July 2000 · Vol. 49, No. 7
OBSERVATION FROM PRACTICE
The Ultrasound-Assisted Physical Examination in the Periodic Health Evaluation of the ElderlyTimothy M. Cowan, MSPH
Submitted, revised, february 6, 2000.
From the department of family medicine, state university of new york at buffalo (t.s., p.a.j., t.m.c.). Reprint requests should be addressed to timothy siepel, rdms, md, 27 franklin st, box 447, springville, ny 14141. E-mail: firstname.lastname@example.org.
BACKGROUND: Except for specific procedures such as blood pressure measurement, the conventional physical examination (PE) does not have sufficient sensitivity to be useful as part of the periodic health evaluation. Ultrasound has demonstrated greater sensitivity and specificity in numerous studies but has been too expensive to be widely employed in health screening. The purpose of our study was to determine whether an examination in which conventional and ultrasound techniques are blended and applied by a primary care physician might be feasible and useful in the periodic health evaluations of senior citizens.
METHODS: Seventy-two patients presenting to a community-based family physician for periodic health evaluations received an ultrasound-assisted physical examination (USA-PE) from a second family physician. The results were reported to the primary physician, and the outcomes were tracked for periods of up to 2 years.
RESULTS: Twenty-two of the 72 patients (31%) had abnormalities found by the USA-PE that were not apparent during the conventional PE. Five of these patients (7%) had serious conditions that received prompt treatment with apparent benefit. Findings included endometrial carcinoma, abdominal aortic aneurysm, carotid stenosis, hydronephrosis, and urinary retention.
CONCLUSIONS: The USA-PE found more abnormalities in this group of patients than conventional PE. Whether it can improve outcomes for senior citizens undergoing periodic health evaluations in a cost-effective manner is yet to be determined.
aged. (J Fam Pract 2000; 49:628-632)
The traditional physical examination (PE) has been limited to the use of the eyes, ears, and hands of the examiner and has excluded technological enhancement beyond the use of simple instruments. The value of the PE in the periodic health evaluation, however, has been called into question.1-6 Except for a few specific segments of the head-to-toe examination, the evidence suggests that it does not detect enough conditions in time to have a favorable impact on the outcome of patients’ health. The US Preventive Services Task Force7 does not list the PE among its recommended interventions for screening of the general or elderly population.
One possible reason for the failure of the PE to have a positive impact as a screening examination is that it is not sensitive enough to detect many diseases in their early stages, when intervention might have more benefit. For example, the PE is relatively insensitive and inaccurate, when compared with ultrasound, in the detection of carotid stenoses, thyroid nodules, various cardiac abnormalities, abdominal aortic aneurysms, renal cancers, hydronephroses, gallstones, and cancers of the uterus, ovaries, and urinary bladder. Ultrasound has demonstrated efficacy in the detection of these conditions in screening studies8-31 but has not been widely employed, primarily because of the cost of formal specialist-performed studies. We hypothesize that blending real-time diagnostic ultrasound into the PE performed by the primary care physician can increase its diagnostic yield with little additional cost. We call this amalgamation of physical and ultrasound examinations the ultrasound-assisted physical examination (USA-PE).
New patients aged 65 years and older who presented to the office of a family physician in western New York for periodic health evaluations were informed about the study and offered the opportunity to participate. Seventy-two patients participated in the study. The study sample predominantly included middle-class suburban white people who had been under regular medical care with other physicians in recent years. We limited our study to seniors in anticipation that they might have a higher incidence of findings and to new patients so that fewer diagnostic tests might have been completed previously.
The Ultrasound-Assisted Physical Examination
Patients who agreed to participate were asked to return for an ultrasound-assisted examination by a family physician who had passed the registry examinations as a registered diagnostic medical sonographer (the examination used to certify ultrasound technicians). Most of the USA-PEs were conducted within 1 month of enrollment and the initial PE. The examinations were performed between October 1, 1996, and June 9, 1998. The Medison 4800 (Medison Co, Ltd, Seoul, Korea), an office-type real-time ultrasonic diagnostic scanner, was used in all USA-PE examinations. This machine has 7.5 and 3.5 mhz probes with duplex pulse-wave Doppler capability.
