GREAT RESOURCES FOR RESIDENCY
HEALTH MAINTENANCE CHECKLIST
The Checklist:
Immunizations:
Cancer Screening:
Chronic conditions:
Obesity
Tobacco
End-of-life discussion
Opioids
Infectious Disease:
HCV
HIV
THE CHECKLIST:
MEN
Vaccines:
Influenza: yearly
PCV 13: (65yo)
PPSV23: (1yr after PCV13 or risk factors)
TD, TDaP: (once, then Td q10y)
Zoster: (60yo)
Cancer:
Colon (50-75yo): FIT q1y, C-scope q10y (also CTC, flex sig)
Prostate (discuss r/b >40 yo AA or 1st degree relative): PSA, repeat q2-4yrs
Lung (55-80yo active >30pk-yr-hx or quit <15yrs): low dose CT chest annually
Chronic diseases:
Tobacco use: Pk-yr hx? Counsel.
Lipids: 35yo males, 45yo females if no risk factors
ASCVD risk: statin if LDL>190, DM 40-75, risk >7.5%
DM2: 45yo unless risk factors
Obesity: BMI >25, counsel q6mo
AAA: Men 65-75yo ever smoker, once
End of life: advanced directive?
Opioids: Use? Pain contract signed? Renewed yearly
Infectious diseases:
HIV: once in a lifetime or risk factors
HCV: DOB 1945-65, or other risk factors
WOMEN
Vaccines:
Influenza: yearly
PCV 13: (65yo)
PPSV23: (1yr after PCV13 or risk factors)
TD, TDaP: (once, then Td q10y)
Zoster: (60yo)
Cancer:
Breast: 50-74yrs mammo q2y (40-49 discuss r/b)
Cervical cancer: 21-29yrs pap q3y, 30-65yrs pap+HPV q5y
Colon: 50-75yo, FIT q1y, C-scope q10y (also CTC, flex sig)
Lung (55-80yo active >30pk-yr-hx or quit <15yrs): low dose CT chest annually
Chronic diseases:
Tobacco use: Pk-yr hx? Counsel.
Lipids: 35yo males, 45yo females if no risk factors
ASCVD risk: statin if LDL>190, DM 40-75, risk >7.5%
DM2: 45yo unless risk factors
Obesity: BMI >25, counsel q6mo
DEXA: >65 (<65 menopausal if risk factors, use FRAX tool)
End of life: advanced directive?
Opioids: Use? Pain contract signed? Renewed yearly
Infectious diseases:
HIV: once in a lifetime or risk factors
HCV: DOB 1945-65, or other risk factors
Other:
Contraceptive counseling
Intimate partner violence
HOW TO USE IT
Copy-paste the checklist at the end of your note (you can do it as Autotext in Impact or make it part of your template at the VA)
Vaccines: Month and year patient got the vaccine. If not indicated write "Not indicated". If indicated but has not yet gotten it, write "Pending, discuss next visit". If patient refused, write "Refused" and make sure to include the date.
Cancer: Month and year screening was performed. Brief comment on findings. Date of repeat screening.
Tobacco: Always include here if the patient currently smokes or not and the total history of smoking. If not discussed previously on your note, comment on patient's interest in quitting and make sure to put the date.
Infections: Mention if test was positive/negative and month and year test was done.
EXAMPLE:
Vaccines:
Influenza: Refused 11/2016
PCV 13: Not indicated
PPSV23: 10/2015
TD, TDaP: 05/2015 last, due for next dose. Discuss next visit.
Zoster: 01/2016
Cancer:
Colon: Colonoscopy 05/2009 with 1 adenomatous polyp, repeat in 05/2019
Prostate: Refused screening 05/2017
Lung: Low-dose CT negative 11/2016, repeat 11/2017
Chronic diseases:
Tobacco use: Smokes 1 PPD, hx of 35 pack-years, no interested in quitting as of 05/18/2017
Lipids: 35yo males, 45yo females if no risk factors
ASCVD risk: Risk 13.5%, on atorvastatin 40 mg.
DM2: A1c 5.8% 05/2016
Obesity: BMI 31, discuss weight loss and Move! next visit
AAA: Not indicated, offer at age 65
End of life: No advanced directive, life expectancy >6mo, not discussed today
Opioids: On Norco 5 TID, last UDS 05/2017 positive for opioids only, pain contract due 11/2017
Infectious diseases:
HIV: Non-reactive 10/2015
HCV: Discuss next visit
VACCINES:
INFLUENZA
Influenza text comes here
PNEUMONIA - PCV 13
Vaccine text comes here
PNEUMONIA - PPSV 23
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TD, TDAP
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ZOSTER
Recommendations per CDC
Administer 2 doses of recombinant zoster vaccine (RZV) (Shingrix) 2–6 months apart to adults aged 50 years or older regardless of past episode of herpes zoster or receipt of zoster vaccine live (ZVL) (Zostavax).
