Clinical Review

It’s time to re-tool the annual exam: Here’s how

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Capitalize on patients’ habit of visiting your office once a year to implement appropriate services


 

References

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 (http://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.

Build a screening form

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.

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