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The health maintenance examination (HME) is focused on providing women with clinical preventive services. These services include traditional screening tests, education about life-style choices and their consequences, and measures aimed at primary and secondary prevention of disease. Clinical preventive services are an important reason that women seek care and help explain why women are more likely to have an identified primary care physician, are more likely to see that physician during any given year, and are more likely than men to have more than one physician.
A woman’s choice of provider is strongly related to her economic status. Wealthier women are much more likely to have both a family physician or internist and an obstetrician! gynecologist, whereas less affluent women, those with comorbidities, and those with a worse self-perceived health status are more likely to have a family physician or internist as their sole source of care. Based on a survey of seven common preventive services (complete physical examination, blood pressure, cholesterol, clinical breast examination, mammogram, pelvic examination, and Pap smear), women who see an obstetrician/gynecologist are more likely to receive these services than women seeing a family physician or internist (5.5 services versus 4.9 services, P < .05). However, most elements of the complete physical examination (including pelvic examination) are not recommended by the United States Preventive Services Task Force for screening purposes, and clinical breast examination is optional in women who have had a mammogram. It is, therefore, unclear whether women seen by obstetrician/ gynecolo-gists received better care or simply more care.
Given the greater likelihood that women seen by internists and family physicians are poor and have comorbidities, it is possible that limited access or appropriate selectivity can explain the lower number of preventive services provided. For example, poor women are less likely to be able to afford a mammogram, and women who have had a hysterectomy (and who may therefore be less likely to see a gynecologist) do not need Pap tests and pelvic examinations. More research is needed to understand how different specialists provide clinical preventive services and whether the appropriate number of services are being ordered by each group.
In this chapter, we discuss the goals and organization of the HME. We also describe the criteria for a good screening test, so clinicians can evaluate new tests and procedures as they become available in the coming years. The recommendations for screening are largely based on the Guide to Clinical Preventive Services of the United States Preventive Services Task Force (USPSTF).This book is highly recommended as a primary reference for every clinician who provides health care services to women because the recommendations for prevention are based on high-quality original research evidence.
Goals of the Health Maintenance Examination
The goal of the HME is to provide appropriate clinical preventive services to the patient, based on her age, race, life-style, and other risk factors. Tailoring the HME is important because providing unneces-sary services is costly and time-consuming. It can even be harmful if it leads to unnecessary invasive testing or inappropriate therapeutic recommendations. For example, the clinical breast examination in a 20-year-old woman (not recommended by the USPSTF) might lead to an unnecessary biopsy and significant emotional trauma. It may also lead that woman to label herself as high risk for breast cancer, when her risk is actually not altered by the presence or absence of benign breast diseases.
What Makes a Good Screening Test?
Medical conditions are appropriate candidates for clinical preventive services when they are common or have important health consequences. Effective and acceptable interventions must be available to treat the condition once identified. For example, it would be difficult to justify screening programs for brain malignancy or pancreatic cancer because these conditions are relatively uncommon and treatment regimens are generally not very effective. Most importantly, detection and treatment during the asymptomatic phase of the illness must provide important benefits to patients compared with treatment once symptoms are clinically apparent. Cervical cancer and breast cancer are good examples of such conditions.
In addition, the characteristics of available screening tests are important. The tests should be accurate enough to detect disease in the asymptomatic phase, while not subjecting too many patients to the discomfort, worry, and cost of “working-up” a false-positive screening test. Accuracy can be described in many ways, including sensitivity, specificity, predictive value, and likelihood ratios. Although a full discussion of these terms is beyond the scope of this chapter, it is important to understand the trade-off between sensitivity and specificity. As sensitivity increases, specificity decreases, and vice versa. A lower sensitivity increases the risk of missing a woman with the disease (higher false-negative rate), whereas a lower specificity increases the risk of labeling a healthy woman as diseased (higher false-positive rate). Screening programs often will use a highly sensitive, less specific test for the initial screen (such as the enzyme-linked immunosorbent assay for HIV infection) and follow it with a highly specific test (the Western blot) to eliminate the false-positive results. Another example is mammography followed by breast biopsy.