Administer 2 doses of RZV 2–6 months apart to adults who previously received ZVL at least 2 months after ZVL
For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred)
Contraindications per CDC
Severe immunodeficiency, e.g., hematologic and solid tumors, chemotherapy, congenital immunodeficiency or long-term immunosuppressive therapy, human TDAP immunodeficiency virus (HIV) infection with severely immunocompromised
Pregnancy
Recent (within 11 months) receipt of antibody-containing blood product (specific interval depends on product)
History of thrombocytopenia or thrombocytopenic purpura
Need for tuberculin skin testing
CANCER SCREENING:
COLORECTAL CANCER
Indications for screening for people at average risk according to USPSTF
Adults aged 50 to 75 years.
USPSTF recommends against routine screening adults aged 76 to 85 years.
USPSTF recommends against screening of adults >85 years.
In addition to above, for people with increased risk of colorectal cancer the US Multi-Society Task Force recommends:
What test(s) to perform?
Stool-based test:
Guaiac-based Fecal Occult Blood Test* (gFOBT) every year
Yearly Fecal Immunochemical Test (FIT) every year (results not influenced by food or medications)
FIT-DNA every 1-3 years
Colonoscopy every 10 years
CT colonography every 5 years
Flexible sigmoidoscopy every 5 years
Flexible sigmoidoscopy every 10 years with yearly FIT
These alternatives are similarly effective to detect cancer. There are no studies comparing them head-to-head and each have their own advantages and disadvantages (see Resources section). Make sure to discuss with your patient which approach is more convenient to them as this increases screening uptake.
(*) Highly sensitive versions of gFOBT should be used, which consist of the take-home multiple sample method (3 samples over 3 days). A gFOBT done during a digital rectal exam in the doctor’s office is not enough for screening. FIT is a single-day test.
Follow-up algorithm
If FOBT or sigmoidoscopy are positive the patient needs to undergo a colonoscopy.
If colonoscopy is positive for polyps:
Benefits
Screening for colorectal cancer in adults aged 50 to 75 years reduces colorectal cancer mortality (e.g. relative risk of death with annual FOBT screening was 0.68; 95% CI 0.56 to 0.82)1.
Adults who have never been screened are more likely to benefit.
Screening is most appropriate for those healthy enough to undergo treatment and those without comorbid conditions that significantly limit their life expectancy.
Harms
The harms of screening for colorectal cancer in adults aged 50 to 75 years are small.
The majority of harms result from the use of colonoscopy, either as the screening test or as follow-up for positive findings detected by other screening tests.
The rate of serious adverse events from colorectal cancer screening increases with age. Thus, the harms of screening for colorectal cancer in adults 76 years and older are small to moderate.
High-Value - Cost conscious
Colorectal cancer screening by any modality is cost-effective.
Consistent trends reveal that FIT performs well compared with other screening tests. Colonoscopy also performs well in most models and, in general, the traditional tests are more cost-effective than the newer modalities.
Resources
Shared Decision Making - Online Tools:
To estimate your patient´s risk of colon cancer click here. This is a great resource, just a little bit long. May take a few minutes and is ideally performed with patient present due to detailed questions.
For advantages and disadvantages of each testing method click here.
For insurance information click here.
H. Gilbert Welch has done extensive research on the risk of overdiagnosis and cancer screening. Check his paper Overdiagnosis in cancer or, if interested in a more in-depth review of these topics, his books Overdiagnosed and Less Medicine More Health are great reads.
Bibliography
Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement 2016
Colorectal Cancer Screening – US Multi-Society Taskforce 2017
Author: Aldo De Ferrari
Reviewed by: Pending
Last updated: 05/2018
BREAST CANCER
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CERVICAL CANCER
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LUNG CANCER
Indications for Screening according to USPSTF
Adults aged 55 to 80 years
History of >30 pack-year of smoking and currently smoke or have quit within the past 15 years
Discontinue low-dose chest CT (LDCT) if patient has not smoked for 15 years or has a health problem that significantly limits life expectancy
Of note, Medicare covers lung cancer screening for patients aged 55 to 77 years only
What test to perform?
Yearly low-dose chest CT (LDCT)
Make sure your patient understands that lung cancer screening is not a single test, but a process that must be done correctly under the direction of a physician.
Lung cancer screening is NOT an alternative to smoking cessation, which is the most important intervention to decrease the risk of dying from lung cancer.
Follow-up algorithm
Usually Radiology will make a recommendation on how and when to follow-up a positive test. Most often this involves repeat imaging and, occasionally, invasive tests like a biopsy.
