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  • Lots of information, lots of guidelines. Therefore we need a framework to use when appraising the guidelines

Learning Objectives

  1. To identify preventive care interventions for patients presenting in clinical practice
  2. To critically analyse evidence for preventive care

Agree

The "Appraisal of Guidelines Research and Evaluation"(AGREE) collaboration has identified different dimensions that a guideline should address in order to demonstrate quality and improve its effectiveness:-

  1. scope/purpose,
  2. clarity/presentation,
  3. rigor of development,
  4. stakeholder involvement,
  5. applicability,
  6. editorial independence.
  • Old system for guidelines is GOBSAT = good old boys sat around a table
    • Consensus guidelines can be incorrect as they're not evidence based.


Scope/purpose

To provide GPs with guidance about what primary and secondary preventive care should be provided opportunistically (when patients present for whatever reasons), or more proactively (involving recalls, reminders, or planned “health checks”) taking into account:-

  • Evidence and application to the population seen in general practice
  • Workload and time available in general practice
    • Limited time means that it is difficult for GPs to carry out all the things listed in guidelines. Therefore need to spend less time on non-evidence-based activities
  • impact on costs to consumers and government.
    • At the current state of growth, the hospital+health budget will, by 2040, exceed the state budget
  • Equity of access to preventive care


Structure

  • Lifecycle chart – children and adult
  • Recommendation
    • Level of evidence
    • Strength of recommendation
  • Recommendations by risk group (BP is standard screening at every age, but we need to be selective for other screening methods)
  • Information on techniques and procedures for assessment or screening
  • Information on socio-economic differentials and strategies to address

Lifecycle charts

  • Screen based on age
  • As population ages, need to do more stuff
  • Only screen in evidence based manner (only evidence-based screens on the chart)

File:PreventiveCare1.png

Recommendations

File:PreventiveCare2.png

Tailoring preventive care to patient risk

What sort of risk factors

  1. Age
  2. Sex
  3. Family history/genetics
  4. Ethnicity including Aboriginality
  5. Previous conditions (e.g. if you have had a previous heart attack we put you on statins and ACEI)
  6. Other risk factors
  7. Socioeconomic status

1+2+5 = Early intervention

Joanne, aged 21, University student

  • Prevention of chronic disease
    • Behavioural risk factors - note that binge drinking is more likely to be a problem
  • Communicable diseases
  • Prevention of vascular and metabolic disease
  • Early detection of cancers
  • Psychosocial

Behavioural risk factors

  • Alcohol Recommendations
    • All patients over 15 years- quantity and frequency (IIB): every 3-4 years
    • Increased risk-opportunistically (IIIC)
    • Increased risk of EtOH related complications -opportunistically (IA)
  • Inequality
    • Many disadvantaged groups have higher levels of risky drinking
    • Risky alcohol use is frequently associated with mental health issues
    • Greater burden of harms in socially disadvantaged groups

Communicable disease: chlamydia

  • Recommendation
    • Screening for chlamydia infection in all sexually active people from 15 to 29 years of age is recommended because of increased prevalence and risk of complications.
  • Technique
    • PCR urine


  • Note that blanket STD screening not indicated in general population - only in sex workers etc. If risk in the population is very high, there is greater benefit from screening. If it's less common, we have less benefit from screening
  • Note consequences of false positives
    • Suicide rate of men who have had a positive PSA test is significant

Prevention of Vascular Disease: Blood Pressure

  • Recommendations
    • Average Risk (Adults 18- 50yrs) : BP every 2 years if BP<120/80 (IA)
    • Increased Risk: BP and Lifestyle counselling every 12 mths (IIA)
    • High Risk: BP, Lifestyle counselling; pharmacotherapy every 6 mths (IA)
  • Inequality
    • Hypertension more common in low SES incl. ATSI people
    • ATSI/ Sth Asian/ Maori/ Pacific Is: BP at least annually from age 15 in areas of high prevalence of HT (IIA)
  • Technique
    • BP- 2 separate occasions and two readings each time
    • Lifestyle Advice

Early Detection of Cancers: Melanocytic Skin Cancer

  • Recommendations
    • Average Risk: Preventive advice opportunistically (IIIB)
    • Increased Risk: Preventive advice and skin examination opportunistically (VB)
    • High Risk: Preventive advice; exam; self exam every 3-12 mths (IIIC)
  • Inequality
    • Nothing specific to Skin Cancer
  • Technique
    • Sun Protection Advice
    • Skin Examination
    • Self Examination Advice

SCCs and BCCs are lower prevalence in ATSI but melanoma still has a significant rate. Therefore information about skin cancer is equally important across the board - inform them about self-examination and sun protection to avoid burning.

Psychosocial: Depression

  • Recommendations
    • Average risk: screen opportunistically from 18 years (IB)
    • Increased risk: screen opportunistically (IIIC) and maintain a high level of awareness for those at high risk
  • Inequality
    • Depression more common in low SES groups
    • Affective disorders more common in unemployed
    • In patients with chronic disease - lower education level and unemployment predictive of depression
  • Technique
    • Two questions

Questions: 1) do you feel depressed/blue? 2) do you feel you get enjoyment out of life?

  • If they are depressed, ask about suicide - don't ask everyone

Better treatments mean that screening becomes less important.

Clinical level: 5As

File:PreventiveCare3.png

Patients with complete data

  • Even though there are things we should be doing, there is great variability between GPs in terms of actually screening for these things
    • We want it around 90% (don't screen terminal patients etc - don't bother people on palliation)

File:PreventiveCare4.png

Audit

  • Comparing risk factors in this particular practice compared to other practices
    • This particular practice has lots of obesity and poor lipid control

File:PreventiveCare5.png

Points for reflection

  • Comments by Chief Investigator:
  • Substantial improvements have occurred for fasting blood glucose. What do you think might be the main reason for this? Can this approach be used in other areas?
  • Rates for smoking, BMI or waist circumference are still relatively low. Are these due to data capture by the CAT or are they missing from the records?
  • Can the proportion of patients aged 45-69 with lipids records be increased?

Roles of non GP staff in preventive care

  • Administrative staff:registers, recall, records, referral
  • Practice nurse: assessment, education, referral, follow up
    • E.g. get nurse to weight/measure waist circumference
  • Allied health and group programs: education, motivation, lifestyle modification, peer support.

Strategies to Implement Preventive Care into Clinical Practice

  • Practitioner prompts or reminders for specific processes of care
  • Computerised decisions aids for practitioners (less so for patients) provided automatically and at the time of decision making, providing recommendations for action
  • Improving patient health literacy and providing patient education materials tailored to patient education and culture.
    • So they know why you're measuring their waist etc

Summary

  • Look at level of evidence
  • Balance with clinical picture and pt interest
  • Watch out for disadvantaged groups
  • Balance needs of individuals with own preventive agenda
  • Be realistic