Dr Hanan AbbasLecturer of Family Medicine

What is evidence based medicine

This means “integrating individual clinical expertise with the best available external clinical evidence from systematic research”.

An approach to teaching and practice to optimize patient outcomes by integrating

• Patient centered• Clinical research• Clinical expertise

Levels of evidence

I Evidence obtained from a systematic review of all relevant randomized controlled trials

II Evidence obtained from at least one properly designed randomised

controlled trial

III Evidence obtained from any of the following:

• well designed pseudo randomised controlled trials

• comparative studies with concurrent controls and allocation not randomised (cohort studies),case control studies

• comparative studies

IV Evidence obtained from case series, either post-test or pre-test and post-test

V Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees

No evidence After thorough searching no evidence was found regarding recommendations in general practice for the target disease or condition

Strength of recommendation

A There is good evidence to support the recommendation

B There is fair evidence to support the recommendation

C There is poor evidence regarding the inclusion or exclusion of the recommendation but

recommendations may be made on other groundsD There is fair evidence against the recommendationE There is good evidence against the recommendation

National guideline clearinghouse

Clinical Preventive Services, Including Screening and/or Counselling or Immunization

Counseling parents and patients more than 2 years old regarding accidental injury prevention

Screening for bladder cancer in adults (Note: Considered but not recommended) Counseling and screening women 40 years and older for breast cancer with mammography Teaching or performing routine breast self-examination (Note: Considered but not

recommended) Referring specified female population for genetic counseling and evaluation for BRCA testing Counseling parents of infants regarding breastfeeding Screening women for cervical cancer with Pap smear (Note: Guideline developers

considered but did not recommend primary screening with human papillomavirus testing and new technologies)

Screening specified populations for colorectal cancer Counseling adults at risk for coronary heart disease regarding aspirin prophylaxis Screening for coronary heart disease with electrocardiograph, exercise treadmill test, or

electron-beam computerized tomography (Note: Considered but not recommended) Screening for depression in specified population Screening specified populations for type 2 diabetes Immunizing children for diphtheria Screening infants for dysplasia of the hip (Note: Considered but not recommended)

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Screening for family violence and intimate partner violence (Note: Considered but not recommended)

Behavioral dietary counseling for specified populations

Screening newborns for hearing loss sensorineural (SNHL) (Note: Considered but not recommended)

Screening neonates for hemoglobinopathies, phenylketonuria (PKU), and thyroid function abnormalities

Immunizing specified populations for hepatitis A

Immunizing specified populations for hepatitis B

Screening specified populations for hepatitis B virus

Screening for hepatitis C virus (Note: Considered but not recommended)

Hormone replacement therapy in postmenopausal women (Note: Considered but not recommended)

Screening specified populations for hypertension

Screening for insulin dependent diabetes mellitus using immune marker screening (Note: Considered but not recommended)

Screening specified populations for iron deficiency anemia

Screening specified populations for lipid disorders with fasting lipid profile or nonfasting total cholesterol and high-density lipoprotein (HDL) cholesterol screening

H.A. 6

Screening for lung cancer with x-ray and/or sputum cytology (Note: Considered but not recommended)

Immunizing children for measles & mumps & pertussis & tetanus Immunizing specific populations for meningococcal disease Folic acid supplementation in specified female population to prevent neural tube

defects Screening and counseling for obesity Screening specified populations for osteoporosis Counseling specified populations regarding calcium intake as prevention Screening for ovarian cancer (Note: Considered but not recommended) Screening for pancreatic cancer using abdominal palpation, ultrasound, or

serological markers (Note: Considered but not recommended) Screening for peripheral arterial disease (PAD) (Note: Considered but not

recommended) Counseling children, adolescents, and adults regarding importance of physical

activity Screening for prostate cancer using prostate specific antigen (PSA) testing or

digital rectal examination (DRE) (Note: Considered but not recommended) Rh (D) blood typing and antibody testing for pregnant women Immunizing children for rubella

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Screening for idiopathic scoliosis in adolescents (Note: Considered but not recommended)

Counseling parents with children in the house regarding smoking Counseling adolescents and adults regarding prevention of

sexually transmitted diseases Screening for testicular cancer (Note: Considered but not

recommended) Screening neonates for thyroid function abnormalities Screening specified populations for tobacco use and providing

smoking cessation counseling Screening specified individuals for tuberculosis using the Mantoux

test Screening specified populations for vaginal cancer (Note:

Considered but not recommended) Vitamin supplementation (A, C, E, beta-carotene; multivitamins

with folic acid; or antioxidant combinations) for prevention of cancer or cardiovascular disease (Note: Considered but not recommended)

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The recommendations include:SR Strongly Recommend: Good quality evidence

exists which demonstrates substantial net benefit over harm; the intervention is

perceived to be cost effective and acceptable to nearly all patients.

