Guidelines for the implementation of prevention in the general practice setting


The Green Book
1.1 About prevention
☰ Table of contents


What is prevention?


While many general practitioners (GPs) and practice nurses (PNs) discuss lifestyle with their patients, this is only the tip of preventive care.1 Prevention in the healthcare context focuses on the health of individuals, communities and defined populations. It includes all measures that protect, promote and maintain health and wellbeing, and that prevent disease, disability and death.2–4
 

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Prevention in practice requires us to extend our patient-centred approach from individuals and families to the entire practice population.

 

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I’ve always been taught to do acute episodic care in response to patient demand. But I have realised that to really look after my patients, I have  to do chronic disease management and prevention, and that I need to do in a proactive and planned way.

– Assoc Prof Charlotte Hespe, Green Book Editorial Committee


Prevention, people and practice population


Prevention is relevant across a person’s lifespan: from pre-conception, fetal stage, childhood and adolescence through to middle age and older. The Red Book shows the preventive activities that apply across age groups.

There are many determinants of health and illness (Figure 2). A preventive approach recognises these and how they interact. It also reaches beyond individuals who seek out or are most receptive to preventive care to encompass the entire practice population.

Figure 2. The determinants of health and illness

Figure 2. The determinants of health and illness

Note: Bold highlights selected social determinants of health.
Reproduced from Australian Institute of Health and Welfare. Australia’s health 2014. Cat. no. AUS 178. Canberra: AIHW, 2014; p. 5.


Prevention and disease


Just as prevention is relevant across a person’s lifespan, it also applies to the natural history of disease (Figure 3). Preventive measures can be applied at any stage along the natural history of a disease to prevent progression. The stages may be divided into the following:5

  • Primordial – consists of actions to minimise future hazards and address broad determinants of health  (eg environmental, economic, social, educational, behavioural and cultural factors) rather than preventing personal exposure to risk factors, which is the goal of primary prevention
  • Primary – seeks to prevent the onset of disease via risk reduction (eg immunisation, smoking cessation)
  • Secondary – the early detection and prompt intervention to correct departures from good health or to treat the early signs of disease (eg cervical screening, bowel screening, mammography, blood pressure monitoring and blood cholesterol checking)
  • Tertiary – reducing impairments and disabilities, minimising suffering caused by existing departures from good health or illness, and promoting patients’ adjustment to chronic or irremediable conditions (eg prevention of complications). You may also come across quaternary prevention, which is action taken to identify patients at risk of overmedicalisation, to protect them from new medical interventions and to suggest ethically acceptable ones.6,7 Electronic health records may in the future be able to assist us in avoiding unnecessary repeat testing and medication errors, thereby playing a role in quaternary prevention.

In reality, the stages of prevention blur.

Figure 3. Primary, secondary, tertiary and quaternary prevention

Figure 3. Primary, secondary, tertiary and quaternary prevention

Reproduced from PH3C Primary Health Care Classification Consortium. Quaternary prevention. Erlangen, Germany: PH3C, 2016. [Accessed 21 March 2018].
 

Prevention and coordinated healthcare


Effective prevention usually requires teamwork within the practice as well as links with other (clinical and nonclinical) services.

Prevention and health promotion are among the core responsibilities of GPs and PNs.3 Through a range of strategies, GPs and PNs have the potential to influence patients to:
 

GPs and PNs may also pursue prevention through health advocacy or lobbying within their discipline.

The preventive approach incorporates opportunistic and planned interventions from the perspective of the whole practice as well as for the individual practitioner and patient. It may include auditing medical records to identify those who are missing out, using special strategies to support patients with low literacy, and being proactive in following up patients who are most at risk.8 External help (eg from PHNs) is often needed to support practices in these types of activities. PHNs are able to help in a range of ways, including de-identified data reviews.

The RACGP has developed a resource on Secondary use of general practice data. This resource provides support to decide whether it is appropriate to release de-identified healthcare data at the request of an external organisation.


PHN case study


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A couple purchased a retiring GP’s practice. They were new to the business and sought assistance from us, their local PHN.

