Resident Editor: Ugochi Nwosu, MD

Faculty Editor: Miranda Dunlop

Bottom Line

• Use EHR and team-based approaches to monitor and engage patients in preventative care and evidence-based screening services
• Screen older patients for depression, visual and hearing acuity as these may contribute to cognitive impairment.

Background

• The routine, annual preventative visit for otherwise healthy, young, asymptomatic individuals has been questioned as there is no evidence of its benefit and may contribute to costs.
• The 2013 Choosing Wisely campaign recommended against annual preventative visits in asymptomatic patients.
• Most evidence-based screening can be done without a visit. Electronic health records (EHR) and support staff, should be employed in surveillance and engagement of , healthy outpatients to ensure uptake of regular preventative care services.
•   Adults aged 65 and older who have  Medicare insurance, are eligible for an Initial Preventative Physical Exam (IPPE) and an Annual Wellness Visit. (AWV)  These visits are  covered by Medicare at no cost to the patient and are designed to develop and implement a comprehensive care plan targeting wellness and prevention.   
• The IPPE and AWV have specific guidelines for implementation: 
  IPPE:  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf and
  AWV:  https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/AWV_chart_ICN905706.pdf
  There are many elements common to both visits, as well as a few elements that are specific for one or the other. In general, the format is as follows.

Medical and Family History

• Assess for new medical diagnoses, surgical events, illnesses and hospital stays. Also gather a list of the patent’s other medical providers (including specialists and complementary or alternative medicine providers). This may be done with a form or interview by ancillary staff which can be reviewed during the visit.
• A similar approach can be used to evaluate all allergies as well as use of medications and health supplements.
• Be sure to assess and discuss important medical events experienced by the patient’s parents, siblings or children with particular focus on illnesses with evidence of heritability that may impact your patient’s risk profile. 
• Assessing smoking, alcohol use and types/routes of illicit drugs is important to provide harm-reduction counseling and determine risk profile for recommended screening.

Physical Examination

• Important to accurately measure height, weight, BMI and blood pressure  to adequately address cardiovascular risk factors.
• Patients should be screened for visual acuity in the IPPE and hearing loss  in the AWV.  A simple but effective way to screen for hearing loss is to use the Whisper Test.

Whisper Test

1. Stand at arm’s length behind the patient to prevent lip reading
2. Ask the patient to occlude one ear to allow testing each side separately.
3. At end-exhalation, whisper a random combination of letters and numbers i.e N-9-Q
4. Ask the patient to repeat what was said.
   1. If correct, move on to the other ear.
   2. If incorrect repeat with a new sequence of 3 letters and numbers.
5. Passing test is repeating 3 out of a possible 6 letters or numbers correctly.

Mental and Cognitive Health

• Patients should be screened for depression and screening forms such as the PHQ-2 and PHQ-9 can be utilized to help determine risk and guide decision making for counseling or referral.
• Functional ability should be assessed with questions assessing ADLS and I-ADLS. A quick screen can be done using the functional activities questionnaire screening form. In addition, direct observation can be used to assess risk of falls.  A useful screening exam is the SPPB: the Short Physical Performance Battery which assesses lower extremity function in three domains: Gait Speed, Balance and Strength.  You can use this UCSF made video as reference:  https://www.bing.com/videos/search?q=short+performance+physical+battery+test&view=detail&mid=0B54BCFCD62C53BD3BF00B54BCFCD62C53BD3BF0&FORM=VIRE
• If there is concern for cognitive impairment on interview with patient or caregiver, further screening can be done with a Folstein Mini Mental State Examination or Montreal Cognitive Assessment or Mini-Cog test.

Counseling and Education

• Provide a personalized written schedule of recommended screening and preventative care that should be reinforced with regular outreach to ensure utilization.
• Use the previously assessed risk factors and health screenings to guide personalized health advising and provide appropriate referrals. Common topics may include weight management, smoking cessation, nutrition and falls prevention.

Advanced Care Planning

• Use the annual preventative visit to assess healthcare goals with patients. Discuss advanced directives and surrogate decision makers.

References

Goroll, Allan H. "Toward trusting therapeutic relationships—in favor of the annual physical." New England Journal of Medicine 373.16 (2015): 1487-1489.

Hughes, Cindy. "Medicare annual wellness visits made easier." Family practice management 18.4 (2011): 10-14.

Hughes, Cindy. "What you need to know about the Medicare preventive services expansion." Family practice management 18.1 (2011): 22.

Mehrotra, Ateev, and Allan Prochazka. "Improving value in health care—against the annual physical." New England Journal of Medicine 373.16 (2015): 1485-1487.

Pirozzo S, Papinczak T, and Glasziou P. "Whispered voice test for screening for hearing impairment in adults and children: systematic review." Bmj 327.7421 (2003): 967.

Society of General Internal Medicine. Five Things Physicians and Patients Should Question. Choosing Wisely,2013. http://www.choosingwisely.org/doctor-patient-lists/society-of-general-internal-medicine/.

Vasunilashorn S, Coppin A, Patel K, Lauretani F, Ferrucci L, Bandinelli S, and Guralnik JM. “Use of the Short Physical Performance Battery Score to Predict Loss of Ability to Walk 400 Meters: Analysis from the InCHIANTI Study. J Gerontol A Biol Sci Med Sci. 2009;64A(2):223-220. doi: 10.1093/gerona/gln022.