R Recommend: Although evidence existswhich demonstrates net benefit, either the benefit is only

moderate in magnitude or the evidence supporting a substantial benefit is only

fair. The intervention is perceived to be cost effective and acceptable to most patients.

NR No Recommendation Either For or Against: Either good or fair evidence exist of at least a small net benefit. Cost-effectiveness

may not be known or patients may be divided about acceptability of the intervention.

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RA Recommend Against: Good or fair evidence which demonstrates no net benefit over harm.

I Insufficient Evidence to Recommend Either for or Against: No evidence of even fair quality exists or the existing evidence is conflicting.

I-HB Healthy Behaviour is identified as desirable but the effectiveness of physician’s advice and counselling is uncertain.

Physicians are encouraged to review not only the needs of individual patients they see, but also of the populations in the communities they serve to determine which specific population recommendations need to be implemented systematically in their practices.

The recommendations contained in this document are for screening and counselling only. They do not necessarily apply to patients who have signs and/or symptoms relating to a particular condition.

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HEALTH MAINTENANCE FOR THE ADULT PATIENT

Diet. Nutritional assessment of intake of fat (saturated fats, polyunsaturated fatty acids, monounsaturated fatty acids , cholesterol, complex carbohydrates, fiber, sodium, iron, and calcium (women) should be initiated.

Eat a variety of foods; maintain a healthy weight; choose a diet low in saturated fat and cholesterol; choose a diet with plenty of vegetables, fruits, and grain products; use complex carbohydrates in moderation and limit intake of simple carbohydrates; use salt and sodium in moderation;

Calcium is especially important for women beginning in their teens decade to reduce the risk of osteoporosis and bone fracture. Average daily intake should be 1,000–1,500 mg.

Exercise. Patients should be given at least a brief exercise prescription, dynamic movement of large muscle groups for at least 20 minutes, 3 or more days per week,

Substance use. Include advice on cessation of tobacco use, Injury prevention. counseling efforts in this area should include use

of safety belts and helmets, prevention of violent behavior, Unintentional injuries include motor vehicle–related injuries and environmental and household injuries.

Preconception counseling. Counseling and risk assessment, in addition to emphasizing general health promotion (abstinence from drugs, and tobacco products and lowering risk of sexually transmitted disease) can reduce risk of congenital malformations and low birth weight, markedly improving outcomes by reducing infant morbidity and mortality.

Recommended counseling strategies include the following:

1. Develop a therapeutic alliance.

2. Counsel all patients.

3. Ensure that patients understand the relationship between behavior and health.

4. Jointly assess barriers to change.

5. Gain patient commitment to change.

6. Involve patients in selecting risk factors to change.

7. Be creative, flexible, and practical, and use a combination of strategies.

8. Design a behavior modification plan.

9. Monitor progress through follow-up contact.

10. Involve office staff (team approach).

Screening

Scientific evidence strongly supports the screening of all adults for cardiovascular risk factors (tobacco use, hypertension, hyperlipidemia, sedentary lifestyle, family history), women older than 40 for breast cancer, and all adult women for cervical and ovarian cancer. Screening for colorectal cancer is recommended for adults older than 40 years.

B. Criteria for screening.

1. The condition must have a significant effect on the quantity of life.

2. Acceptable methods of treatment must be available.

3. The condition must have an asymptomatic period during which detection and treatment significantly reduce morbidity and mortality.

4. Treatment in the asymptomatic phase must yield a therapeutic result superior to that obtained by delaying treatment until symptoms appear.

5. Tests that are acceptable to patients must be available at a reasonable cost to detect the condition in the asymptomatic period.

6. The incidence of the condition must be sufficient to justify the cost of screening. Test sensitivity, specificity, are important factors in the selection and evaluation of screening tests. Poor sensitivity or specificity can lead to a high rate of false-positive and false-negative results, both of which carry potentially serious consequences for patients.

Screening for coronary artery disease and hypercholesterolemia

Blood pressure readings should be obtained at every office visit and at least once every 2 years.

Total cholesterol should be measured periodically in men aged 35–65 and women aged 45–65; there is insufficient evidence to recommend for or against routine screening of younger men and women. Also, the appropriate frequency of and interval between screenings has not been established.

However, after age 40, given the prevalence of cardiovascular disease, screening should occur at least every 5 years.

Given the importance of lipid subfractions in therapeutic decisions, a fasting lipid profile should be obtained.

