分論壇二基層衛(wèi)生與社區(qū)交流基于循證醫(yī)學(xué)的老年人健康體檢

1、基于循證醫(yī)學(xué)的老年人吳華市寶安區(qū)醫(yī)院（）市衛(wèi)生計生能力建設(shè)和繼續(xù)教育中心社區(qū)居民老王的體檢需求 65歲，退休； 平素體健，無特殊不適； 高血壓6年，規(guī)律治療，好，未發(fā)現(xiàn)其他疾??； 抽煙20余年，現(xiàn)1包/2-3天，偶爾飲酒； 父親有高血壓病、心梗病史，母親高血壓； 腫瘤疾病史；無老王的周期性 生活 體格檢查。 輔助檢查：健康狀況評估Ø 血常規(guī)、尿常規(guī)、Ø 肝功能（血清谷草轉(zhuǎn)氨酶、血清Ø 腎功能（血清肌酐和血尿素）Ø 空腹血糖Ø 血脂（Tc、TG、LDL、HDL）Ø 心電圖Ø 腹部 B 超（肝膽胰脾）轉(zhuǎn)氨酶和總膽紅素）補充項目主

2、要內(nèi)容定義現(xiàn)狀和問題基于循證醫(yī)學(xué)的老年ppp主要內(nèi)容定義現(xiàn)狀和問題基于循證醫(yī)學(xué)的老年ppp定義是指通過醫(yī)學(xué)和方法對受檢者進行身體檢查，了解受檢者健康狀況、早期發(fā)現(xiàn)疾病線索和健康隱患的診療行為，用于和群體健康狀況評價與疾病風(fēng)險、及早期篩查的一種醫(yī)學(xué)行為、方法與過程 。問題 重視和輔助檢查，輕視病史和體格檢查1959年與2000年診斷正確率比較年代1959年2000年漏診率24%41%誤診率7%15%問題 忽略重要的功能評估Ø 生活方式Ø 心理健康Ø 認知功能Ø 跌倒風(fēng)險Ø心風(fēng)險問題 體檢套餐化，套餐劃分缺乏科學(xué)依據(jù)問題 報告解讀過度依賴數(shù)據(jù)，數(shù)據(jù)

3、不嚴謹問題 體檢后的健康管理缺乏持續(xù)性主要內(nèi)容定義現(xiàn)狀和問題基于循證醫(yī)學(xué)的老年ppp循證醫(yī)學(xué)（Evidence Based Medicine）基于循證醫(yī)學(xué)的！老王的體檢需求老王的體檢需求-EBM Patient：高血壓，血壓好，無其他心腦癥狀 Intervention：頸動脈狹窄的篩查 Comaprison：查 Outcome：延長生存期EBM：醫(yī)學(xué)實踐的步驟1. 確定臨床實踐中的問題2. 檢索有關(guān)醫(yī)學(xué)文獻3. 嚴格評價文獻4. 應(yīng)用最佳證據(jù)，指導(dǎo)臨床決策5. 評估1-4項的效果和效率，不斷改進臨床關(guān)注的問題與沒有進行篩查的人群相比，進行頸動脈超聲檢查的高血壓命嗎？會延長壽評估適用于老王的證據(jù)

4、Jonas DE, Feltner C, AHR,. Screening for asymptomatic carotid arterystenosis: A systematic review and meta-analysis for the US Preventive Services Task Force. Ann Intern Med 2014;161(5):33646.Abbott AL. Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asy

5、mptomatic severe carotid stenosis: Results of a systematic review and analysis. Stroke 2009;40(10):e57383.Abbott AL, Paraskevas KI, Kakkos SK,. Systematic review of guidelines forthe management of asymptomatic and symptomatic carotid stenosis. Stroke 2015;46(11):3288 301.Abbott AL, Adelman MA, Alexa

6、ndrov AV,. Why calls for more routinecarotid stenting are currently inappropriate: An international, multispecialty, expert review and position statement. Stroke 2013;44(4):118690.Abbott A. Critical issues that need to be addressed to improve outcomes for patients with carotid stenosis. Angiology 20

7、16;67(5):42026.Abbott AL, Nicolaides AN. Improving outcomes in patients with carotid stenosis: Call for better research opportunities and standards. Stroke 2015;46(1):78.結(jié)論 目前沒有證據(jù)表明這項檢查給帶來好處，但有該檢查給帶來的證據(jù)，包括明顯的手術(shù)和成本； 目前的證據(jù)不能做出可靠的分層，不足以特異性的識別出可以受益動脈內(nèi)膜剝離術(shù)（CEA）的； 不能據(jù)此推薦給做頸動脈支架植入術(shù)，因為與CEA相比，頸動脈支架植入術(shù)將造成高出兩倍

8、的中風(fēng)或。（榜樣）！U.S. Preventive Services Task FourceCarotid Artery Stenosis: ScreeningUSPSTF Release Date: July 2014Thyroid Cancer: ScreeningRelease Date: May 2017Chronic Obstructive Pulmonary Disease: ScreeningRelease Date: April 2016Pancreatic Cancer: ScreeningRelease Date: February 2004Cardiovascular D

9、isease Risk: Screening With ElectrocardiographyRelease Date: June 2018Cardiovascular Disease: Risk Assessment With Nontraditional Risk FactorsRelease Date: July 2018Celiac Disease: ScreeningRelease Date: March 2017Cognitive Impairment in Older Adults: ScreeningRelease Date: March 2014Hearing Loss in

10、 Older Adults:ScreeningRelease Date: August 2012Peripheral Artery Disease and Cardiovascular Disease: Screening and Risk Assessment With the ABIRelease Date: July 2018Skin Cancer: ScreeningRelease Date: July 2016Vitamin D Deficiency: ScreeningRelease Date: November 2014Impaired Visual Acuity in Olde

11、r Adults: ScreeningRelease Date: March 2016PSA-based screening for prostate cancerMen ages 5569For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)based screening for prostate cancer should be an individual one. Before deciding whether to be screened,men shou

12、ld have an opportuto discuss the potential benefits andharms of screening with their clinician and to incorporate their values and preferences in the decision.C RecommendationMen age 70 and olderThe USPSTF recommends against PSA-based screening for prostate cancer in men age 70 years and older.D Rec

13、ommendationDepression in Adults: ScreeningRelease Date: January 2016Abnormal Blood Glucose and Type 2 DM: ScreeningRelease Date: October 2015Abdominal Aortic Aneurysm: ScreeningRelease Date: June 2014High Blood Pressure in Adults: ScreeningRelease Date: October 2015Lung Cancer: ScreeningRelease Date

14、: December 2013Osteoporosis to PreventFractures: ScreeningRelease Date: June 2018Colorectal Cancer: ScreeningRelease Date: June 2016Obesity in Adults: Screening andManagementRelease Date: June 20122014基本項目共識續(xù)表續(xù)表居民老王的健康狀況、65歲 平素體健，無特殊不適性高血壓病6年 抽煙，偶爾飲酒，； 家庭條件較好； 早發(fā)CVD史 PE：BMI29.2kg/m2、BP130/82mmHg 心肺腹無異常居民老王推薦項目 生活 體格檢查健康狀況評估 跌倒篩查 日常生活活動和家庭評估 視力和損傷評估 評估吸煙的狀態(tài)、尼古丁的依賴性和戒煙的 超重和肥胖的評估 運動和體力活動評估 缺血性心病(ICVD)10年發(fā)病風(fēng)險評估血壓