Case 1

 

Brian wants a check-up…

 

 

 

This 61-year old man illustrates issues related to prevention and screening in general practice. Almost 90% of the population see a GP every year. As GPs we deliver preventive care in a number of ways; opportunistically (provided when patients present with other problems or concerns), by anticipating the preventive needs of patients by providing reminders for preventive care, and by proactively targeting high risk individuals who may be least likely to seek out preventive care.

 

 

Learning Objectives

·        Understand the different types of prevention

·        Access accurate and up-to-date information about preventive activities to undertake with your patients, including appropriate guidelines

·        Manage behavioural risk factors in general practice

·        Understand the principles of screening, different types of screening, and factors used to determine the quality of screening tests.

 

 

Brian’s Clinical Summary

 

Past Medical History:

            Nil

 

Past Surgical History:

            Nil

 

Allergies:

            Nil known

 

Meds:

            Nil

           

Social History:

            Ex-smoker – 25 pack year history, quit 3 years ago

            Drinks alcohol – 1-2 standard drinks daily

 

Occupational History:

            Retired accountant

 

Family History:

            Bowel cancer – father and brother

 

 

Case Notes:

 

You have only met Brian once before – last year when he moved into your local area from interstate. You care for his wife, Cheryl, who sees you regularly for management of her ischaemic heart disease and diabetes. Cheryl has made this appointment for Brian because he turned 61 last week and Cheryl feels he should be visiting you regularly now for check-ups. Brian thought a check-up and some tests wouldn’t hurt to make sure he ‘doesn’t have anything’.

 

The ‘Check-up’:

 

When a patient asks for a ‘check-up’ they are asking for the impossible – your reassurance that they have a clean bill of health. What you are actually doing when you provide a ‘check-up’ for a patient is undertaking a health assessment designed to prevent, detect and control specific conditions or risk factors. The elements of your assessment will depend on many factors, including the age and sex of your patient. You will then identify preventive activities that are appropriate and relevant to your patient.

 

Preventive activities are defined as “actions aimed at eradicating, eliminating or minimizing the impact of disease and disability on people”. There are different types or ‘levels’ of prevention.

 

Defining ‘Levels of Prevention’:

 

Primary Prevention – prevention of diseases or disorders in the general population by encouraging community-wide measures such as good nutritional status, physical fitness, immunisation, and making the environment safe. Primary prevention maintains good health and reduces the likelihood of disease occurring.

 

Secondary Prevention – detection of the early stages of disease (before symptoms occur), and prompt and effective intervention to prevent disease progression. Secondary prevention strategies include screening programs such as cervical, breast or colorectal cancer screening.

 

Tertiary Prevention – prevention or minimisation of complications or disability associated with established disease. Preventive measures are part of the treatment or management of the target disease or condition.

 

In addition, prevention programs can be applied at either a universal (whole of population), selective (targeted to at risk groups), or indicated level (where individuals have significantly increased risk).

 

Selecting which preventive activities to undertake with which patients is a general practice challenge. The RACGP Guidelines for Preventive Activities in General Practice (The ‘Red’ Book) provides current evidence based guidelines for primary and secondary preventive activities in general practice. The guidelines can be used in day-to-day practice to indicate which preventive activities may be relevant in various age groups and how often these activities should be performed. 

 

 

Issues to Consider:

 

a)      Using the RACGP Guidelines for Preventive Activities in General Practice, what preventive activities would you consider in a 61-year old male?

b)      What difference would it make to the preventive activities you would consider if Brian were Aboriginal? (You may wish to refer to the RACGP Evidence Based Guidelines for Preventive Activities in Aboriginal and Torres Strait Islander peoples).

 

 

c)      Are there any differences in how primary care is most effectively delivered to Aboriginal and Torres Strait Islander peoples? Review the following document ‘Indigenous Primary Care Improvement’ if you are not sure.