Organization of the Health Maintenance Examination
Age- and risk factor-specific recommendations for screening during the history, physical examination, and laboratory evaluation phases of the HME are discussed below. They are based on recommendations from the Guide to Clinical Preventive 1-2, 1-3, and 1-4 for easy application to clinical practice.
Although patients often think of screening and health maintenance in terms of the physical examination and laboratory testing. Perhaps the greatest potential benefit derives from simply talking to patients about their lifestyles, risk factors, family history, and habits. In younger women, who are at the greatest risk for sexually transmitted diseases, it is particularly important to address risky sexual behavior and effective contraception. Women of all ages should be asked at each visit about use of tobacco, and smokers should be offered assistance in quitting. Women of all ages should also be asked about alcohol use during their HME. The most effective screening instrument for alcohol abuse among women is the TWEAK question-naire. Although the CAGE questionnaire is more widely used, it is less sensitive for the detection of alcohol abuse in women.The TWEAK question-naire and guidelines for interpretation are summarized.
The USPSTF advocates a relatively long list of items to discuss with women of all ages. They include injury prevention (use of lap and shoulder belts, bicycle/motorcycle helmets, smoke detectors, and storage of firearms), diet and exercise, dental health, and the issues around sexual behavior and substance use described above. Although difficult to cover in a single HME visit, they can be addressed by creative providers using a variety of approaches:
Patient education handouts
Many providers will address some of these issues over time during both acute care and HME visits, tracking their educational progress on a form or a flow sheet in the chart.
Special Considerations For Older Women Women’s educational needs change as they age. Perimenopausal women should receive counseling regarding the risks and benefits of hormone replacement therapy. In general, only women at high risk for breast cancer and low risk for coronary artery disease will not benefit from hormone replacement therapy. A useful algorithm to help patients evaluate the risks and benefits. Elders should be counseled to reduce the risk of falls by removing throw rugs and installing assistive devices in the bath as necessary. In a nursing home setting, the following have been identified as risk factors for falls: psychotropic medication use, prior falls, wandering, use of a cane or walker, declining functional status, age over 87, unsteady gait, ability to transfer independently, and not using a wheelchair. In-home exercise training can reduce the risk of falls.
Physical Examination Many of the elements of the physical examination to which patients have become accustomed, such as cardiac auscultation, bimanual pelvic examination, and assessment of the patellar tendon reflex, have little if any value as screening tests. Although appropriate in symptomatic patients, and for evaluation of specific complaints, they should not be considered a necessary element of the HME.
The only elements of the physical examination that should routinely be performed are height, weight, and blood pressure. Clinical breast examination (CBE) in addition to mammography may provide some incremental value over mammography alone. The greatest sensitivity of the CBE was observed with a 5- to 10-min examination by specially trained examiners, not practical in most office settings. Breast self-examination (BSE) has a very low sensitivity (12 to 25 percent) and uncertain specificity, and many are calling its routine use into question? Unfortunately, no largescale trials have randomized women to BSE or no BSE, so good evidence is not available. In summary, CBE should be carefully performed annully by a trained health care provider. Physicians might consider training nurses or midlevel providers who can take the 5 or 10 min necessary to perform a thorough and useful CBE.
The pelvic examination has long been a traditional part of the HME. However, except as a method for obtaining Pap smears or cervical cultures, the USPSTF does not recommend pelvic examination as a routine screeening test. Although ovarian cancer can occasionally be dectected using the plevic examination, they are usally advanced and untreatable when found this way.