Benefits - Recommend to discuss using a shared-decision making tool (see Resources section)
Annual screening for lung cancer with LDCT in high-risk persons can prevent a substantial number of lung cancer–related deaths.
The magnitude of benefit to a particular individual depends on that person's risk for lung cancer — those who are at highest risk are most likely to benefit.
Screening cannot prevent most lung cancer–related deaths, and smoking cessation remains essential.
Harms - Recommend to discuss using a shared-decision making tool (see Resources section)
Harms include false-negative and false-positive results, incidental findings, overdiagnosis, and radiation exposure.
False-positive LDCT results occur in a substantial proportion of screened persons; 95% of all positive results do not lead to a diagnosis of cancer.
A modeling study performed for the USPSTF estimated that 10% to 12% of screen-detected cancer cases are overdiagnosed —that is, they would not have been detected in the patient's lifetime without screening.
Resources
Shared-decision making tools online:
Lung cancer risk calculator. Great guide to use with your patients.
Shared-decision making tools print:
Lung Cancer Screening: A Summary Guide for Primary Care Clinicians
Lung Cancer Screening: A Clinician’s Checklist
H. Gilbert Welch has done extensive research on the risk of overdiagnosis and cancer screening. Check his paper Overdiagnosis in cancer or, if interested in a more in-depth review of these topics, his books Overdiagnosed and Less Medicine More Health are great reads.
Bibliography
PROSTATE CANCER
The USPSTF states that for men aged 55-69 years, the decision to undergo periodic screening with PSA should be an individual one. Patients and clinicians should discuss benefits and harms together (shared-decision making). Clinicians should not screen men who do not express a preference for screening.
The USPSTF recommends against screening for men older than 69 years of age.
Indications for men at average risk of prostate cancer according to different organizations (see table below).
Who is considered high risk?
African American men
Men with a first-degree relative with prostate cancer, particularly if diagnosed <65 years of age.
What test to perform?
USPSTF and ACP recommend screening with PSA testing only. The role of digital rectal examination (DRE) is unclear.
A PSA >4.0 µg/L has:
A sensitivity of 21% for detecting any prostate cancer and 51% for detecting high-grade cancers (Gleason ≥8)
A specificity of ~91%
A PPV of ~25% (a PSA >10 µg/L has a PPV of 42 to 64%).
A PSA <4.0µg/L has a NPV of 85%.
Frequency of screening
It is unknown how often testing should be done.
The PLCO trial screened men yearly and found no benefit. A reasonable approach based on the ERSPC trial (European Randomized Study of Screening for Prostate Cancer) may be to test every 2-4 years (range 2 - 7 years in that trial).
In ERSPC trial the subgroup with a threshold cutoff for biopsy of >2.5 and screening every 2 years had the largest benefit from screening (but also the highest number of complications)
Follow-up algorithm (based on ACS guidelines)
PSA <2.5 µg/L: normal, no further testing.
PSA 2.5 - 4.0 µg/L: considered intermediate. Per ACS a DRE may be helpful in this population to decide whether or not to do a biopsy.
PSA >4.0 µg/L: has been traditionally considered positive requiring further testing (e.g. biopsy).
Important: there are no true PSA cutoffs to distinguish cancer from noncancer. Please take the information above very carefully as this recommendations do not come from high-quality studies. Also keep in mind that the PSA test has poorer discriminating ability in men with symptomatic BPH.
Benefits
Adequate evidence from randomized clinical trials shows that PSA-based screening programs in men aged 55 to 69 years may prevent approximately 1.3 deaths from prostate cancer over approximately 13 years per 1000 men screened.
Screening programs may also prevent approximately 3 cases of metastatic prostate cancer per 1000 men screened.
Current results from screening trials show no reductions in all-cause mortality from screening.
Harms
False alarms related to high number of false-positive results associated with DRE and especially PSA
High false-negative rates
Positive screening results may lead to further testing, such as biopsies, which can be painful and lead to complications (pain, fever, hematospermia, and hospitalization)
Overdiagnosis (detection of cancer that is not destined to cause future morbidity and mortality) in 20-50% of all men diagnosed with prostate cancer
Overtreatment and associated harms. About 1 in 5 men who undergo radical prostatectomy develop long-term urinary incontinence requiring use of pads, and 2 in 3 men will experience long-term erectile dysfunction. More than half of men who receive radiation therapy experience long-term sexual erectile dysfunction and up to 1 in 6 men experience longterm bothersome bowel symptoms, including bowel urgency and fecal incontinence.
Benefits usually emerge years or even decades after screening and occur in a small number of men
Value of screening
According to ACP, prostate cancer screening with PSA is considered low-value care given that “the chances of harm with screening outweigh the chances of benefit for most men and that the direct and indirect costs associated with biopsy, repeated testing, aggressive therapy, patient anxiety, and missed work are significant.”