 

 

 

Case Notes:

 

Brian is a pensioner. He doesn’t generally go to doctors because he is well and has no medical problems so he feels there’s no need. He used to work as an accountant before he retired a year ago and moved to Tasmania.

 

Brian spends most of his time in the garden, pottering about the house and helping out with his daughter and her kids. He goes to golf once a week for the men’s social competition but other than that hasn’t made too many friends yet. He used to smoke but gave it up three years ago when one of his work colleagues died from lung cancer. He likes to have a beer or two in the evenings.

 

SNAP:

 

Smoking, nutrition, alcohol and physical inactivity (SNAP) are common behavioural risk factors among patients attending general practice, and contribute significantly to the burden of chronic disease in our population.

 

SMOKING: According to the National Tobacco Strategy (2004 – 2009), 21% of males and 18% of females in the general population smoke daily. In Aboriginal and Torres Strait Islander peoples this figure is 50%. The prevalence of smoking is also higher in people with mental health problems. The yearly societal cost of tobacco smoking in Australia is $21 billion.

 

NUTRITION: Nutritional factors are associated with many health problems in Australians. The prevalence of overweight and obesity continues to increase in the Australian population. Rates of exclusive breastfeeding for the first 6 months of life are low. Diets low in fruit and vegetables are associated with cancer and cardiovascular disease and contribute approximately 3% to the Australian burden of disease.

 

ALCOHOL: According to the National Drug Strategy (2004 – 2009), the prevalence of alcohol dependence in the Australian population is 3.5%. The health effects of alcohol consumption are much broader than the medical problems with which it is commonly associated. Alcohol consumption is a factor associated with reported domestic violence (13%), assault (47%), suicide and self-inflicted injury (61%), falls (52%), fire injuries (44%), motor vehicle accidents (30%) and drowning (21%).

 

PHYSICAL INACTIVITY: Physical inactivity accounts for approximately 8000 deaths per year in Australia. It is responsible for 7% of Australia’s burden of disease.

 

 

Issues to Consider:

a)      Make a list of all of the health problems Brian’s lifestyle risk factors place him at risk of.

b)      Outline your approach to managing Brian’s lifestyle risk factors by apply the ‘5 A’s’ described in the RACGP SNAP Guide.

c)      How do you assess Brian’s readiness to change his lifestyle?

d)      Outline the issues you would address with Brian in your systematic approach to motivational interviewing.

 

Case Notes:

 

Brian is worried about developing bowel cancer. He has a family history of colon cancer (his father was diagnosed at age 62 and his brother died at age 55 from colon cancer). He is also worried about developing lung cancer because he used to smoke. He thought a chest x-ray would be a good idea to check he doesn’t have lung cancer.

 

 

Screening

 

Screening can be defined as detection of unrecognised disease or conditions by using reliable tests, examinations or other procedures. The main types of cancer screening are:

-         Population screening – screening the entire population (e.g. vision)

-         Selective screening – screening groups with specific risk factors (e.g. sexual health screening).

 

Screening can also be:

-         Opportunistic – e.g. offering PAP smear when a patient presents for an unrelated condition

-         Case-finding – screening offered as part of a routine check-up

 

NB Patients with symptoms should not be offered screening – they require appropriate diagnostic tests.

 

The characteristics of a screening test allow us to determine how effective the test is in correctly labelling someone as having the disease or not having the disease.

  • The sensitivity of a test is the proportion of those with the disease correctly identified by the test.
  • The specificity of a test is the proportion of those without the disease correctly identified by the test.
  • The positive predictive value of a test is the proportion of those with a positive test who actually have the disease.
  • The negative predictive value of a test is the proportion of those with a negative test who actually don’t have the disease.

 

The predictive value of screening tests is not only dependent on how good the test is. It is also dependent on the prevalence of the disease. If the disease has a very low prevalence, even a very sensitive test is going to result in lots of false positive results.

