Periodical Health Care
Associate Prof. Dr. Memet IŞIK
Ataturk University Medical Faculty
Department of Family Medicine
[email protected]
Web: http://aile.atauni.edu.tr/profil=doc.-dr.-memet-isik
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2
WHAT DO PRİMARY CARE PHYSİCİANS?
Sağlık Bakımı
Sağlığı
iyileştirme
Riskten
koruma
Primary Prevention
Risk
azaltma
Erken
tanı
Komplikasyon
azaltma
Tertiary Prevention
Secondary Prevention
Individual Preventive Medicine!
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WHAT DO PRİMARY CARE PHYSİCİANS?
Health Care
İmprove
Health
Prevent Risk
Primary
Prevention
Decrease
Risk
Early
Diagnosis
Secondary
Prevention
Individual Preventive Medicine!
Decrease
Complications
Tertiary
Prevention
4
Prevention of What?
5
CAUSES OF DİSEASES(%)
50
45
40
35
30
25
20
15
10
5
0
Ulaşım
Access
to care
Genetik
Genetic
Çevre
Davranış
Environment Behaviors
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İnsurance companies:
“Mortality decreases in persons how have regular check up!”
CHECK-UP
(1921)
Some diseases don’t give a symptom, when they give symptoms to be
diagnosed, there would not be enough time to treatment: the “checkup” era is
over. Now its time of periodic health examination which changes according to
age, exposure, gender, personal risks
PERIODIC HEALTH EXAMINATION
(1970)
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The purpose of the periodic health
examination is to evaluate health status,
screen for risk factors and disease, and
provide preventive counseling interventions
in an age-appropriate manner.
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The goal of screening and evaluation
• to prevent the onset of disease or the
worsening of an existing disease.
• measurement of blood pressure to detect
hypertension
initiate treatment and
prevent subsequent morbidity (e.g., stroke
or renal failure) or mortality.
• to educate patients about behavioral
patterns or environmental exposures that pose
risks for future diseases. Counseling about
smoking prevention and cessation to prevent
lung cancer and emphysema, seat belt use to
prevent motor-vehicle injuries, or modifying
sexual practices to prevent the spread of
sexually transmitted disease.
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Does it work?

In the United States Stroke (stroke) mortality has decreased by 50%
since 1972
 Early

diagnosis and effective treatment of hypertension
Cervical cancer mortality decreased by 80%
 neonatal
screening
 Decrease
in mental disfunction
phenylketonuria screening
Congenital hypothyroidism
National Center for Health Statistics. http://www.cdc.gov/nchs/r&d/ndi/ndi.htm
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Vaccination and polio
• Polio eradication efforts began in 1989 in Turkey.
• Every year 6.5 million children are immunized
• Recent cases seen in 1998
Morbidite
hızı(1/100.000)
Mortalite
hızı(1/1.000.000)
1,8
0,7
1,6
0,6
1,4
0,5
1,2
1
0,4
0,8
0,3
0,6
0,2
0,4
0,1
0,2
0
1999
1997
1995
1993
1991
1989
1987
1985
1983
1981
1979
1977
1975
1973
1971
0
Sağlık Bakanlığı, Polio morbidite ve mortalite hızları. http://www.saglik.gov.tr/extras/istatistikler/temel2000/97.htm
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Daily Practice
 30
year old woman visits your for a check-up. No
history of any disease but she is concerned about
breast cancer.
 Should
you perform a breast examination?

Should you teach breast self examination?

Should you ask a mammography?
 How
do you decide?
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Effective Screening Criteria-1
1. Prevalence of the disease should be high
PHE is not logical for the disease with a very low prevalence.
- The incidence of osteogenesis imperfecta is : 1/10 000/year
Medline Plus. Medical Encyclopedia. Osteogenesis imperfecta.
http://www.nlm.nih.gov/medlineplus/ency/article/001573.htm
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Effective Screening Criteria-2
For early diagnosis, there should be predictive risk
factors or tests
The reliability and the cost of the test should be known
Tahmin ettirici risk faktörleri veya testler olmalı
Testin güvenilirliği ve maliyeti bilinmeli
- CRP: is cheep but no specific
- Echocardiography : Sensitive and specific, but expensive
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Which Screening Test?
Take into account:
• Incidence
•Sensitivity (Duyarlık)
• Prevalence
•Specificity (Özgüllük)
• Morbidity
• Mortality
of the disease
•PPV (Pozitif Tahmin)
of the test
•NPV (Negatif Tahmin)
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Basic Parameters
(+) Test
Hasta
(Prevalans)
Sağlıklı
10
(-) Test
4
6
80
PPV
NPV
Toplum-100 kişi
Sensitivity
(Duyarlık)
Spesificity
(Özgüllük)
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SENSİTİVİTY: ABİLİTY TO İDENTİFY POSİTİVE RESULTS.
THE SENSİTİVİTY OF A TEST İS THE PROPORTİON OF PEOPLE
WHO HAVE THE DİSEASE WHO TEST POSİTİVE FOR İT. IF A
TEST HAS HİGH SENSİTİVİTY THEN A NEGATİVE RESULT
WOULD SUGGEST THE ABSENCE OF DİSEASE.
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Sensitivity
Disease
Test
Present
Absent
Positive
a
b
Negative
c
d
Sensitivity
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Specificity: The proportion of patients who do not have
the disease who will test negative for it.

