Guidelines for preventive activities in general practice 7th edition

Introduction and user guide

Preventive activities before pregnancy

Genetic counselling and testing

Preventive activities in children and young people

Preventive activities in middle age

Preventive activities in older age

Communicable diseases

Prevention of chronic disease

Prevention of vascular and metabolic disease

Early detection of cancers

Psychosocial

Screening tests of unproven benefit

Appendices

Disclaimer

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Introduction

General practitioners consult with 86% of Australians each year. One of our challenges is to make the most of this opportunity to contribute to preventive health care which¹:

is opportunistically provided when patients present with other problems or concerns
anticipates the preventive needs of patients by providing reminders for preventive care, and
proactively targets high risk individuals who may be least likely to seek out such care.

Agreement should be reached between the clinician and patient about what preventive actions are to be taken. General practitioners should be aware of the potential psychosocial impact of preventive care, such as a diagnosis being made after screening and the need for adequate counselling following diagnosis. Informed consent should be obtained for any screening and for any actions taken following screening.

Screening

Screening involves asking questions of, or conducting tests on, patients ‘to identify those individuals who are more likely to be helped than harmed by further tests or treatment to reduce the risk of a disease or its complications’.²

The World Health Organization (WHO) has produced guidelines^3,4 for the effectiveness of screening programs. We have kept these and the United Kingdom National Health Services’ guidelines² in mind in the development of recommendations about screening and preventive care:

The condition

should be an important health problem
should have a recognisable latent or early symptomatic stage
the natural history of the condition, including development from latent to declared disease, should be adequately understood

The test

should be simple, safe, precise and validated
should be acceptable to the target population
the distribution of test values in the target population should be known and a suitable cut-off level defined and agreed

Treatment

there should be an effective treatment for patients identified with evidence that early treatment leads to better outcomes
there should be an agreed policy on who should be treated and how

Outcome

there should be evidence of improved mortality, morbidity or quality of life as a result of screening and that the benefits of screening outweigh the harm
the cost of case finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole

Consumers

should be informed of the evidence so that they can make an informed choice about participation.

Screening activities in general practice are complex; they involve patients accessing care as well as general practices adopting systematic approaches to registering and recalling patients, and organising their efforts to maximise the effectiveness of each consultation in providing preventive care.⁵ Effective screening requires consideration of subgroups in the population who may have a higher prevalence of a disease or risk factor, or who may have difficulty accessing services.⁶

In these guidelines, screening usually refers to early detection using questions or a test, which GPs perform when patients present either for preventive care or opportunistically when patients present for other reasons (also known as case finding). Proactive recall of patients for screening is warranted for high risk groups or for conditions where population coverage has been identified by the government as a public health priority. These include immunisation and screening for cervical, breast and colorectal cancers and diabetes. However, it may be inappropriate to recall patients for assessment of conditions that have not been identified for population screening, such as for overweight or chlamydia infections.

There are an increasing number of Medicare items for health assessments in particular population groups: preschool children, Aboriginal children and adults, refugees, the intellectually disabled, those aged 45–49 years (with a risk factor), and those aged 75 years or over. There is evidence that these assessments improve the likelihood of preventive care being received.⁷ However, it is also important that such ‘health checks’ involve preventive interventions for which there is clear evidence of their effectiveness.

Preventive activities appropriate for age and risk status may also be provided opportunistically to patients as part of normal consultations. For example, it is appropriate to check if a particular patient has been recently screened for cancer when they present for other conditions and screen at that or a subsequent visit. It is also appropriate to assess risk factors such as smoking, physical inactivity or overweight, and offer interventions during the same or subsequent consultations if indicated.

Each preventive activity uses up some of the available time that GPs have to spend with their patients. It may also involve direct or indirect costs to the patient. Therefore it is important that each activity is based on sound research evidence of what is effective. This means that some activities are not recommended in this preventive guide because there is insufficient justification or because the cost or time outweigh the benefits, as demonstrated in carefully designed research studies. These guidelines include activities of relevance to general practice for which research has demonstrated benefit.

While the ‘red book’ is well accepted in Australian general practice, the implementation of recommendations still falls short in certain areas and for certain population groups. This represents a challenge for general practice. Specific implementation strategies designed to improve the coverage of preventive care are discussed throughout these guidelines.

These may include:

specific targeting of preventive interventions
better utilisation of information technology and management systems
better teamwork within the practice, and
working with other health professionals and community resources external to the practice.

Equity issues

Making sure that preventive care services reach those who most need them and may be less likely to access them requires a population approach in general practice. Unless specific consideration is given to the reach of preventive care provided and efforts are targeted toward particular groups, there is the risk of increasing inequalities in health in the community. Health inequalities are differences in health status that are ‘unnecessary, avoidable, unfair and unjust’⁸ which may be associated with socioeconomic status (SES), gender, ethnicity or rural and remote location. These inequitable differences in health status are thought to be responsible for about 17% of the total disease burden in Australia.⁹ While mortality in Australia is improving, inequities are not improving or are worsening.¹⁰ Much of this inequitable disease burden is preventable through primary and secondary prevention, encompassing health promotion and early detection and intervention.¹⁰ A more comprehensive approach to working in disadvantaged communities should take account of ‘literacy, income, cultural values, access to services and media’.¹¹ This issue is discussed in more detail in the RACGP publication, Putting prevention into practice: guidelines for the implementation of prevention in the general practice setting (the ‘green book’) 2nd edition.

Socioeconomically disadvantaged communities

However socioeconomic disadvantage is defined – whether by area of residence, occupation, income, education level or race – disadvantage is associated with a higher prevalence of, and a higher mortality from, most diseases, and particularly, the major chronic diseases that form such a large part of the work of general practice.¹² Studies have shown that preventive care is targeted to some extent at ‘low SES’ individuals in general practice.¹³ Nevertheless, these groups may make less use of preventive services,¹⁴ despite the higher need.

Aboriginal people and Torres Strait Islanders

While Indigenous Australians are at high risk of many diseases and premature death, and are more likely to be socioeconomically disadvantaged, they are less likely to receive many aspects of preventive care. Guidelines for providing evidence based preventive care services to Aboriginal people and Torres Strait Islanders have been developed. These can be found at www.racgp.org.au/aboriginalhealthunit.

Culturally and linguistically diverse communities

This term covers many different cultures and arrival backgrounds, ranging from refugee experiences to economic migration. Refugees in particular may have a high disease burden and may come from countries where there is little in the way of preventive care.^15–17

Rural and remote communities

The health of rural communities is determined in part by lower income levels and socioeconomic conditions, as well as the higher percentage of Aboriginal people and Torres Strait Islanders.¹⁸ Access to services is again influenced by this mix, and rurality and low SES may compound disadvantage.^19,20 Men in rural communities have particular low use of preventive health services.²¹