The Ultrasound-Assisted Physical Examination in the Periodic Health Evaluation of the Elderly
METHODS: Seventy-two patients presenting to a community-based family physician for periodic health evaluations received an ultrasound-assisted physical examination (USA-PE) from a second family physician. The results were reported to the primary physician, and the outcomes were tracked for periods of up to 2 years.
RESULTS: Twenty-two of the 72 patients (31%) had abnormalities found by the USA-PE that were not apparent during the conventional PE. Five of these patients (7%) had serious conditions that received prompt treatment with apparent benefit. Findings included endometrial carcinoma, abdominal aortic aneurysm, carotid stenosis, hydronephrosis, and urinary retention.
CONCLUSIONS: The USA-PE found more abnormalities in this group of patients than conventional PE. Whether it can improve outcomes for senior citizens undergoing periodic health evaluations in a cost-effective manner is yet to be determined.
The traditional physical examination (PE) has been limited to the use of the eyes, ears, and hands of the examiner and has excluded technological enhancement beyond the use of simple instruments. The value of the PE in the periodic health evaluation, however, has been called into question.1-6 Except for a few specific segments of the head-to-toe examination, the evidence suggests that it does not detect enough conditions in time to have a favorable impact on the outcome of patients’ health. The US Preventive Services Task Force7 does not list the PE among its recommended interventions for screening of the general or elderly population.
One possible reason for the failure of the PE to have a positive impact as a screening examination is that it is not sensitive enough to detect many diseases in their early stages, when intervention might have more benefit. For example, the PE is relatively insensitive and inaccurate, when compared with ultrasound, in the detection of carotid stenoses, thyroid nodules, various cardiac abnormalities, abdominal aortic aneurysms, renal cancers, hydronephroses, gallstones, and cancers of the uterus, ovaries, and urinary bladder. Ultrasound has demonstrated efficacy in the detection of these conditions in screening studies8-31 but has not been widely employed, primarily because of the cost of formal specialist-performed studies. We hypothesize that blending real-time diagnostic ultrasound into the PE performed by the primary care physician can increase its diagnostic yield with little additional cost. We call this amalgamation of physical and ultrasound examinations the ultrasound-assisted physical examination (USA-PE).
Methods
Study Population
New patients aged 65 years and older who presented to the office of a family physician in western New York for periodic health evaluations were informed about the study and offered the opportunity to participate. Seventy-two patients participated in the study. The study sample predominantly included middle-class suburban white people who had been under regular medical care with other physicians in recent years. We limited our study to seniors in anticipation that they might have a higher incidence of findings and to new patients so that fewer diagnostic tests might have been completed previously.
The Ultrasound-Assisted Physical Examination
Patients who agreed to participate were asked to return for an ultrasound-assisted examination by a family physician who had passed the registry examinations as a registered diagnostic medical sonographer (the examination used to certify ultrasound technicians). Most of the USA-PEs were conducted within 1 month of enrollment and the initial PE. The examinations were performed between October 1, 1996, and June 9, 1998. The Medison 4800 (Medison Co, Ltd, Seoul, Korea), an office-type real-time ultrasonic diagnostic scanner, was used in all USA-PE examinations. This machine has 7.5 and 3.5 mhz probes with duplex pulse-wave Doppler capability.
Before performing the USA-PE, the physician-sonographer reviewed the patient’s history and medical record. A conventional screening PE was performed; pelvic and rectal examinations were not repeated in our study. The diagnostic ultrasound machine was then used to screen the carotid arteries, the thyroid, the heart (assessed with 2 dimensional sonography only), the abdomen, and the pelvis. In total the USA-PEs, including both conventional PE and ultrasound-assisted components, took approximately 15 minutes each.
The findings of the USA-PE were made available to the primary physician, who then ordered confirmatory studies, made referrals, or decided on other interventions as he or she saw fit. Because of limited resources, positive findings were confirmed only if considered clinically significant, and negative findings were not confirmed. Thus, we did not confirm all gallstones, renal cysts, and other findings that, in the judgment of the primary physician, did not indicate further action. The 2 physicians periodically reviewed the progress and outcomes of the patients.