 

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We assisted them in recruiting a PN by advertising on the PHN website and in monthly newsletters. We provided in-practice training for the PN who had come from a hospital setting – educating the nurse on the cycles of care, using recall reminder systems and maintaining practice protocols such as cold-chain.

We provided software installation and training to the practice, which enabled them to audit their aspects of their practice. With this software, we provided the practice with a report and supported them over the next 12 months in improving their recording of risk factors, patient data entry, and identifying patients with missed diagnoses and billing opportunities. Additionally, this process served as a continuing professional development (CPD) opportunity in quality improvement for the GPs, who now often frequent our free CPD nights.

The business owners felt this help was invaluable.

– Alessandro Luongo, Clinical QI Coordinator, South Western Sydney PHN


Measures to improve access to preventive healthcare by Aboriginal and Torres Strait Islander peoples are especially important, given their higher burden of disease and the barriers that exist to preventive healthcare. More information is available in the National Guide.


Collaboratives case study


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Health and Wellbeing North Ward is a multi-skilled and integrated medical practice offering primary care alongside other allied health providers. As a collective, it focuses on the proactive identification and treatment of risk factors before disease appears, and on patient-centred management of existing conditions.

 
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The practice has a large Aboriginal and Torres Strait Islander community in its area. To provide holistic and culturally aware care, the practice employs a specialist Aboriginal and Torres Strait Islander healthcare worker. Having a dedicated staff member for this community allowed the practice to:

  • run regular day clinics to address chronic condition management
  • offer consistent appointments for the local Aboriginal and Torres Strait Islander population and the local school that educates Aboriginal and Torres Strait Islander children from the broader area
  • provide home visits to those with access and/or language barriers
  • offer Medicare-rebatable healthcare plans for chronic and mental health conditions through their multidisciplinary set-up.

Patients responded very positively toward the extra care. Patient feedback surveys showed a 95% positive reaction, and practice numbers grew by 38% over two years. The care fostered a sense of loyalty and community among patients, with follow-up appointments kept and measurable improvements in health outcomes.

 

– Adapted from Improvement Foundation Australia. Australian Primary Care Collaboratives Program, Case study: Health and Wellbeing North Ward, ‘Multi-skilled, holistic agency adopts “wellness” philosophy’. Adelaide: Improvement Foundation Australia, [no date].

 
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Teamwork within an Aboriginal and Torres Strait Islander health service – Health checks
Patients aged 18 years and over are identified and screened for cardiovascular risk, chronic diseases and smoking via the Medicare Health Assessment for Aboriginal and Torres Strait Islander People (Medicare Benefits Schedule [MBS] item 715).
 

Suitable clients are invited to participate in after-hours exercise group sessions with a personal trainer, twice a week for two hours. Sessions include advice and education on diet and healthy eating, with the aim to decrease body mass index (BMI), increase health literacy and provide better management of chronic disease. Smoking cessation support is also offered and promoted.

– Fiona Thompson, Clinical Services Manager, Pangula Mannamurna Aboriginal Corporation

   

Visit 'Key Aboriginal and Torres Strait Islander organisations' for a list of useful contacts

The Green Book



 
 