All patients should be counseled about intake of dietary saturated fat and other measures to reduce coronary heart disease (CAD)

The most important risk factors for CAD to screen for remain smoking, diabetes, and hypertension as well as hypercholesterolemia.

Screening for osteoporosis.

osteoporosis risk factors should be screened for in all women . Perimenopausal women at increased risk are Caucasian or Asian, have a history of bilateral oophorectomy before menopause, have a slender build, smoke or have smoked tobacco, have low calcium consumption patterns, a sedentary lifestyle, and a positive family history of the condition.

IV. Immunizations

Hepatitis A vaccine for health care and lab workers, for injection or street drug users and their partners, for institutionalized persons and their caregivers, as well as for persons traveling abroad to endemic areas or wherever periodic outbreaks occur.

Hepatitis B vaccine if high-risk status (health care workers, intravenous drug users, homosexual persons, dialysis recipients, blood product recipients).

Chemoprophylaxis

This important component of adult health maintenance, often underprescribed, involves the use of medications or supplements prospectively to prevent potential future diseases. Indications (benefits), risks of use and nonuse, dosage, precautions, and possible side effects of chemoprophylactic agents are basic issues for the family physician in helping patients decide whether or not to adopt a specific intervention as a health maintenance strategy.

Recommended chemoprophylactic agents

1. Aspirin therapy. Recent longitudinal trials indicate a benefit for women as well as men from daily or every-other-day use of aspirin after age 40 to prevent

vascular disease, especially if the patient is at high risk or has a family history of coronary artery disease and no risk of stroke or bleeding.

Other recent studies have suggested that regular aspirin at doses recommended for prevention of cardiovascular disease may also decrease the risk of and mortality from colorectal cancer for both men and women.

Hormone replacement therapy (HRT). There is general agreement for the use of estrogen alone (in women with no uterus) or an estrogen–progesterone combination (in women with intact uterus) for prevention and treatment of osteoporosis, especially for patients with early menopause, or at a high risk of osteoporosis. Recent data suggest that the cardioprotective benefit of HRT during the first year is in question, with only possible benefit after 4–5 years of use.

HRT should be avoided among women with above-average risk of breast cancer and with a history of deep venous thrombosis.

Effective physician and office-based strategies

A. Involve the office staff. A team approach to the delivery of preventive services is highly effective.

Examples of specific staff functions include reviewing records to prompt clinicians and patients regarding preventive Care, issuing reminders to patients and clinicians, following up on test results, All immunizations and many screening activities can be successfully provided by nurses

B. Incorporate routine documentation tools into your practice.

C. Facilitate patient compliance. Make available patient education materials and information. Patient-held

mini-records, promote increased responsibility among patients for their own health maintenance activities

Patient education materials should also be appropriately directed in terms of the patient's literacy level and other pertinent factors (older than 60 years, requiring large print, etc.).

D. Establish health maintenance guidelines (standards and objectives) for the practice and evaluate achievement through audits and continuous quality improvement approaches. Practice systems to foster adult health maintenance activities can be most effectively evaluated through periodic reviews of charts and specifying other indicators of quality.

E. Develop mini-counseling topics. Ten preventive topics, 3–10 minutes in duration and updated as necessary, can maximize the impact of “teachable moments.” The list may include exercise, smoking cessation, stress reduction, injury prevention, discipline and parenting skills, and family health promotion.

F. Reminder systems. Generate compliance reminders.

II. Primary prevention to older adults

Injury prevention. Injuries are a frequent cause of death in the elderly.

1. Elderly patients should be counseled regarding the dangers of falls and the benefits of exercise. Avoidable causes of falls include environmental hazards, such as poor lighting or throw rugs, visual deficits, and debilitation. Physicians should counsel older adults to gradually increase their exercise capacity by walking, gardening, or doing household chores. In addition to reduced fall risk, benefits demonstrated in population studies include lower incidence of cardiovascular disease, improved mood, and lower incidence of osteoporosis.

Osteoporosis. Hormone replacement therapy (HRT) (estrogen and progestin for women with a uterus, estrogen alone for those without) should be considered for women at risk of osteoporosis.

Calcium supplementation (daily total of at least 1,000–1,500 mg of elemental calcium) should be recommended whether or not HRT is given.

While the task force did not recommend routine screening, the National Osteoporosis Foundation recommends bone mineral density testing on all white women 65 years or older

Dyslipoproteinemia (hypercholesterolemia). Whereas secondary prevention of cardiovascular diseases with lipid-lowering drug therapy is well established, primary prevention is controversial.

