It’s time to re-tool the annual exam: Here’s how
Capitalize on patients’ habit of visiting your office once a year to implement appropriate services
IN THIS ARTICLE
Recent advances in the understanding and detection of cervical cancer have resulted in a recommendation to increase the screening interval with a Pap smear from annually to every 2 or 3 years for low-risk patients. We know that cervical cancer requires the persistence of high-risk human papillomavirus (HPV) types to develop, and this knowledge has provided high-level evidence that annual cervical cancer screening is not beneficial for most women.
Where does this shift in the surveillance strategy for cervical cancer leave us? Implementing new screening intervals gives us a wonderful opportunity to reevaluate the annual exam, and to educate ourselves and patients about interventions that make an impact on health.
Eliminate the annual exam?
Do we still need routine encounters with our patients? In this article, I address 2 topics that can help answer the question: I review the evidence that supports annual “well-woman” visits and outline the interventions that have proven benefit.
Time to retire a time-honored tradition
The utility of an annual health visit—ie, a comprehensive head-to-toe physical exam coupled with a battery of tests for early identification of disease and intervention—came into question with the rise of evidence-based medicine in the mid-1970s and, eventually, became unsupportable. In 1979, the Canadian Task Force on the Periodic Health Examination concluded that the value of only a few preventive interventions was supported by data. In 1989, Oboler and colleagues concluded that “comprehensive annual exams in asymptomatic adults have little screening value…”1
The American College of Physicians, American Medical Association, US Preventive Services Task Force (USPSTF), and US Public Health Service all concur: The routine, annual, comprehensive physical exam is unnecessary. Instead, physicians should institute a selective approach to identifying and preventing health problems in all patients—one based on gender, age, health history, and risk factors.
Some interventions have helped
The incidence of, and mortality from, cervical cancer dropped strikingly in the United States with the advent of annual screening with the Pap smear. Mammography has recently been proved to increase the early detection rate of breast cancer and to reduce the rate of death from breast cancer. The challenge we face, therefore, is to determine which screening tests and interventions are valuable and will translate into improved health outcomes. The USPSTF has set out broad recommendations on 10 areas of screening for women:
- monitor blood pressure
- screen for cervical and colorectal cancers, depression, diabetes, and osteoporosis
- test for chlamydial infection
- measure the cholesterol level
- perform mammography.
New tool helps you develop an exam
Available for you is an excellent online resource developed by the Agency for Healthcare Research and Quality (AHRQ) for adopting the USPSTF screening recommendations. AHRQ has created the “electronic preventive services select” (or ePSS) Web site (epss.ahrq.gov), which is searchable by patient sex, age, and behavioral risk factors. The evidence for various preventive services is graded, guiding you on both interventions that are strongly recommended and those that should not be offered routinely because they lack data to support utility.
Make the transition with a systematic approach
We can capitalize on the habit that patients have established and have them come in annually for appropriate, evidence-based services. How do we make the change from the typical ObGyn visit—one that includes a breast and pelvic examination, cervical cancer screening, and mammography—to an evidence-based, annual well-woman visit that can be rapidly implemented and easily documented, using a paper or an electronic medical record?
I recommend creating templates for the annual well-woman visit that are age-specific and include check boxes for the age-appropriate history, physical exam, testing, and counseling that you’ll provide. You can create a distinct form for each of the various age and risk groups or, more simply, devise a single form that includes all guidelines for screening, from which you choose the appropriate areas based, again, on age and risk status.
What should you include on the template that you create? Here are possible items, based on what I use in my practice:
History. Document the patient’s age, allergies, medications, contraceptive method, and risk factors (eg, smoking, a history of infection with high-risk HPV types, and a significant family history of colon, breast, and ovarian cancer and of heart disease and diabetes). Develop a problem list of concerns that the patient, and you, have. Note: I ask the patient to complete a checklist review of systems at every annual visit; doing so helps identify specific health concerns she may want to discuss.
Physical exam. Measure height, weight, body mass index, and blood pressure. Check off items included in the examination of breast, abdominal, and pelvic structures, and elaborate on abnormal findings in a space provided. Include an area on the form for noting “other” concerns, such as findings of skin, musculoskeletal, upper respiratory, and cardiac assessments—any of which is performed as indicated.
Lab testing. Document routine testing with 1) a check box to indicate which tests have been ordered and 2) a line on which to note the tests that were identified as appropriate but were not performed or were deemed inappropriate—and why. Such documentation is helpful when coding pay-for-performance measures.
Counseling. Develop a list that includes smoking cessation, weight loss, exercise, contraception, and prevention of osteoporosis and sexually transmitted infection. The list helps you recall, and discuss, essential areas (TABLE 1).
The goal in developing and using a template? It provides a single, easy-to-use form that is flexible and applicable to all women, and that encourages consistent adherence to guidelines for screening and prevention.
Remember to provide lifestyle counseling!