Before performing the USA-PE, the physician-sonographer reviewed the patient’s history and medical record. A conventional screening PE was performed; pelvic and rectal examinations were not repeated in our study. The diagnostic ultrasound machine was then used to screen the carotid arteries, the thyroid, the heart (assessed with 2 dimensional sonography only), the abdomen, and the pelvis. In total the USA-PEs, including both conventional PE and ultrasound-assisted components, took approximately 15 minutes each.
The findings of the USA-PE were made available to the primary physician, who then ordered confirmatory studies, made referrals, or decided on other interventions as he or she saw fit. Because of limited resources, positive findings were confirmed only if considered clinically significant, and negative findings were not confirmed. Thus, we did not confirm all gallstones, renal cysts, and other findings that, in the judgment of the primary physician, did not indicate further action. The 2 physicians periodically reviewed the progress and outcomes of the patients.
Follow-up data were reported through October 9, 1998.
We confined the reporting of results to findings of the USA-PE that were not already known. If we found gallstones, for example, that were already documented we did not report them as a new finding.
Of the 72 patients who completed the study, 28 (39%) were found to have 34 abnormalities on the USA-PE that were not noted during the PE. Seven of these abnormalities could not be confirmed by specialist examinations, leaving 22 patients (31%) with 27 abnormalities. The [Table] illustrates these, as well as the patient-specific findings and any corresponding interventions that occurred as a result. One of the 7 confirmed cardiovascular findings was treated (carotid endarterectomy) while the other 6 were assigned to be monitored. Three patients had previously undetected urinary retention and have subsequently been treated. Two patients were found to have a potentially cancerous tumor, and biopsies were performed. There was 1 diagnosis of endometrial cancer, and the patient has undergone surgery and chemotherapy. Nine renal cysts and 4 gallstones did not require further action.
Accuracy of Findings
Seven of the 34 abnormalities found were not confirmed by formal studies. The only finding known thus far to have been missed by the USA-PE is a case of aortic stenosis, also missed by both physicians during the PE. It was found during an echocardiogram that had been ordered to confirm mitral stenosis found during the USA-PE.
On the basis of known costs of leasing ultrasound equipment,32 hiring physicians in western New York,33,34 and the time allocated for these examinations, the cost of performing a USA-PE is estimated at approximately $30 in addition to the costs of the conventional examination (generally 99205, 99215, or 99397). At $30, the additional cost of examining the 72 patients in this study would have been $2160 if the physician time and ultrasound machine had not been donated. Given the fees from our locale35 for intravenous pyelogram, $90; transthoracic echocardiogram, $300; renal ultrasound, $80; carotid Dopplers, $170; abdominal sonogram, $110; thyroid sonogram, $80; and pelvic sonogram, $90, the costs of studies necessary to confirm USA-PE true positives totaled $2150, cost to refute false-positives, $1140. Adding these 2 costs together and distributing them over the 72 patients gives an additional cost of $45.69 per patient for the USA-PE. More costs were generated as some of the true positives required consultations, surgeries, hospitalizations, and other interventions, but those costs are not tallied here.
In our study of 72 senior patients who had been under regular medical care, 22 (31%) were found to have previously undiscovered abnormalities revealed by USA-PE. Although many of these abnormalities did not seem clinically significant, others were of major importance, and their discovery led to interventions that were beneficial to the patients. Five patients (7%) had interventions for conditions discovered by the USA-PE, such as endometrial carcinoma, carotid endarterectomy, and various urologic interventions. Although some of these discoveries appeared to be a direct consequence of the application of ultrasound to the examination, in other cases, such as the distended bladders, the diagnosis might have been made with PE, although it was not by these examiners. Also, the instance of endometrial carcinoma would likely have been diagnosed without ultrasound screening, since the patient had reported vaginal spotting and the primary physician had initiated gynecologic referral. The USA-PE expedited these diagnoses in an efficient and accurate manner, however, and appeared to have prevented certain diagnostic errors.
