Health Maintenance Case File

Health Maintenance Case File

Eugene C. Toy, MD, Gabriel M. Aisenberg, MD

Case 1

A 66-year-old woman comes in for a routine physical examination. She reports going through menopause at age 51. Her other medical and family history is unremarkable. Social history is remarkable for a 30 pack-year smoking history. On examination, she is found to have a blood pressure of 120/70 mm Hg, heart rate of 70 beats per minute (bpm), and temperature of 98°F. Her weight is 140 lb, and her height is 5 ft 4 in. The thyroid is normal to palpation. Breast examination reveals no masses or discharge. Abdominal, cardiac, and lung evaluations are within normal limits. Pelvic examination shows a normal multiparous cervix, a normal-sized uterus, and no adnexal masses. She had undergone a mammogram 3 months ago. The patient states that she has regular Papanicolaou (Pap) smears and that the last one, performed 1 year ago, was normal.

▶ What is your next step?

▶ What would be the most common cause of mortality for this patient?

ANSWERS TO CASE 1:

Health Maintenance

Summary: A 66-year-old woman presents with

• 30 pack-year smoking history
• Mammogram performed 3 months ago
• Last Pap smear, normal, a year ago

Next step: Each of the following should be performed: colorectal cancer screening, lung cancer screening, dyslipidemia and blood glucose screening, immunizations (pneumococcal vaccine, herpes zoster vaccine, influenza vaccine, tetanus vaccine [if not within 10 years]), and smoking cessation counseling.

Most common cause of mortality: Cardiovascular disease.

ANALYSIS

Objectives

1. Describe which health maintenance studies should be performed for a patient older than 65 years. (EPA 1, 3)
2. Recognize the most common cause of mortality in a woman in this age group. (EPA 12)
3. Verbalize that preventive maintenance consists of immunizations, cancer screening, and screening for common diseases. (EPA 1, 12)

Considerations

The approach to health maintenance consists of three parts: (1) screening for cancer, cardiovascular disease, or other conditions; (2) immunizations; and (3) behavioral counseling regarding healthy behaviors such as regular exercise and tobacco cessation. For a 66-year-old woman, cancer screening includes mammography for breast cancer screening every 2 years until age 74 and colon cancer screening every 10 years with a colonoscopy until age 75 (can also screen with fecal occult blood testing annually or flexible sigmoidoscopy every 5 years). Because this patient is a current smoker with a 30 pack-year history, lung cancer screening with low-dose computed tomographic (CT) chest scan is also warranted. Cervical cancer screening can be stopped at age 65 if all previous Pap smears have been normal. Screening for cardiovascular disease includes high blood pressure screening every year and testing for dyslipidemia in men starting at age 35 and in women starting at age 45 or sooner if there are risk factors such as family history, history of diabetes, tobacco use, or body mass index (BMI) greater than 30. Immunizations for this patient would include tetanus booster every 10 years, pneumococcal vaccine, herpes zoster vaccine, and yearly influenza immunization. Screening for abnormal blood glucose levels is also recommended. The most common cause of mortality in men or women over 65 is cardiovascular disease.

APPROACH TO:

Health Maintenance 

DEFINITIONS

COST-EFFECTIVENESS: Comparison of resources expended in an intervention versus the benefit, which may be measured in life-years or quality-adjusted life-years (QALY).

PRIMARY PREVENTION: Identifying and modifying risk factors in subjects who have never had the disease of concern.

SCREENING TEST: Device used to identify asymptomatic disease in the hope that early detection will lead to an improved outcome. An optimal screening test has high sensitivity and specificity, is inexpensive, is easy to perform, and has readily available treatment for the disease being screened for.

SECONDARY PREVENTION: Actions taken to reduce the morbidity or mortality once a disease has been diagnosed.

CLINICAL APPROACH

Preventive Care

Aside from care focused on treating acute or chronic illnesses, a cornerstone of medical practice includes preventive care. As stated in the modern Hippocratic Oath, “I will prevent disease whenever I can, for prevention is preferable to cure.” A directed approach to intervene on common pathologies helps keep patients healthy or detects disease early enough that interventions are more effective. There are several types of preventive care:

1. Immunizations: Aside from childhood immunizations, routine adult immunizations include influenza, pneumococcal, diphtheria, tetanus, and acellular pertussis (Td/Tdap), zoster, as well as others, such as hepatitis A or B vaccines, in certain situations.
2. Behavioral counseling: Inquiry and counseling regarding regular exercise, avoidance or cessation of tobacco, moderate alcohol use, and screening for depression.
3. Chemoprevention: Use of medication to prevent disease, such as use of statin therapy to prevent cardiovascular events.
4. Screening: Identification of disease or risk factors in an asymptomatic patient.

