Screening and prevention

chapter 13 Screening and prevention



INTRODUCTION AND OVERVIEW


Although the healthcare system still tends to undervalue and under-fund preventive medicine and health promotion, there has nevertheless been a growing recognition of the need to undertake preventive activities and screening within primary healthcare. General practitioners are well placed to be at the forefront of these activities because of their long-term and regular contact with patients and families, providing avenues for both opportunistic and structured approaches.


Preventive and screening activities require informed, disciplined and motivated patients as well as doctors. It also requires the support of reliable systems for recording data and sending reminders. Respective colleges in Australia through the RACGP,1 and in the United Kingdom, United States and many other countries, along with the World Health Organization,2 have actively reviewed evidence and made recommendations for best practice in screening and preventive activities. This chapter attempts to distill some of the key points raised by these recommendations.



PREVENTION


There are three main levels of prevention.


• Primary—the aim is to prevent an illness before it has got under way, such as through the promotion of healthy lifestyle and nutrition to prevent bowel cancer. Here the cost/benefit ratio tends to be most favourable but it can be difficult to motivate patients who are still ‘well’ to make the changes required to prevent an illness many years hence. Here the side effects of lifestyle change are beneficial.

• Secondary—the aim is to identify an illness early in its development before it has caused significant symptoms and while it is still reversible, such as the early detection of bowel cancer with faecal occult blood measurement or colonoscopy. This is where most funding for prevention and screening is directed within the healthcare system.

• Tertiary—here the condition is well under way and causing symptoms. Now the aim is to prevent further recurrence and complications through more radical treatments, such as for advanced bowel cancer. Here the cost/benefit ratio is least favourable and the side effects of treatment can be considerable.


PATIENT EDUCATION


Helping patients to make healthy change in their lives is one aspect of clinical medicine that requires as much art as science. Factors that enhance this process include:3


• health literacy and making sure the message is appropriate to the patient’s education level, language skills and cultural background

• the doctor–patient relationship, which is based on trust and mutual agreement

• provision of enabling strategies such as stress management, goal setting, the cycle of change and behavioural strategies (see Ch 7, Behaviour change, for more details)

• communication skills and methods such as a face-to-face delivery, providing the opportunity to ask questions, reinforcing key messages, using motivational interviewing skills and clarifying concerns and misconceptions

• consideration of the costs and benefits for changing or not changing the given behaviour

• individualising advice to better manage the behavioural enhancers and barriers

• managing relapse and reframing it as a learning opportunity rather than a failure

• the use of decision aids and reading materials such as patient education sheets.


SCREENING


Screening, whether through physical examination (e.g. blood pressure, random blood glucose) or special tests (e.g. mammography, colonoscopy), is the mainstay of preventive activities within general practice. Which tests to order, how often to perform them and for whom—and whether to order them at all—are far from clear-cut. Guidelines often shift with each new study that comes out, making decisions difficult for clinicians and patients.


Research must determine whether there are significant gains to be made that outweigh the costs to the patient and community in terms of time, emotional and physical discomfort, side effects and monetary expense, before a test can be widely recommended and funded. These issues may also need to be addressed with an individual patient in order for them to have a positive attitude to screening activities. In other words, the case for screening needs to be made—it should not be assumed that a patient will wish to follow guidelines just because they are there.


The WHO recommends that for a screening activity to be widely taken up, it should be identifying important health conditions (i.e. common, disabling and/or life-threatening) where there is a window of opportunity between latency and clinical manifestation. The test should be simple, as uninvasive as possible, safe, accurate and supported by evidence. Treatment for the health condition should be available and have been demonstrated to have a beneficial outcome. The outcomes should be of benefit in terms of morbidity or mortality, the benefits should outweigh the side effects and it should be cost-effective.


There are many shades of grey in answering these questions and in deciding who, where and when people are screened. Ultimately, it is the patient who will make their own informed choice as to whether to accept the guidelines or their doctor’s advice, and so although guidelines are useful, they will need to be individualised for each patient. A very anxious patient, for example, may be a candidate for screening at an earlier age than someone less anxious. Furthermore, guidelines may vary between various groups in the community (e.g. taking into account the relevance of ethnic background or socioeconomic status) as to who may be at greater or lesser risk.


Specific recommendations on screening for various conditions in children and adults are given in the charts in Guidelines for Preventive Activities Over the Lifecycle, which can be downloaded and/or printed for use in the patient records (see the Resources list at the end of this chapter). The charts provide an excellent summary that can be used to help to keep track of which examinations and tests have been done and what the key findings were. Further details regarding each of these activities can also be explored on the RACGP Red Book (page numbers are given on the charts), which can also be downloaded and/or printed.



ISSUES IN PREVENTION AND SCREENING


This section comments on some specific issues in relation to particular conditions or patient groups. Other chapters also have content on this topic—see, for example, the chapters on sexual health (Ch 61), cardiovascular disease (Ch 25), diabetes (Ch 26), cancer (Ch 24) and psychiatry and psychology (Ch 40).



PREGNANCY


Apart from the usual medical care and attention to gynaecological history, a number of factors need attention prior to and during pregnancy. These include:


• history of previous pregnancies, past medical history, blood pressure, blood glucose level, BMI, periodontal disease, thyroid function, family history of genetic illnesses

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Jun 3, 2017 | Posted by in GENERAL SURGERY | Comments Off on Screening and prevention

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