Drink alcohol in moderation
Eat healthy—ie, high-fiber, low-fat foods, including fruits and vegetables
Exercise often—ie, aerobic, weight-bearing, and balance activities
Maintain healthy weight*
Use a condom during sexual intercourse
Use a contraceptive
*Be prepared to provide strategies for effective, sustainable weight loss to your patients
What do guidelines recommend that we embrace as interventions to make a difference in patients’ long-term health? Research and consensus have established that the annual well-woman visit be organized around clinical areas of concern, comprising 7 primary intervention areas and 3 optional areas of general health (TABLE 2). In addition, ObGyns are well-positioned to add several areas of counseling, support, and intervention:
- lifelong contraception management and planning
- pre-pregnancy counseling
- prevention of sexually transmitted infection
- identification of sexual concerns
- management of menopause.
Prevention of cervical Ca. With approval last year of the vaccine against several HPV types, we are in an unprecedented position to recommend vaccination against HPV—and other diseases.
Chlamydial infection. “Grade-A” evidence supports annual screening for Chlamydia trachomatis for 1) all sexually active women 25 years and younger and 2) older women who engage in high-risk behavior (eg, more than one sex partner).
Pap smear and HPV typing. ACOG and the American Cancer Society recommend annual Pap smear testing beginning 3 years after the onset of sexual activity and continuing until 30 years of age. Routine testing for high-risk HPV subtypes may be undertaken with the Pap smear for women older than 30 years.
For most women who test negative for HPV and who have negative Pap smear cytology, Pap smear testing should be repeated no more often than every 3 years. Women who are positive for a high-risk HPV type despite a negative Pap smear should continue to be screened annually with cytology and HPV testing.
Breast health. Many groups recommend training women to perform monthly breast self-examination (BSE), although the USPSTF states that there is “insufficient evidence to recommend for or against” BSE. All groups do, however, advise an annual breast examination by a clinician, along with annual or biennial mammography beginning at 40 years of age and annual mammography beginning at 50 years.
Although many women do detect a breast lump when performing a BSE, it is unclear whether BSE improves survival from breast cancer. That’s because many lumps that women discover are benign.
Generally, therefore, I tell patients to pay attention to their breasts as they would other body parts: Don’t ignore an obvious change but don’t feel it is necessary to perform a standardized examination of the breasts monthly; evidence just does not support such a need.
Cardiovascular health. Assess blood pressure in every patient at every visit. Persistently high readings (>130/80 mm Hg) should prompt action—whether lifestyle modification or medication. Many physicians are slow to treat young women with so-called labile or borderline hypertension because the onset of cardiovascular disease is generally at an older age in women, but evidence shows that women suffer from proportionately more strokes at a young age than men do. Aggressive management of persistent hypertension may improve outcome.
- Aspirin therapy is recommended for prevention of stroke in women 45 to 65 years who are at risk. Do not recommend aspirin routinely, however, for women younger than 65 years as a means of preventing myocardial infarction.
- Perform a baseline lipid profile on all women older than 45 years. A woman who has a risk factor for cardiovascular disease—smoking, hypertension, obesity or overweight, a family history of early-onset cardiovascular disease—should be screened at any age.
- Screening may be performed as a random lipid profile to eliminate the barrier of returning after an 8-hour fast. Only women who have a significant abnormality need to return for repeat testing after an overnight fast.
- I usually intervene with lifestyle modification recommendations first—more exercise, weight loss, more monounsaturated fats and omega-3 fats in the diet—and have the patient return for a fasting lipid profile after 3 to 6 months.
Although quality evidence is lacking on the benefit of counseling about weight reduction and exercise, my experience is that providing a message to patients consistently about a healthy lifestyle is more effective than almost any other medical intervention. To have an impact on cardiovascular health, however, it is imperative that we have basic knowledge about nutrition and exercise physiology—which were not taught in medical school.
It is, clearly, not useful to simply tell a patient to lose weight. Evidence does support sustained weight loss when a person participates in an organized program, such as Weight Watchers. Even moderate weight loss is associated with a reduction in the risk of hypertension, an improvement in lipid levels, and a substantial reduction in the risk of breast cancer.
I find that this last statistic—namely, that lifetime physical activity and maintenance of normal body weight is associated with a 20% to 40% reduction in the risk of breast cancer compared with the risk in women who do not exercise or who gain 10 kg or more above their high school weight—is a huge motivator. Why? It’s well-known that women are more concerned about breast cancer than about cardiovascular disease—even though statistics demonstrate that heart disease is the leading cause of death among women.
Diabetes. Women who have a history of gestational diabetes also have a markedly increased risk of type II diabetes within 5 years of the pregnancy. Clearly, these women, as well as those who are obese, have a strong family history of diabetes, or have abnormal lipid levels, should be screened with a random glucose measurement. Women who suffer chronic monilial infection should also be assessed for diabetes.
Colorectal cancer. The second leading cause of cancer death and the fourth most common cancer in the United States carries the same risk for women as it does for men. Polyps and cancers are more likely to present on the right (ascending) side of the colon in women, however, making screening with flexible sigmoidoscopy potentially less useful.