Dr Hanan Abbas

Lecturer 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 grounds
D There is fair evidence against the recommendation
E 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)

H.A. 5
 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

H.A. 7
 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)

H.A. 8
 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 exists
 which 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.
H.A. 9
 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.

H.A. 10
 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.