  1. Geense WW, van de Glind IM, Visscher TL, van Achterberg T. Barriers, facilitators and attitudes influencing health promotion activities in general practice: An explorative pilot study. BMC Fam Pract 2013;14:20.
  2. American College of Preventive Medicine. Preventive medicine. Washington, DC: ACPM, [date unknown].  [Accessed 2 March 2018].
  3. Gelly J, Le Bel J, Aubin-Auger I, et al. Profile of French general practitioners providing opportunistic primary preventive care – An observational cross-sectional multicentre study. Fam Pract 2014;31(4):445–52.
  4. Drewes YM, Koenen JM, de Ruijter W, et al. GPs’ perspectives on preventive care for older people: A focus group study. Br J Gen Pract 2012;62(604):e765–72.
  5. The Association of Faculties of Medicine of Canada. Chapter 4: Basic concepts in prevention, surveillance, and health promotion. In: AFMC. AFMC primer on population health: A virtual textbook on public health concepts for clinicians. Canada: AFMC, updated 2017. [Accessed 2 March 2018].
  6. Pandve HT. Quaternary prevention: Need of the hour. J Family Med Prim Care 2014;3(4):309–10.
  7. Wagner H. Quaternary prevention and the challenges to develop a good practice comment on 'Quaternary prevention, an answer of family doctors to overmedicalization'. Int J Health Policy Manag 2015;4(8):557–58.
  8. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2016.
  9. Glasgow RE, Vinson C, Chambers D, Khoury MJ, Kaplan RM, Hunter C. National Institutes of Health approaches to dissemination and implementation science: Current and future directions. Am J Public Health 2012;102(7):1274–81.
  10. National Collaborating Centre for Methods and Tools. Implementing best practice guidelines: The RNAO toolkit. Hamilton, ON: McMaster University, updated 2017. [Accessed 2 March 2018].
  11. Cane J, O’Connor D, Michie S. Validation of the theoretical domains framework for use in behaviour change and implementation research. Implement Sci 2012;7:37.
  12. Eccles MP, Hrisos S, Francis JJ, et al. Instrument development, data collection, and characteristics of practices, staff, and measures in the Improving Quality of Care in Diabetes (iQuaD) Study. Implement Sci 2011;6:61.
  13. Grol R. Personal paper. Beliefs and evidence in changing clinical practice. BMJ 1997;315(7105):418–21.
  14. Michie S. Implementation science: Understanding behaviour change and maintenance. BMC Health Serv Res 2014;14(Suppl 2):9.
  15. Fogarty International Center. Implementation science information and resources. Bethesda, MD: FIC National Institutes of Health, updated 2018.  [Accessed 2 March 2018].
  16. Zwar NA, Richmond RL, Halcomb EJ, et al. Quit in general practice: A cluster randomized trial of enhanced in-practice support for smoking cessation. Fam Pract 2015;32(2):173–80.
  17. Halcomb EJ, Furler JS, Hermiz OS, et al. Process evaluation of a practice nurse-led smoking cessation trial in Australian general practice: Views of general practitioners and practice nurses. Fam Pract 2015;32(4):468–73.
  18. 18.    de Lusignan S, Hague N, van Vlymen J, Kumarapeli P. Routinely-collected general practice data are complex, but with systematic processing can be used for
    quality improvement and research. Inform Prim Care 2006;14(1):59–66.
  19. Stoto MA. Population health measurement: Applying performance measurement concepts in population health settings. EGEMS (Wash DC) 2015;2(4):1132.
  20. Cervero RM, Gaines JK. The impact of CME on physician performance and patient health outcomes: An updated synthesis of systematic reviews. J Contin Educ Health Prof 2015;35(2):131–38.
  21. Verbakel NJ, de Bont AA, Verheij TJ, Wagner C, Zwart DL. Improving patient safety culture in general practice: An interview study. Br J Gen Pract 2015;65(641):e822–28.
  22. Gillam S, Siriwardena AN. Leadership and management for quality. Qual Prim Care 2013;21(4):253–59.
  23. Dawda P, Jenkins R, Varnam R. Quality improvement in general practice: An inquiry into the quality of general practice in England. London, UK: The King’s Fund, 2010.
  24. Walters SJ, Stern C, Robertson-Malt S. The measurement of collaboration within healthcare settings: A systematic review of measurement properties of instruments. JBI Database System Rev Implement Rep 2016;14(4):138–97.
  25. Gibson O, Lisy K, Davy C, et al. Enablers and barriers to the implementation of primary health care interventions for Indigenous people with chronic diseases: A systematic review. Implement Sci 2015;10:71.
