Most family physicians can relate to the same avalanche of forms and requests coming through the office.
Patient X is planning to move to a local retirement home, and requires a detailed physical, a chest x-ray, proof of immunizations, and a whole host of bloodwork.
Patient Y is starting a nursing course in the fall, and requires a physical to confirm that they “are free of any significant disease”, immunization records to fulfill their specific criteria, as well as blood work to confirm that they are immune to specific diseases.
What is most striking about these forms is how different the requests are, depending on the organization or facility that is requesting the information. Two retirement homes with similar set-ups often ask for completely different information. Similarly, schools offering the same program can widely vary in what medical information they require of their students.
Also notable is that a lot of the information that they ask for is not evidence-based. Tests without utility have significant costs, and these costs are downloaded onto our public system.
An ideal solution to this issue is for local public health departments to set evidence-based standards for what should be asked for by retirement homes, schools, and employers. This will set a baseline for what our public system should cover, and make it very clear that any additional requests are unnecessary, and would then have to be paid for by the requesting individual or the patient.
Let me attempt to provide some specific guidance. First I will address the pre-retirement home assessments that have become commonplace. We know that a physical examination in a patient without significant disease has no utility. It should not be required, requested, or offered. Screening bloodwork? This should be done in keeping with primary care guidelines, and not on the retirement home’s timeline. They demand a chest x-ray of every patient to rule out TB. Where is the evidence for this? If their concern is picking up rare latent cases of TB, shouldn’t we also be screening for TB in the community? Or in hospitals? The answers to these hypotheticals is a resounding no, and our public health units need to be fiscally responsible and make recommendations to stop these requests. Whether Tamiflu prophylaxis is effective is an article unto itself, but certainly the wisdom in ordering yearly creatinine levels in all retirement home patients to dose Tamiflu needs to be questioned. It’s an expensive program, with highly questionable benefits.
For school and employment requests for immunization information, this process needs to be standardized. Most organizations make reasonable requests for tetanus, diphtheria, polio, and pertussis information, but many make non-evidence based requests for serology for measles, mumps, and rubella, requesting re-immunization even for patients who have received 2 doses of MMR, lack antibody-mediated immunity, but likely possess cell-mediated immunity.
These assessments and requests from private organizations place an incredible financial burden on our strained health care system, and health units can help to alleviate some of this strain by providing evidence-based templates that these organizations and facilities are bound to comply with.