Author: Paul Hayes
The RACGP’s Guidelines for preventive activities in general practice (Red Book) has been updated for its 9th edition.
Research and quality evidence are pillars in the effectiveness of many professions. In the case of healthcare, these areas can move at a rapid pace and it is vital medical practitioners are able to keep up with what is best for them and their patients.
The new 9th edition of the RACGP’s Guidelines for preventive activities in general practice (Red Book), which was released in late 2016, has been updated to ensure Australia’s GPs have access to preventive recommendations that are based on the most up-to-date evidence-based guidelines.
‘Evidence changes and new studies are published, new techniques come along,’ Prof Nick Zwar, GP and Chair of the Red Book editorial committee, told Good Practice. ‘We need to look at the evidence and update the guidelines so GPs are abreast of what is supported by the best evidence.’
The Red Book, which was first published in 1989, was last updated in 2012 and is designed to provide GPs and practice teams with guidance on opportunistic and proactive preventive care. The publication features a total of 15 chapters, including areas such as genetic counselling and testing, communicable diseases, prevention of chronic disease, screening tests of unproven benefit, and many more (refer to breakout on page X for full list of Red Book chapters).
‘Preventive activities are crucial for population health,’ Prof Zwar said. ‘And in general practice and primary care, we can do a lot to address many of the health issues that affect our society and the way that, for example, tobacco use, risky alcohol, etc can make a big difference to people’s health and use of health services.
‘Prevention is so important and the Red book is a crucial resource.’
Once the decision was made in 2015 to update the Red Book, the RACGP established an editorial committee. This was made up of experienced GPs from all over Australia, as well as one consumer representative, with a principal GP assigned to be in charge of the content in each chapter.
The first stage was a consultation phase to seek feedback on the 8th edition of the Red Book, and to allow GPs and other stakeholders to provide suggestions for improvement and relevant evidence for the 9th edition. Members of the editorial committee, with the support of RACGP staff members, then conducted thorough searches and reviews of relevant guidelines and evidence from all over the world.
The committee met monthly over a period of 15 months to discuss key issues and any contentious areas in terms of evidence and recommendations, and to rigorously review the evidence and debate the draft content.
The next step was a second consultation phase involving external bodies, such as the Cancer Council, Genetics Association and Breast Screen Australia. This was followed by finalisation of content, including an internal RACGP review and Council endorsement.
The updated 9th edition of the Red Book was then officially launched at the RACGP’s Annual Conference for General Practice – GP16 – in Perth in October 2016.
‘The update is quite a long development,’ Prof Zwar said. ‘The content leads for various chapters take leadership of looking at the evidence, synthesising it and developing new text for the updated edition.
‘It’s a rigorous process that looks at all of the evidence and at a lot of expert opinion.’
Additions and updates
The Red Book is designed to help GPs offer the best preventive care to all patients who walk through their doors. However, delivering such care to different socioeconomic and cultural groups can be difficult.
‘[In the updated Red Book] we have rewritten how we deal with health and equity,’ Prof Zwar said. ‘Because one of the challenges for prevention and preventive activities is delivering them to people who are less advantaged – people on low incomes, people who live in rural Australia, Aboriginal and Torres Strait Islander peoples, to people who don’t speak English, etc.
‘The health inequity sections were rewritten to try to present them as a more structured guide as to what GPs and general practice staff members might be able to do to address health inequity in regards to prevention.’
The updated health inequity section includes suggestions for GPs such as the use of motivational interviewing and counselling techniques, plain-language and culturally appropriate written materials, using interpreter services during consultations, and more.
One of the most important clinical areas in which information and evidence has evolved in recent years is screening for early detection of cancers.
‘The cancer section of the Red Book has been quite comprehensively reviewed,’ Prof Zwar said. ‘There is a lot happening in terms of cancer screening, and a lot of new studies related to prostate cancer screening.
‘But it’s not just to prostate cancer screening. It’s also cervical cancer and breast cancer screening, and the risks as well as benefits of screening programs.’
In the case of cervical cancer, the information contained the Red Book is particularly important in light of coming changes to the National Cervical Cancer Program. Effective from 1 May 2017, women aged 25 and older will have their two-yearly the Pap smear replaced with a Human papillomavirus (HPV) test/cervical screening test every five years.
‘Cervical cancer screening in Australia has been extremely successful … and GPs are integral to the program because we are the major Pap test providers in the country,’ Prof Danielle Mazza, GP and content lead for the Red Book’s cervical cancer and breast cancer screening sections, told Good Practice.
‘Women have become accustomed to the two-yearly Pap smear and that consultation, which is often an opportunity for GPs to talk about a large range of preventive healthcare issues.
‘GPs will be the key component of the implementation of this new National Cervical Cancer Program and the new edition of the Red Book provides information about transitioning for the [cervical cancer screening] changes.’