Resources
Points to discuss on a shared-decision making approach per ACP
H. Gilbert Welch has done extensive research on the risk of overdiagnosis and cancer screening. Check his paper Overdiagnosis in cancer or, if interested in a more in-depth review of these topics, his books Overdiagnosed and Less Medicine More Health are great reads.
Bibliography
American Cancer Society Guideline for the Early Detection of Prostate Cancer (2010)
PLCO trial (2012)
ERSPC trial (2014)
CAP trial (2018)
Author: Aldo De Ferrari
Reviewed by: Dr. Winter Williams
Last updated: 05/2018
CHRONIC CONDITIONS:
LIPIDS
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ASCVD RISK
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DIABETES
Indications for screening according to USPSTF (Grade B)
Adults 40-70 years old who are overweight or obese
Importance
Diabetes is the leading cause of blindness, renal disease, and amputations
What test to perform?
Three different screening tests:
Fasting plasma glucose
Oral glucose tolerance test
Hemoglobin A1c
Screening intervals
An optimal screening interval is not known but the American Diabetes Association recommends every 3 years
Is there a treatment?
Combination counseling on a healthful diet and physical activity. Insufficient evidence to suggest medication has the same benefits as behavioral interventions
Benefits
Evidence suggests that tight glycemic control can reduce macrovascular complications (myocardial infarction and stroke)
Harms
Short-term anxiety but not long-term psychological harms
Bibliography
Author: Ashley Vorenkamp
Reviewed by: Pending
Last updated: 05/2018
HYPERTENSION
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OBESITY
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TOBACCO
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ABDOMINAL AORTIC ANEURYSM SCREENING
Definition of AAA
AAA is defined as a dilated aorta with a diameter at least 1.5 times the diameter measured at the level of the renal arteries.
In most individuals, the diameter of the normal abdominal aorta is approximately 2.0 cm (range 1.4 to 3.0 cm).
For practical purposes, an AAA is diagnosed when the aortic diameter exceeds 3.0 cm.
Indications for screening according to USPSTF
Men aged 65-75 years who have ever smoked (smoking defined as >100 cigarettes in lifetime).
Men aged 65-75 years who have never smoked can selectively be offered screening based on the patient's medical history, family history, other risk factors, and personal values.
What test to perform?
One-time abdominal ultrasound. US is considered the screening modality of choice for AAAs because of its high sensitivity and specificity, as well as its safety and relatively low cost.
If, for whatever reason, your patient had a CT abdomen and pelvis with or without contrast between ages 65-75 years that showed no AAA, you probably do not need to obtain an ultrasound (of note, this observation is based on this study). This also applies for MRI.
Follow-up algorithm
Aortic diameter <2.6 cm: Re-screening is not recommended
Aortic diameter 2.6-2.9 cm: Follow-up imaging at 5-year intervals is recommended
Aortic diameter 3.0-3.4 cm: Follow-up imaging at 3-year intervals is recommended
Aortic diameter 3.5-4.4 cm: Follow-up imaging at 12-month intervals is recommended
Aortic diameter 4.5-5.4 cm: Follow-up imaging at 6-month intervals is recommended
Aortic diameter ≥5.5 cm: Surgical repair is recommended
Benefits
One-time screening with US for AAA has been shown to be effective in reducing AAA-related mortality and AAA rupture in men 65 years and older. It is also associated with increased elective AAA operations and decreased emergency AAA operations.
Harms
Psychological distress, particularly for patients with small AAAs that do not require immediate intervention and will likely never cause harm.
Adverse outcomes from management of the AAA. The perioperative (30-day) mortality rate with elective AAA repair in major randomized trials varied from 2.7 to 5.8 percent, depending upon comorbidity factors and the type of procedure.
Medicare Coverage
Males between 65 and 75 years of age who smoked at least 100 cigarettes.
Males or females with a family history of AAA.
Bibliography
USPSTF Guidelines 2014
Surveillance intervals for small AAAs JAMA 2013
Check Uptodate, has a good and relatively brief article on this topic.
Template
As you may remember, we performed an abdominal ultrasound on 0718 to rule out the presence of an abdominal aortic aneurysm, which is an abnormal dilation of the aorta (the big vessel that brings blood to all of our body). This test is performed to all men aged 65-75 years that have smoked at some point in their lives, even if they already quit smoking.
I have the pleasure to inform you that your ultrasound was normal and no aneurysm was found on your aorta. This is excellent news.
For questions or concerns, please call us at xxx-xxxxxxx. We would like to see you back in clinic in xx months. You can always get an appointment earlier if needed. If you do not have one, please call the clinic at xxx-xxxxxxx ext. xxxx at least one month ahead of time.
Author: Aldo De Ferrari
Reviewed by: Pending
Last updated 11/2017
OPIOIDS
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