 

Cancer Screening Programs

 

The World Health Organisation (WHO) has a set of principles for screening. According to the WHO benchmarks for assessing a screening test:

  1. The condition should be an important health problem
  2. There should be an accepted treatment for patients with recognised disease.
  3. Facilities for diagnosis and treatment should be available.
  4. There should be a recognisable latent or early symptomatic stage.
  5. There should be a suitable test or examination.
  6. The test should be acceptable to the population.
  7. The natural history of the condition, including development from latent to declared disease, should be adequately understood.
  8. There should be an agreed policy on whom to treat as patients.
  9. The cost of case finding should be economically balanced in relation to possible expenditure on medical care as a whole.
  10. Case finding should be a continuous process and not a once and for all project.

 

Additionally, for population screening programs the following should also be considered:

  1. Screening should be highly specific and sensitive.
  2. The prevalence of the disease screened for should be high enough to warrant screening.
  3. The health implications should be serious enough to justify the expense and effort.
  4. The disease screened for should be one that is slowly advancing and not immediately life-threatening.
  5. The screening procedure should be simple, inexpensive and acceptable to the population to be screened.
  6. The screened disease should be one for which early diagnosis results in improved prognosis.
  7. Screening should lead to more effective treatment at an early stage.

 

The strength of the evidence supporting many different screening tests and the settings in which they should be applied is detailed in the RACGP Red Book – Guidelines for Preventive Activities in General Practice.

 

 

Issues to Consider:

 

a)      What cancer screening tests are appropriate for Brian?

b)      What is your response to Brian’s request for a chest x-ray? Using the WHO criteria for screening tests outlined above, assess the pros and cons of chest x-ray as a screening test for lung cancer in ex-smokers.

c)      What specific advice about bowel cancer screening are you going to provide Brian with?

 

Guidelines for Cancer Screening - click to view

 

Case Scenarios in Screening – click to view

 
Guidelines for general health screening:

 

Screening can also include providing a comprehensive check for a particular age group or gender:

 

  • Womens health- well women check

          http://www.mydr.com.au/womens-health/health-checks-women-should-have

 

  • Mens health- well bloke check

            K:\gpttweb\Population Health\Health Promotion\Brian R\The Well Blokes Check- for population health module.pdf

 

  • Aged care check (Health Assessment)

           http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare_mbsitem_75andolder

 

Summary:

 

This case illustrates many concepts related to prevention and screening in general practice. As a GP you deliver preventive care in a number of ways; opportunistically (provided when patients present with other problems or concerns), by anticipating the preventive needs of patients by providing reminders for preventive care, and by proactively targeting high risk individuals who may be least likely to seek out preventive care. You should now have a better understanding of the different types of prevention, be able to access accurate and up-to-date information about preventive activities to undertake with your patients (including appropriate guidelines) and feel better able to manage behavioural risk factors in your practice. You should also have a better understanding of the principles of screening, different types of screening, and factors used to determine the quality of screening tests.

 

References and Further Reading:

 

Anti Cancer Council of Victoria http://www.accv.org.au

 

Australian Health Ministers Advisory Council. National Tobacco Strategy (2004-2009). Department of Health and Ageing.

 

Australian Health Ministers Advisory Council. National Drugs Strategy (2004-2009). Department of Health and Ageing.

 

Australian Institute of Health and Welfare. Australia’s Health 2000. AIHW 2000. http://www.aihw.gov.au

 

Beaglehole R, Bonita R, Kjellstrom T. Basic Epidemiology. WHO 1993.

 

Kerr C. Handbook of Public Health Methods. McGraw-Hill. 1998.

 

National Cancer Institute. http://www.cancernet.nci.nih.gov

 

National Health and Medical Council. Clinical Guidelines. http://www.health.gov.au/nhmrc/publications

 

Royal Australian College of General Practitioners. http://www.racgp.org.au

- SNAP Guidelines

- Guidelines for Preventive Activities in General Practice

- Putting Prevention into Practice