Pap Test. The Papanicolaou test is central to the health maintenance visit for most women. Although traditionally done annually, long-term follow-up of women who have had regular Pap tests and a better understanding of the biology of cervical cancer have led to a revision in these recommendations. In some countries, a screening interval of 3 to 5 years is standard practice. The USPSTF recommends that Pap smears begin with the onset of sexual activity and be repeated at least every 3 years, with more frequent examinations reserved for women at high risk (previous abnormal Pap test, multiple partners, or early onset of sexual activity). This recommendation is based on high-quality evidence from cervical cancer screening programs in Canada and Europe, which found that the incidence of invasive cervical cancer was reduced 64 percent when the interval between Pap tests was 10 years, 83.6 percent at 5 years, 90.8 percent at 3 years, 92.5 percent at 2 years, and 93.5 percent at 1 year If women have been consistently screened throughout their lives, it is reasonable to stop Pap tests at age
Mammography. Mammography is another important screening test for women aged 40 and older. Although some groups have recommended a “baseline” mammogram between ages 35 and 40, no evidence supports this recommendation, and the practice should be abandoned. Mammography between the ages of 40 and 49 is similarly controversial. Because the premenopausal breast tissue is denser, and cancer less common, there is less benefit of screening this age group than for women aged 50 to 69. Although this explanation may be plausible and logical, some empirical evidence fuels the controversy.
In 1995, Kerlikowske9 reported the results of a meta-analysis of the potential benefits of screening mammography in women under age 50 compared to women over age 50. Women over age 50 receiving mammograms had a 26 percent reduction (95 percent confidence interval was 17 to 34 percent) in breast cancer mortality risk. Women aged 40 to 49 had a 7 percent reduction in breast cancer mortality risk (95 percent confidence interval showed the range of risk varied between a benefit of 24 percent to a harm of 13 percent). In other words, based on the literature, it is possible that younger women may have some benefit, but there may also be a harm to screening. This synthesis of the literature was confirmed by a cost-effectiveness analysis.lO When compared to women not receiving mammography, screening of women aged 50 to 69 was associated with a 12 day increase in life expectancy per woman, at a cost of $704/woman and a cost-effectiveness of $21,400/year of life saved. Screening women between the ages of 40 and 49 would increase life expectancy by 2.5 days at an additional cost of $676/woman. This translates to an incremental cost-effectiveness of $105,000/year of life saved.
This controversy was underscored by the apparently conflicting recommendations of the National Cancer Institute (NCI). The 1993 NCI recommendations spoke only to screening women over the age of 50; no evidence indicated benefit to screening younger women. In 1997, a Consensus Development Panel, after reviewing the available research, issued a statement indicating that screening with mammography for women aged 40 to 49 could not be recommended and that decisions regarding mammography in this age group should be individualized. This recommendation would have placed the decision between a woman and her health care provider. Although shared decision-making is an admirable and appropriate goal, its implementation may be a problem in the absence of decision support tools. With these latter issues under consideration, combined with Congressional pressure, the National Institutes of Health issued their latest recommendation that women over age 40 should be screened. Regardless of the controversy and ongoing debate, screening this age group has become the de facto community standard in the United States.
Discontinuing Screening. Recommendations are less clear regarding when to stop screening for cervical and breast cancer. Women who have had a hysterectomy in which the cervix was removed for nonmalignant disease do not require Pap testsY For cervical cancer, the risk of new invasive cancer is extremely low beyond age 65 to 70, as long as a woman has had consistent, normal screening throughout her life. However, many low-income women have not had such screening and would benefit from continued Pap smears into their seventies. Although the USPSTF2 found no evidence for or against mammography beyond age 69, screening should be considered for women in otherwise good health until at least age 75, given the high incidence of breast cancer among women aged 69 to 75.
Blood Tests. Many patients have come to expect “blood work” as a regular part of the HME. The focus, however, should be on lifestyle choices, education, and risk factor assessment. According to the USPSTF, the only blood tests indicated for otherwise healthy women as part of the HME are blood cholesterol measurements between age 45 and 69 years of age and rubella serology for women of childbearing age who have an uncertain vaccination history. Recently, the American College of Physicians recommended that women over age 50 be screened using the sensitive thyroid-stimulating hormone (TSH) test. Free thyroxine levels, using the same blood sample, should be obtained if the TSH is either nondetectable or greater than 10 mU/L, and patients in whom both tests are abnormal should be treated. If only one is abnormal, then the patient should be retested in 4 to 6 months. It is estimated that mass screening for thyroid disease would benefit 1 of 71 women over age 50 years who are screened.
