Resources for the Comprehensive Geriatric Assessment based
Proactive and Personalised Primary Care of the Elderly
The Annual Physical in Proactive Care
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With increasing calls to reassess the value of the annual physical examination of the well patient, the value of this time-honoured practice is now questioned by some authorities.
Citing a lack of research evidence in support of the annual physical and calls for its abandonment dating back almost 30 years from professional organizations, some are advocating replacing the annual physical with relationship-building visits (Mehrotra A, 2015).
One of the difficulties in assessing the role of the annual physical is that its content is poorly defined and its focus has evolved over time (Han PK, 1997).
The potential components of the annual physical include history taking, screening questions designed to uncover undetected illness or risk factors such as smoking, counselling to address those risk factors, a full physical exam, ordering of recommended preventive services, and routine testing (e.g., complete blood counts, electrocardiograms, and urinalyses) in asymptomatic patients.
Studies show that annual physicals do not reduce morbidity or mortality, though they may be associated with reduced patient worry and increased use of preventive care (Boulware LE, 2007).
Moreover, the annual physical may actually be harmful. Some aspects of traditional annual physicals, such as the comprehensive physical exam (which might, for example, detect thyroid nodules) and routine tests (such as urinalysis), have low specificity, which means that most positive results in asymptomatic patients will be false positives, with unnecessary further investigations ensuing and not infrequently leading to iatrogenic complications of their own (Krogsboll LT, 2012).
Past calls to simply eliminate annual physicals have proven ineffective in changing clinical practice.
That failure has probably been driven by a belief in the clinical community that there are potential benefits.
Physicians tend to believe that the annual physical is a key method for identifying and ordering missing preventive care. Most important, they see the annual visit as a critical mechanism for establishing and renewing relationships with their patients — though the question of whether physicals improve these relationships has not been well studied.
Three key steps could help address both the views of the clinical community and the prior evidence base.
First, a new type of visit could be created whose exclusive role is to establish relationships.
The majority of patients who receive a physical every year have established relationships with their physicians and come to the practice regularly for other reasons.
For those who have not seen a primary care physician recently, valid arguments can be made that a physical serves as a mechanism for establishing a relationship.
With that need in mind, these “primary care maintenance” visits could be limited to the minority of patients who have not seen a physician for a given period, perhaps 3 years, or who are switching to a new primary care provider.
Such visits would focus solely on building a relationship through questions about the patient’s medical history and social situation, not on the physical exam or screening laboratory tests.
Second, primary care providers could change their approach to ensuring that patients' preventive care is up to date.
Many physicians see the annual physical as a stop-gap measure for providing preventive care. But the majority of preventive care is ordered or provided at visits outside the annual physical, and passively waiting for patients to come in for physicals has not been an effective strategy.
The emphasis in a practice needs to shift from such passivity to active engagement of the patient population.
For example, new criteria for meaningful use of electronic health records emphasize active surveillance to ensure that preventive care services are up to date.
Other approaches, including automated methods of screening such as online health risk assessments, questionnaires delivered in the waiting room, and delivery of preventive care at any type of health care encounter, could better ensure that preventive care is current for the entire patient population.
Third, to make these changes viable, coding for reimbursement by state and private entities would need to encompass the content of these relationship-building visits.
Not everyone agrees.
Some argue that, compared with the cost of treating the damage done by the big silent killers, the costs of regular check-ups are modest.
Rather than abandoning the annual physical, others advocate enhancing it, using a multidisciplinary team approach in a patient-centred proactive care model of care, turning the appointment into a comprehensive annual health review.
Tasks such as medication renewals, immunizations, routine referrals, screening tests, checking vital signs, and basic documentation could be done by non-physician staff.
Dividing the work would free physicians to engage in relationship building and allow for in-depth discussion of the patient’s life stresses, health issues, personal values, and healthcare preferences, resulting in a more personalized experience.
In geographic areas with a shortage of primary care physicians, nurse practitioners or physician assistants with physician backup could provide these functions.
Logistics and viability of this approach in many smaller GP practices may boil down to finances.
Start-up costs are not insignificant because of the investment needed for electronic medical records, as well as hiring new staff and training them.
The volume-based, fee-for-service strategy is not working, with low payment rates leading to high visit volume and rushed services.
Roughly half of primary care is still delivered by small practices, and those folks need payment reform so that they can afford to do the practice reform.
The proactive care medical team model entails extra staff, which means that the practice needs extra financial resources.
Eliminating the annual physical might appear contradictory to our health care system's increased attention to prevention.
But it is evidence-based prevention that's key, and the annual physical is not evidence-based: research has demonstrated both its minimal benefit and potential harms.
As the benefits of Proactive Care become more and more well documented, many GP practices are creating or joining or creating a multidisciplinary team and adopting a Comprehensicve Geriatric Assessment based model of Primary Care for their elderly patients, which sees the traditional annual check-up of the well patient replaced by a much broader and more effective intervention.
This is one of several topics presented in the Perspectives sector of this toolkit