table D-4 for Adults: Immunizations not recommended

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Preventive care
(Blueprints Family medice, Martin S. Lipsky)

The focus of preventive care is age-dependent, reflecting the changes in disease prevalance across the adult life span. In the secondary prevention to prevent or limit future disease is important. Ht is a significant risk factor for heart disease and stroke. The consequences of Ht may not be seen for years after a person develops high blood pressure. So, BP evaluation & tx is preventive measure for future disease that may not manifest itself until the patient is 70 years of age or beyond. The most common causes of death in adults aged 19 to 40 years are accident, homicides and suicides. Screening for cardiovasculer risk factors and malignancy become a focus of health care visits for individuals over age 40.
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.
Each recommendation statement was followed by a Summary of Evidence as follows: 1. Burden of the Illness 2. Accuracy & Reliability of the Test 3. Availability of the Effective Treatment for the illness being screened for 4. Cost-effectiveness issues 5. Recommendations of other organizations & other countries

(Task Force on Philippines Guidelines on PHEX, 2004)

Screening for Hypertension

. Recommendations:
1. Screening for hypertension is recommended (level 2) 2. The auscultatory method using a mercury sphygmomanometer is recommended for the diagnosis of hypertension as well as for the monitoring of blood pressure (level 2)

3. Ambulatory blood pressure monitoring is not recommended for screening (level 2)

(Task Force on Philippines Guidelines on PHEX, 2004)

Screening for Dyslipidemia

Recommendations:
1. Screening for dyslipidemia using a non-fasting total cholesterol level alone should be done in individuals aged 40 or above with no other risk factors (level 2) 2. Screening for dyslipidemia using a complete lipid profile [Total Cholesterol, Low Density Lipoprotein (LDL), High Density Cholesterol (HDL) & Triglycerides) should be done in:
a. Patients with two or more of the following risk factors (smoker, obese, post-menauposal) b. Patients with evidence of familial dyslipidemia (xanthoma, family history of early cardiovascular disease) (level 2)

(Task Force on Philippines Guidelines on PHEX, 2004)

Screening for Diabetes

.Recommendations:
1. Selective screening using fasting plasma glucose is recommended for high-risk individuals (patients 40 y.o. and above, smokers, obese, patients, with a family history of DM, patients with evidence of familial dyslipidemia & those with history of delivery of babies large for gestatitional age (level 2) 2. Mass screening for DM using fasting plasma glucose (FPG) levels or the oral glucose tolerance test (OGTT) is not recommended (level 2)

(Task Force on Philippines Guidelines on PHEX, 2004)

Screening for Obesity

Recommendations:
Screening for obesity using the waist-to-hip ratio (WHR) or body mass index (BMI) is recommended for apparently healthy individuals (level 3)

The US Preventive Services Task Force


Recommendations covers:

1. Various age groups: Birth to 10 years Ages 11 to 24 years Ages 25 to 64 years Ages 65 years and older
2. Four aspects: Screening Counseling Immunizations Chemoprophylaxis

(Task Force on Philippines Guidelines on PHEX, 2004)

Screening for Sedentary Lifestyle

.Recommendations:
Screening with regard to sedentary lifestyle is recommended (Level 4)

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Assignments
.

1. Burden of Illnesses (Morbidity & Mortality) in Indonesia & the World 2. Perilaku Hidup Bersih & Sehat (PHBS) 3. PHE in the US from Rakel

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