Of these preventive measures, screening requires firm medical evidence that it may offer benefit, and thoughtful consideration from the practitioner before he or she initiates screening and recommends to an asymptomatic patient that he or she undergoes a medical intervention with potential harms (eg, cost, radiation exposure, anxiety regarding false-positive tests, biopsies, or other follow-up examinations). The World Health Organization outlined the following principles of screening:

1. The condition must be an important health problem.
2. There should be an effective treatment for the condition.
3. Facilities for diagnosis and treatment of the condition should be available to the patient.
4. There needs to be a latent or preclinical stage of the disease in which it can be detected.
5. There should be an accurate test to detect the condition.
6. The test should be acceptable to the patient or the population.
7. The natural history of the disease should be understood to guide intervention or treatment.
8. The cost of case-finding should be balanced within the context of overall medical expenditures.

Using these criteria, one may deduce that it would not be useful to screen for Alzheimer disease since there is no curative treatment and no evidence that early intervention alters the course of the disease. Regarding cost-effectiveness, health care economists perform sophisticated analysis for screening and other medical care, but one rough measure of cost-effectiveness is QALY, combining longevity with quality of life as a single measurement. In the United States, medical interventions, including cancer screening, are often considered cost-effective at a cost of $50,000 to $100,000 per QALY gained.

Health Maintenance by Age Group

Among Americans between ages 15 and 45, accidents and homicide are the leading causes of death, so preventive care may include counseling regarding behavioral risk reduction, such as seatbelt use, avoiding alcohol or texting while driving, or substance abuse. It is important to consider that the rising prevalence of obesity in younger populations may necessitate earlier screening of cardiovascular disease, including dyslipidemia, blood pressure, and abnormal blood glucose, which are reflected in newer guidelines.

After age 45, the leading causes of death are malignancy and cardiovascular disease, so screening is focused on risk factor reduction for those diseases, such as control of blood pressure and hyperlipidemia and early detection of cancers. Regarding cancer screening tests, the American Cancer Society and various subspecialty organizations publish various recommendations, which are often not in agreement. The US Preventive Services Task Force (USPSTF) is an independent panel of physicians and epidemiologists appointed by the Department of Health and Human Services to systematically review the evidence of effectiveness of clinical preventive services (though they do not consider cost effectiveness). Offering cancer screening to older patients should consider estimated life expectancy (typically at least 10 years), comorbid conditions, and ability or willingness to undergo cancer treatment if a cancer is detected (eg, to tolerate a hemicolectomy if a colon cancer is found). The USPSTF recommendations for cancer and other health screenings are listed in Table 1–1.

Reproduced with permission, from The Guide to Clinical Preventive Services 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/prevention/guidelines/guide/index.html.

The use of vaccinations is another important component of preventive health in older adults. Routine immunizations include annual influenza vaccine (especially important in the geriatric population since >90% of influenza-related deaths occur in patients over 60 years), pneumococcal vaccines (23-valent polysaccharide vaccine [PPSV23] and 13-valent pneumococcal conjugate vaccine [PCV13] should be given sequentially), and herpes zoster live-attenuated vaccine for immunocompetent patients over age 60 or recombinant herpes zoster vaccine for patients over age 50.

CASE CORRELATION

• See also Case 6 (Hypertension, Outpatient) and Case 51 (Type 2 diabetes diagnosis and management).

COMPREHENSION QUESTIONS

1.1 A 59-year-old woman is being seen for a health maintenance appointment. She has not seen a doctor for over 10 years. She had undergone a total hysterectomy for uterine fibroids 12 years ago. The patient takes supplemental calcium. The provider orders a fasting glucose level, lipid panel, mammogram, colonoscopy, and a Pap smear of the vaginal cuff. Which of the following statements is most appropriate regarding the screening for this patient?

A. The Pap smear of the vaginal cuff is unnecessary.

B. In general, colon cancer screening should be initiated at age 60, but this patient has very sporadic care; therefore, colonoscopy is reasonable.

