12 - The Periodic Health Examination

Abstract

Primary and secondary prevention is an essential part of primary care and the patient-centered medical home, but the appropriate services and their frequency vary with the age, gender, and the risk factors of each individual patient. A periodic health examination should focus on: screening tests with strong evidence of effectiveness; lifestyle counseling directed toward healthy diet, physical activity, and avoiding tobacco use and risky use of alcohol and other drugs; and discussion of possible preventive medications such as aspirin and statins. The most comprehensive prevention recommendations are produced by the U.S. Preventive Services Task Force (USPSTF), an ongoing panel of experts whose recommendations are used by major primary care subspecialty groups. The USPSTF bases its recommendations on two factors: an estimate of the net benefits (benefits minus harms) of a service and an assessment of the certainty of that estimate, based on the quality of supporting scientific evidence. Grade A recommendations require high certainty of a substantial net benefit, most often from large, prospective, controlled studies that measure morbidity or mortality. Grade B recommendations have high certainty of moderate net benefit or have moderate certainty for substantial benefit. USPSTF recommendations are more conservative than those of some organizations that may give more weight to earlier detection of disease. Clinicians can draw several general conclusions from an evidence-based approach to prevention: be selective in the use of screening tests, especially in older patients, and involve patients in decisions about specific services for which a small chance of benefit must be balanced against possible harm.