Specificity =
+
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Specificity
Disease
Test
Present
Absent
Positive
a
b
Negative
c
d
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POSİTİVE PREDİCTİVE VALUE
Disease
Test
Present
Absent
Positive
a
b
Negative
c
d
PPV: Testte pozitif çıkanların gerçekten hasta olma ihtimali

PPV=
+
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NEGATİVE PREDİCTİVE VALUE
Disease
Test
Present
Absent
Positive
a
b
Negative
c
d
NPV: Test negatif çıkanların sağlıklı olma ihtimali

NPV=
+
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Relation between PPV and Prevalence
pupulation
= 100,000
Sensitivity
= % 90
Specificity
= % 90
Cancer Prevalence = % 1
Cancer Prevalence = % 0.1
Ca +
Ca -
test +
900
9,900
Test + 90
9,990
test -
100
89,100
test - 10
89,910
PPV = % 8.3
Ca +
Ca -
PPV = % 0.9
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Effective Screening Criteria-3
Mortality and morbidity of the disease should be high
Factors affecting morbidity and mortality of the apart from the
disease type.
- Age
- Gender
- Race- genetics
- Geographic location
- Living habits (culture)
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Effective Screening Criteria
4.
There should be an acceptable treatment
It is nonsense to screen the incurable diseases
Lung Ca?
5.
There should be a prodromal period without symptoms.
Şikayetlerin olmadığı bir “erken dönem” olmalı
- AIDS
- Syphilis?
- Cervical cancer?
- Breast cancer
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Natural Course of a Disease



1  2  3  4
1. biological start
2. early diagnosis is possible
3. clinical diagnosis
4. the result
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An aggressive Cancer
Beginning
6 ay
Symptoms
1 yıl
Death
Screening test
performed once
a year
Beginning
2 year
Symptoms
4 year
Death
Less aggressive Cancer
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BREAST CANCER

Is an important disease for women

The most common cancer in women. 30 thousand cases per year in Turkey.

Symptoms can be detected before they occur


Cure is possible


Self-examination, physical examination, Mammography
Surgery, Chemotherapy, Radiotherapy
Benefit of treatment is greater than the discomfort
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Periyodik Muayene Zararlı Olabilir mi?
Asymptomatic
person
Screening
Test normal
Test abnormal
True negative
False negative
True pozitive
False pozitive
Relieving
Delay in diagnoses
Treatment
Anxiety
The average error rate of a test : %5
Ian R. McWhinney. A Textbook of Family Medicine. Oxford University Press, USA 1997.
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AKİF BEY

52-year-old ...

A company executive ...

Last week one of his colleagues hospitalized in the coronary
care unit due to heart attack

No complaints, but is concerned about.

He wants to have a "check-up" to find out whether he has a
heart disease.
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AYNUR HANIM

34 y.o, teacher...

Her mother died at the age of 55 due to breast ca.

One of her friend adwised her to have an mammography.
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KAMİL BEY

42 y.o., farmer.

Smoking for 30 years.

One of his friend who is also a havy smoker diagnosed as lung
ca. .

He wants to have a chest x ray..
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Checkup chaos in our country
-- Chest X-ray to scan lung diseases,
--Urine test for screening urinary tract disorders,
--ECG for screening CVD
--Microfilm for tuberculosis screening,
--PSA for prostate cancer screening,
- Breast self-examination, for cancer breast cancer
--Complete blood count for blood disease screening
--Influenza vaccine for the prevention of influenza in
healthy young people
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How to Perform Periodic Health Examination?
• Although they are healthy, individuals are invited
for a control by giving appointment at regular
intervals.
• Service based on PHE criteria is provided to
individual? - Consultation - Vaccine
- Home visit – Examination
- Prophylaxis - test (screening)
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Suggestions in Our Country?
For the year 2014
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Suggestions for PHE
Not to do
1. Pancreatic cancer screening in asymptomatic people
2. Bladder cancer screening in asymptomatic people
3. Peripheral arterial disease screening in asymptomatic people
4. Lung cancer screening in asymptomatic people
5. Thyroid cancer screening in asymptomatic people
6. Immune marker screening for type 1 diabetes in asymptomatic
people
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Suggestions for PHE
7.
8.
9.
10.
Genital HSV screening in asymptomatic people
Routine ECG screening in asymptomatic people
Routine urine examination in asymptomatic men
Routine urine examination in women (with the except of
diabetic and homeless women)
11. Routine thyroid function tests (with the except of under sixty
years of age and neonatal period)
12. Ovarian cancer screening in women who are not at risk
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SUMMARY
Which of the following is not an element of the
periodic health examination?
•
Consultancy
•
Vaccination
•
Examination
•
Treatment of Diseases
•
Home visits
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Which one of the following are not taken into account in
determining PHE suggestion rules?
• There should be an asymptomatic period of the disease for
scanning.
• There should be an acceptable treatment for the disease
• Morbidity and mortality of the disease should be low
• The prevalence of the disease in the community should be
high
• There should be predictive risk factors or tests for early
diagnosis
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In regard to PHE, which of the following is
true for implementation ?
• ECG screening for heart disease
• Complete blood count for the screening of blood
diseases
• Chest radiography for scanning of lung
diseases
• Measurement of weight and height in children
in every application
• Making healthy checkup once a year to every
individual
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