  26. 26.    Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: A systematic review. Prev Chronic Dis 2013;10:E26.
  27. Olsson LE, Jakobsson Ung E, Swedberg K, Ekman I.
    Efficacy of person-centred care as an intervention in controlled trials – A systematic review. J Clin Nurs 2013;22(3–4):456–65.
  28. Hayes SL, Mann MK, Morgan FM, Kelly MJ,  Weightman AL. Collaboration between local health and local government agencies for health improvement. Cochrane Database Syst Rev 2012;10:CD007825.
  29. Cunningham FC, Ranmuthugala G, Plumb J, Georgiou A, Westbrook JI, Braithwaite J. Health professional networks as a vector for improving healthcare quality and safety: A systematic review. BMJ Qual Saf 2012;21(3):239–49.
  30. Chung VC, Ma PH, Hong LC, Griffiths SM. Organizational determinants of interprofessional collaboration in integrative health care: Systematic review of qualitative studies. PLoS One 2012;7(11):e50022.
  31. Glasgow RE, Kessler RS, Ory MG, Roby D, Gorin SS, Krist A. Conducting rapid, relevant research: Lessons learned from the My Own Health Report project. Am J Prev Med 2014;47(2):212–19.
  32. Agency for Healthcare Research and Quality. National strategy for quality improvement in health care. Rockville, MD: AHRQ, updated 2016. [Accessed 2 March 2018].
  33. Janamian T, Upham SJ, Crossland L, Jackson CL. Quality tools and resources to support organisational improvement integral to high-quality primary care: A systematic review of published and grey literature. Med J Aust 2016;204(7 Suppl):S22–28.
  34. Salisbury C, Procter S, Stewart K, et al. The content of general practice consultations: Cross-sectional study based on video recordings. Br J Gen Pract 2013;63(616):e751–59.
  35. Booth BJ, Zwar N, Harris MF. Healthcare improvement as planned system change or complex responsive processes? A longitudinal case study in general practice. BMC Fam Pract 2013;14:51.
  36. Lau R, Stevenson F, Ong BN, et al. Achieving change in primary care – Causes of the evidence to practice gap: Systematic reviews of reviews. Implement Sci 2016;11:40.
  37. Leeman J, Calancie L, Hartman MA, et al. What strategies are used to build practitioners’ capacity to implement community-based interventions and are they effective?: A systematic review. Implement Sci 2015;10:80.
  38. Lau R, Stevenson F, Ong BN, et al. Achieving change in primary care – Effectiveness of strategies for improving implementation of complex interventions: Systematic review of reviews. BMJ Open 2015;5(12):e009993.
  39. Irwin R, Stokes T, Marshall T. Practice-level quality improvement interventions in primary care: A review of systematic reviews. Prim Health Care Res Dev 2015;16(6):556–77.
  40. O’Mara-Eves A, Brunton G, McDaid D, et al. Community engagement to reduce inequalities in health: A systematic review, meta-analysis and economic analysis. Public Health Research. Southampton, UK: NIHR Journals Library, 2013.
  41. Long JC, Cunningham FC, Braithwaite J. Bridges, brokers and boundary spanners in collaborative networks: A systematic review. BMC Health Serv Res 2013;13:158.
  42. Attieh R, Gagnon MP, Estabrooks CA, et al. Organizational readiness for knowledge translation in chronic care: A review of theoretical components. Implement Sci 2013;8:138.
  43. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implement Sci 2009;4:50.
  44. Watkins C, Harvey I, Langley C, Gray S, Faulkner A. General practitioners’ use of guidelines in the consultation and their attitudes to them. Br J Gen Pract 1999;49(438):11–5.
  45.  Berwick DM, Nolan TW, Whittington J. The triple aim: Care, health, and cost. Health Aff (Millwood) 2008;27(3):759–69.
  46. 4Bodenheimer T, Sinsky C. From triple to quadruple aim: Care of the patient requires care of the provider. Ann Fam Med 2014;12(6):573–76.
  47. Sikka R, Morath JM, Leape L. The quadruple aim: Care, health, cost and meaning in work. BMJ Qual Saf 2015;24(10):608–10.
  48. The Royal Australian College of General Practitioners. Standards for patient-centred medical homes: Patient- centred, comprehensive, coordinated, accessible and quality care. East Melbourne, Vic: RACGP, 2016.
  49. Lembke T, Ewald D, Rahbar S. Patient centred medical home: A quality improvement handbook for general practice [V1.0]. NSW: Australian Government; North Coast Primary Health Network, [date unknown].