Several patients had abnormalities discovered that did not lead to any immediate intervention, such as small aortic aneurysms, gallstones, and subcritical carotid lesions. Such discoveries may be beneficial if they stimulate regular surveillance and lifestyle changes. Balanced against these postulated advantages is the anxiety such knowledge might produce, though the risk of such anxiety is inherent in the process of comprehensive health evaluations. Previous work by our group36 reported a high patient acceptance of ultrasound screening and a patient recommendation that it should become a routine part of the PE.
Ultrasound has been studied in the screening of all the organs accessed by the USA-PE, namely the carotids, thyroid, heart, abdomen, and pelvis, in most cases with some success demonstrated. In carotid screening, success has been mixed, with some claiming cost efficacy,8 and others disputing it.37 Even so, reviewing data from Lee,37 it appears that the problem with carotid screening is not so much the cost of the test but the marginal benefit to the treatment that follows a positive result (carotid endarterectomy).
Studies of thyroid ultrasound screening9-12 have demonstrated a much higher incidence of abnormalities than is commonly found by PE. Filatov9 reported that 7.5% of the study population had thyroid abnormalities. Head to head with PE, Brander13 found that 43 of 77 nodules detected by ultrasound had escaped detection during PE. Fourteen of them exceeded 2 cm.
In cardiac screening, the Cardiovascular Health Study Group14 obtained echocardiograms of 5201 senior adults in 4 communities and found that 190 (3.6%) had abnormal ejection fractions, and 26 (0.5%) had moderate to severe aortic stenosis. In a series of 200 consecutive transthoracic echocardiograms of patients who had already been evaluated with PE, Waggoner18 found a new diagnosis in 17 (8.5%) and additional information in 94 patients. Clinical assessment of systolic function was concordant in only 50% of patients with valvular disease.
Large studies of abdominal ultrasound screening have been conducted, especially in Russia and Japan. Filatov9 screened the abdomens and thyroids of 1092 industrial workers and found abnormalities in 26.1%. Oshibuchi19 screened the abdomens of 715 Japanese workers and found “gross abnormalities” in 44.5% of the men and 34.2% of the women. Vallencien21 and Jayson and Sanders22 found that many renal carcinomas are fortuitously discovered (37% and 61%, respectively) and that this group was likely to be at an earlier stage and have a better outcome than the group who presented with symptoms. Searching for abdominal aortic aneurysms, various authors23-25 found a 6.5% to 10% prevalence in older and/or hypertensive groups.
In the pelvis, ultrasound has demonstrated utility in detection of endometrial, ovarian, and bladder malignancies.26-31 Ciatto29 found 3 endometrial cancers in 2025 women; DePriest26 (using transvaginal ultrasound) 6 ovarian cancers in 6470 women; Shimazui30 9 bladder tumors in 5706 examinees.
In each of these anatomical areas of the neck, heart, abdomen, and pelvis, ultrasound has demonstrated some utility in the detection of diseases, many of which are not very accessible to PE. Each of these diseases is by itself somewhat rare, however, so to screen for all of them with specialty studies is cumbersome and prohibitively costly. But if primary care physicians could accurately screen for all these conditions with a $30 test, it may be cost-effective and could improve the outcome of periodic health evaluations in senior citizens. Indeed, the US Preventive Services Task Force38 states that the cost of screening tests is one of the prime considerations in considering them for recommendation, and in the case of abdominal aortic aneurysms in particular, if the cost of ultrasound screening could be brought low enough it would be preferred over PE.
Our small study is preliminary and descriptive but suggests that primary care physicians can increase their diagnostic yield by adding brief screening with ultrasound to their examinations. Whether that can be true of primary care physicians in general and whether we could demonstrate a value to this examination by improving the outcomes of seniors undergoing periodic health evaluations in large-scale studies remains speculative but invites further study.
We were assisted by the loan of an ultrasound machine from Medison Co, Ltd, and received technical and editorial assistance from the Office of Research and Development staff, State University of New York at Buffalo and the staff of David S. Clifford, MD. Also, special thanks to the patients from Dr Clifford’s practice who participated in this study.
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