Return of the Annual Physical
Return of the Annual Physical
Abstract & Commentary
By Mary Elina Ferris, MD, Clinical Associate Professor, University of Southern California. Dr. Ferris reports no financial relationship to this field of study.
Synopsis: Recommended periodic preventive services are more likely to be performed through a scheduled screening physical examination or other dedicated preventive visits.
Source: Boulware LE, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med. 2007;146:289-300.
Based on a recommendation from the American College of Physicians to the Agency for Healthcare Research and Quality (AHRQ), their Evidence-Based Practice Center Program sponsored this systematic review of the risks and benefits of the "Periodic Health Examination." A model was developed to define the study subject and rank the evidence, looking at outcomes for the delivery of standard preventive services associated with or without these types of examinations or dedicated visits.
The review identified 7,039 eligible articles published between 1973 through 2004, identifying 50 articles for consideration of randomized control or observational studies. One third were from countries outside the United States, and multiple practice settings and health care systems were included. Some of the larger trials were performed before 1989 when national preventive guidelines were introduced.
These periodic health examinations included patient histories and risk assessments as well as physical examinations, although the specific topics addressed varied. High outcomes for gynecological exam, Pap test, cholesterol screening and fecal occult blood testing were found, with medium association for immunizations and mammography. Increased outcomes proximal in time to the examination were seen for blood pressure changes, and moderately for disease detection, and changes in body mass index, patient attitudes and health habits. Other clinical preventive services had mixed associations. One study also documented a reduction in patient worry when a periodic health examination was performed.
Commentary
After living through years of physical exam bashing, its proponents may live to see vindication. Clinicians who had previously utilized these dedicated preventive visits were scorned when evidence-based medicine did not support the value of the annual exam for asymptomatic patients. We were told to incorporate preventive screenings into acute and follow-up visits for increased efficiency (and economy).
However, this review of the literature over the past 30 years disputes the previous conclusions. A "periodic health examination" was associated with increased delivery of preventive services, both for those services at the time of the exam and scheduled soon thereafter, when compared to patients who did not have these dedicated examinations. This may not surprise busy clinicians who rarely have time to address prevention unless sufficient time is allocated, and in fact surveys of both internists and family physicians have revealed ongoing support for these exams despite lack of evidence.1-2
While there are other approaches to increase preventive services, such as reminder systems, checklists and other personnel to encourage patient compliance, this review does support the return to a dedicated periodic health examination for preventive services if we wish to increase their usage. The authors note that no "harm" was associated with this kind of exam but they do not address the costs involved. With new systems of grading clinicians on the horizon based on their delivery of preventive services, we may find ourselves once again scheduling the "annual physical examination."
References
1. Prochazka AV, et al. Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers. Arch Intern Med. 2005;165(12):1347-1352.
2. Luckmann R, Melville SK. Periodic health evaluation of adults: a survey of family physicians. J Fam Pract. 1995;40:547-554.
Recommended periodic preventive services are more likely to be performed through a scheduled screening physical examination or other dedicated preventive visits.Subscribe Now for Access
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