The National Cholesterol Education Program advocates screening elderly persons with a good life expectancy by measuring high-density lipoprotein and total cholesterol. Most authorities recommend against treating elderly patients without known ischemic heart disease with

lipid-lowering drugs because only one trial has been done that included men and women older than 65 years and large numbers of patients must be treated to prevent one adverse outcome. The decision must be individualized, based on the senior's quality of life, life expectancy, other risk factors, cost, and patient preferences.

Breast cancer

There is universal consensus to offer mammography every 1–2 years for women aged 40 to 50, and annually thereafter. The American

Cancer Society (ACS) recommends obtaining a baseline mammogram at age 35. There is no consensus at what age to stop screening.

The U.S.Preventive Services Task Force (USPSTF) recommends routine screening until age 69, with continuing mammograms on an individual basis.

The ACS and the American College of Obstetricians and Gynecologists recommend that clinical breast examinations be started prior to age 40. These examinations should be performed annually after age 40.

There is insufficient evidence to recommend for or against teaching breast self-examination

Cancer colon

Persons with a positive family history should receive a colonoscopy by age 50. However, a recent study suggests that colonoscopic screening can detect advanced neoplasms in asymptomatic adults that were not detected with sigmoidoscopy

fecal occult blood tests (FOBTs) remains the most cost-effective screening tool in people older than age 50. If the test result is positive, follow-up examination with colonoscopy or flexible sigmoidoscopy plus air contrast barium enema (ACBE) should be undertaken.

People older than 50 years may also benefit from screening with flexible sigmoidoscopy every 3–5 years. With a history of colon polyps, people should receive a colonoscopic screening every 5–10 years.

Cancer colon:

Colorectal cancer. Rectal examination is not a useful screen in the asymptomatic patient. Fecal occult blood testing done yearly has been shown to reduce mortality from colon cancer by 33% (8,9), although the utility of this test may be less in the elderly due to a higher false-positive rate in the elderly.

Rigid sigmoidoscopy has also been demonstrated to be effective in reducing mortality from cancer in the distal colon, but the optimal frequency of this screening is not clear. There is insufficient evidence to recommend one test over the other.

Cervical cancer

Women with cervixes who are or have been sexually active should have smears at least every 3 years.

Prostate cancer. Prostate-specific antigen (PSA) for prostate cancer is not recommended by the USPSTF.

Cervical cancer screening. Regular Pap testing is recommended for all women who are or have been sexually active and who have a cervix. Screening should begin with onset of sexual activity and be repeated at least every 3 years.

Glaucoma. Routine screening by primary care physicians is not recommended. High-risk populations (blacks older than 40, whites older than 65, and those with a positive family history, diabetes, or severe myopia) may be referred to eye specialists for screening. The optimal interval for screening is not known.

B. Hypertension. Blood pressure should be measured at least yearly.

C. Hypothyroidism. Routine screening is not recommended, but clinicians should have a low threshold for ordering a serum thyroid-stimulating hormone level (TSH) because of its subtle presentation.

Special senses. Visual and hearing loss contribute to functional decline and cognitive impairment. Vision may be tested with Snellen's chart, and hearing loss may be screened by history.

B. Polypharmacy. Simplifying drug regimens improves compliance, reduces the incidence of adverse drug reactions, and saves money. Common offending drugs are those whose indications were never clear or the indications for which have disappeared (e.g., digoxin, H 2 antagonists).

C. Cognitive impairment and depression. Both of these are common in the elderly. The Folstein Mini-Mental State Examination is specific but not very sensitive for dementia. Many depression-screening instruments (e.g., Geriatric Depression Scale) are available.

Chemoprophylaxis

A. Aspirin. Although the value of aspirin is well established for secondary prevention of stroke and myocardial infarction, its role in primary prevention is less clear

B. Multivitamins. The role of vitamin supplementation in the prevention of cardiovascular disease is still evolving, but diet supplementation with one multivitamin a day is safe and benefits those older adults with poor diets.

Breast cancer

Mammography combined with clinical breast examination has been proven to reduce mortality from breast cancer in women aged 50 through 69 years. The USPSTF guidelines recommend cessation of breast cancer screening at age 70.

Prostate cancer

A digital rectal examination for prostate cancer has a very low yield. The prostate-specific antigen (PSA) test is elevated in the elderly not only in those with prostate cancer but in men with benign prostatic hypertrophy as well. Although PSA testing identifies significant numbers of men with prostate cancer confined to the gland, it does not appear that mortality is reduced in those in whom early prostate cancer is found.

Men older than 65–70 most likely will die of a co-morbid condition other than prostate cancer. Therefore, with the possible exception of patients who request testing and have been informed of its drawbacks, PSA screening is not recommended for elderly men.