Delivering health maintenance care can occur at either planned or unplanned encounters. Most providers will find it easy to address the issues discussed above when “wellness” is the primary agenda. Although a recent study found that family physicians perform preventive care at about one-third of acute and chronic care visits, it is dif ficult to prioritize preventive care at these times. In this section, we address some ways of putting prevention into practice.
Common Problems In Deilvery of Preventive Services A recent study by Stange and colleagues provides the first comprehensive look at the day-to-day practice of a group of family physicians. Commonly performed preventive care activities during visits for illness care or chronic disease follow-up include smoking cessation (42 percent) and recommendations for exercise (42 percent) and flu shots (33 percent). Additional counseling included discussions of tobacco and alcohol use, hormone replacement, diet, contraception, and screening issues. In addition to these elements, the USPSTF suggests that providers keep alert for several other conditions: skin cancer, thyroid disease (especially in postpartum patients), depression, family violence, and drug and alcohol abuse. Many of these can be addressed at wellness visits as well as at other visits.
Family physicians can be attuned to individual concerns when other family members are seen. When we see a patient in the office, we frequently (just under 20 percent of the time) address health concerns of other family members! This “surreptitious” care often serves as an opportunity to reinforce advice given at earlier encounters, to remind patients to return for periodic examinations, or to evaluate new problems. For instance, it is common for a parent accompanying at a well child visit to inquire about a mole or some other concern.
Promoting Good Health Behaviors What are the main objectives of counseling and patient education? They are twofold: to change behaviors and to improve health status. Health care workers can effectively help women to control their weight, begin to exercise, and use contraception. When health care concerns are addressed, women experience improved outcomes in hypertension, breast cancer, and diabetes control. There are many possible issues to be discussed, perhaps more than can be covered in the typical 30 to 45 mins set aside for the HME. Several approaches may help prioritize which issues are covered. First, identify any pressing problems (e.g., chest pain, suicidal ideations, volatile domestic circumstances, etc.) that might even force postponement of elements of the HME. Next, identify the patient’s goals. What issues are on her mind? What interventions have the greatest potential impact? and common interventions and their impact on life expectancy for the average woman and for those at higher risk, respectively. For example, in a 35-year-old woman with mild hypertension who smokes, has a cholesterol over 200 mg/ dL, and has a body mass index of 50, the single intervention with the greatest impact on life expectancy is smoking cessation. This information must then be balanced with her own sense of what is achievable and important to her. Keep in mind that most of the published literature focuses on mortality. Some might argue that though this is an important and easily measured end-point, it is not the most important one. Quality of life, maintenance of function, and prevention of morbidity are more important for many of our patients. Fortunately, for many of the preventive interventions available, the beneficial impact on mortality is also reflected in quality of life.
Some interventions, however, involve significant trade-offs that require discussion with the patient. Three studies have evaluated the use of tamoxifen in preventing breast cancer in women at high risk. Two of the studies were terminated early due to a lack of benefit and an increased rate of thromboembolic events (deep vein thrombosis and pulmonary embolism). The third study was a larger trial that showed benefit. if 1000 high-risk women were treated with tamoxifen for 5 years, breast cancers and deaths could be prevented.
When strategies based on a combination of the patient’s preferences and the likely benefits are prioritized, the likelihood of success increases. When women play an active role in the decision-making, they have a personal stake in carrying out the plan, thereby improving compliance with it. The USPSTF2 also suggests the following coun-seling and education strategies:
These general strategies should be supplemented with the specific strategies discussed in other chapters.
Therapeutic or Preventive Medications And Other Interventions At various stages in the life of women, the role of medications and other supplements should be explored. For women in their childbearing years (aged 15 to 44), it is important to discuss contraceptive needs and possible future childbearing. As discussed in many contraceptive options exist. The use of folic acid for women contemplating a pregnancy should be encouraged. A woman’s need for rubella vaccination should be considered; women who are not immune to rubella should be immunized before they become pregnant.