C. Because the patient takes supplemental calcium, a dual-energy x-ray absorptiometry (DEXA) scan is not needed.

D. Pneumococcal vaccination should be recommended.

1.2 A 65-year-old man has had annual health maintenance appointments and has followed all the recommendations offered by his primary care provider. The practitioner counsels him about pneumococcal vaccine. Which of the following is the most appropriate statement about this vaccine?

A. It is recommended for patients who are age 60 and older.

B. The vaccination is administered in a two-dose series.

C. The pneumococcal vaccination consists of only a conjugate vaccine.

D. This vaccine is not recommended if a patient is immunocompromised.

1.3 An 18-year-old woman is being seen for a health maintenance appointment. She has not had a Pap smear previously. She currently takes oral contraceptive pills. She began sexual intercourse 6 months previously. Which of the following statements is most appropriate regarding health maintenance for this individual?

A. A Pap smear should not be performed in this patient at this time.

B. The human papilloma virus (HPV) vaccine should be administered only if she has a history of genital warts.

C. The most common cause of mortality for this patient would be suicide.

D. Hepatitis C vaccination should be offered to this patient.

ANSWERS

1.1 A. Cervical cytology of the vaginal cuff is unnecessary when the hysterectomy was for benign indications (not cervical dysplasia or cervical cancer) and when there is no history of abnormal Pap smears. Colon cancer screening (answer B) is generally started at age 45 or 50 and not at age 60. DEXA scan for osteoporosis (answer C) is recommended for women starting at age 65 or earlier for women with elevated fracture risk. Pneumococcal vaccine (answer D) is generally given at age 65.

1.2 B. The pneumococcal vaccine actually consists of two vaccines (not one, as in answer C), PCV13 vaccine and PPSV23. It is recommended to give the PCV13 vaccine at age 65 (not age 60, as in answer A), followed 1 year later by PPSV23. Conjugate vaccines induce a T-cell–dependent immune response for longer-lasting immunity, while polysaccharide vaccines induce a T-independent response that achieves relative immunity in adults and older children. It is recommended for individuals aged 65 and above and sooner for those with certain medical conditions or an immunocompromised state (answer D). It has been shown to greatly reduce the incidence of bacterial pneumonia and associated complications, such as bacteremia and meningitis. Pneumococcal disease affects 18,000 older adults every year in the United States, and growing strains of antibiotic-resistant organisms make the vaccine all the more important.

1.3 A. Cervical cytology should be deferred until age 21. This is due to the fact that adolescents many times will clear the HPV infection and cause an abnormal Pap smear to normalize. The Advisory Committee on Immunization Practices (ACIP) recommends that the HPV vaccine should be recommended to both males and females between the ages of 9 and 26 (not dependent on history of genital warts, as in answer B). The most common cause of mortality for adolescent girls is motor vehicle accidents (not suicide, as in answer C). No vaccine is currently available for hepatitis C (answer D).

    CLINICAL PEARLS    

▶ The basic approach to health maintenance is age-appropriate immunizations, cancer screening, and screening for common diseases.

▶ The most common cause of mortality in a woman younger than 20 years is motor vehicle accidents.

▶ The top two causes of mortality in men or women age 45 or older are cardiovascular disease and cancer.

▶ Women older than 65 years should be screened for osteoporosis, heart disease, breast cancer, and depression.

▶ Obesity is a major concern and has numerous complications, including diabetes, hyperlipidemia, heart disease, sleep apnea, and respiratory difficulties.

▶ Tobacco use should be queried at each visit, and patients should be counseled actively about cessation; pharmacologic therapy is associated with a higher success rate.

REFERENCES

Antoniou SA, Antoniou GA, Granderath FA, et al. Reflections of the Hippocratic oath in modern medicine. World J Surg. 2010;34(12):3075-3079. 

Martin GJ. Screening and prevention of disease. In: Jameson JL, Fauci AS, Hauser K, et al, eds. Harrison’s Principles of Internal Medicine. 20th ed. New York, NY: McGraw Hill; 2018:26-31. 

US Preventive Services Task Force. Guide to clinical prevention services 2014. http://www.ahrq .gov/professionals/clinicians-providers/guidelines-recommendations/guide/index.html. Accessed November 1, 2015. 

Wilson JMG, Jungner G. Principles and practice of screening for disease. Geneva, Switzerland: World Health Organization; 1968.

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