With the exception of folic acid, vitamin supplements have not been proven to improve health outcomes or reduce mortality. At the core of the controversy regarding the value of dietary supplements are the questions about what level of nutrient intake optimizes health and whether an adequate intake of nutrients can be obtained from the diet. In addition to recommending an adequate intake of folic acid to young women, it is appropriate to recommend a dietary supplement of vitamin D and vitamin B or many elderly patients because it is unlikely that the diet will provide the required quantity of these nutrients. Although the role of vitamin C in the prevention of heart disease, cancer, and cataract formation is still controversial, the dietary requirement for vitamin C is increased by about 60 mg/d in tobacco smokers and supplementation in this population is appropriate.
Another issue relates to the use of aspirin. Several cohort studies, including the Nurses’ Health Study, suggest that aspirin has some benefit in the primary prevention of myocardial infarction (a 25 percent reduction in risk) but not for stroke. Other randomized trials that enrolled women have shown some mixed results. Thus far, no large prospective trials of aspirin for the primary prevention of myocardial infarction or stroke in women have been completed, although one, the Women’s Health Study, is ongoing. Data are also inconclusive with respect to the use of aspirin among women with previous stroke or heart attack. Elwood conducted a randomized controlled trial of aspirin and placebo in over 1600 patients with confirmed myocardial infarction and found a small, statistically insignificant, reduction in mortality. That study only enrolled 248 women. The Aspirin Myocardial Infarction Study was another trial involving patients with previous acute myocardial infarction. Although there was a small reduction in nonfatal cardiovascular events, there was an increase in mortality among aspirin users. The authors of this study could not recommend the routine use of aspirin in survivors of acute myocardial infarction. The available studies have not enrolled sufficient numbers of women to provide good data on the risks and benefits of aspirin for women.
Alternative/Complementary Approaches. Many women use lternative/complementary approaches to maintain health. Homeopathic remedies, herbal supplements, acupuncture, chiropractic manipulation, aromatherapy, imagery, various massage techniques, and naturopathy are just a few examples of complementary practices. They are used more often than most physicians realize. In one population-based survey of 3000 adults, 49 percent used at least one nonmedically prescribed alternative therapy. Users were typically more well-educated working perimenopausal women of normal weight. About 20 percent used an alternative practitioner (chiropractors, naturopaths, reflexologists, etc.); these individuals were more likely to be younger, overweight women living in rural areas.
Although many practices are unproven, some alternative practices may be beneficial. For example, supplementation with vitamin E was very popular as an alternative medicine long before it was studied in clinical trials. Among perimenopausal women with frequent hot flushes and only modest improvement with estrogen, the addition of soy protein in the diet may serve as a useful adjunct. Other measures, such as acupuncture, have not been subjected to placebo-controlled trials but have become incorporated into mainstream medicine as an adjunct to smoking cessation and in managing painful conditions. The danger of dismissing alternative practices glibly is that patients may become disenfranchised from traditional beneficial practices. In addition, they may be reluctant to disclose the use of alternative treatments.
Although supplements are commonly used and some appear to be beneficial, their use is not without problems. Because the Food and Drug Administration does not regulate them, issues of quality control and consistency from lot to lot (even with the same manufacturer) are potential problems. The lack of rigorous research or published research to support many claims makes it difficult to evaluate their true benefit. The final issue relates to safety. Many patients are under the impression that, because these are “natural products,” they are safe. The literature contains many reviews, case reports, and case series of toxicity associated with herbal preparations. Additionally, there are many documented interactions between alternative and traditional remedies (e.g., serotonin toxicity associated with patients taking St. Johns wort and fluoxetine). Finally, there have been reports of contamination with heavy metals and other potentially toxic substances and even adulteration of preparations.
The HME is an important aspect of primary care. Not only do these visits help build rapport with patients, they help health care providers identify the health care values and goals of their patients. Knowledge of these goals and values is important in negotiating a plan of preventive care with a patient. Although these issues are often addressed at the time of a regularly scheduled checkup, it may be appropriate to address some preventive issues at illness-related visits.
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