The Red Book also includes new information on balancing the benefits and potential risks of mammography when screening for breast cancer.
‘This edition of the Red Book highlights the move towards giving increased significance to the individual risk of the patient who is sitting in front of you, rather than just having a broader approach [to breast cancer screening],’ Prof Mazza said.
‘We refer to Cancer Australia’s tools that help to determine what degree of risk of breast cancer a patient might have, and we also refer to the availability of various new options for women who have a high level of risk. For example, chemoprevention, which is the taking of medication to try and reduce risk.
‘We recommend GPs consider those and other options for their patients.’
Screening for prostate cancer is also an area in which greater levels of evidence have come to light in recent years. While the RACGP maintains its position that prostate-specific antigen (PSA) testing not be recommended for population screening, the new edition of the Red Book recommends using ‘decision support’ to keep individual patients more informed about the benefits and potential harms of PSA screening.
‘[The latest research] confirmed the evidence from previous editions of the Red Book; that there is not a clear benefit of prostate cancer screening in asymptomatic men,’ Prof Zwar said. ‘We have now provided information about new trials and about tools to assist the discussion with men as to whether they want to have prostate cancer screening.
‘So if a man chooses to go to down that path, they do so in an informed way after an evidence-based discussion with their doctor.’
Genetic counselling and testing is another aspect of preventive health where research and evidence have developed.
Identifying patients who may be at risk of a genetic disorder requires a comprehensive family history and, as such, the 9th edition of the Red Book has used the latest available evidence to formulate a family-history screening questionnaire (FHSQ). The FHSQ is designed to help identify whether certain patients require a more detailed assessment of family history of cancer, heart disease or diabetes.
‘This tool can be used as part of the patient’s assessment at their first visit to a practice,’ Prof Zwar said at the Red Book launch at GP16. ‘If patients are uncertain about their family history, they can be asked to discuss the FHSQ with their relatives prior to completing the questionnaire.
‘The FHSQ is helpful in that it saves GPs going straight to technological things like testing people from blood to look at their genes. This may throw up a whole lot of things and may be of little relevance, but may just cause worry for the patient.’
Given one of the most important aspects of preventive medicine is knowing what not to do, it makes sense that the ‘Screening tests of unproven benefit’ chapter has expanded further in the updated edition of the Red Book.
‘Just because you can, doesn’t mean that you should,’ Prof Zwar said.
What originally began as a relatively small section of the 5th edition of the Red Book (2003) now includes two very detailed tables – ‘Screening tests not recommended in low-risk general practice populations’ and ‘Screening tests of indeterminate value’.
According to Assoc Prof John Litt, content lead and original driving force for the chapter, the latest edition helps to provide more context as to why these tests may not necessarily be recommended.
‘I went through all of the current professional guidelines, and when they were all in agreement that made it really easy and there wasn’t much to talk about,’ he told Good Practice. ‘Where there was mixed or variable quality of evidence, where one country is saying “you ought to be screening for this” and another country is saying “don’t do it”, then that leads to inconsistency and leaves GPs with different views.
‘We have tried to provide a little bit more of a discussion and the reasoning behind recommendations when the evidence is either weak, inconsistent or even lacking.’
Assoc Prof Litt believes that, in addition to the potential financial cost of unnecessary tests of limited or no benefit, individual patients may be faced with needless concern in the face of what can appear to be a major medical issue.
‘Every time we investigate a perceived problem or provide a diagnosis we give patients a medical label, which can have adverse consequences. These include anxiety and unnecessary investigations that may cause harm and uncertainty,’ he said.
‘For example, a lot people with an abnormal PSA may worry about what it means even though, for many, the results may not progress. When the results do progress, you may end up treating the results with further investigations and interventions that can potentially often cause harm. This is especially problematic if the person does not have an aggressive prostate cancer.
‘The instigation of unnecessary or poor screening tests commits the doctor to a series of subsequent medical investigations and treatments that put the patient at risk of significant harms.’
Widely accepted as the main guide to the provision of preventive care in Australian general practice, the Red Book continues to play a key role in the everyday practice of GPs throughout the country. Its function in supporting evidence-based preventive activities in primary care means its updates must be of the highest quality.
‘The Red Book has developed a certain status because people have learnt they can trust it,’ Prof Zwar said. ‘We have tried to keep it brief enough that it’s useful in day-to-day practice and I think it’s a vital publication.’
Prof Mazza described the Red Book as a ‘wonderful resource’ because it does what so many other guidelines do not in that it offers information in a patient-centred way.
‘It enables GPs to access information in a comprehensive way for the patient who is sitting there in front of them,’ she said. ‘It helps to understand across reproductive health, cancer, dermatology, mental health and many other aspects of healthcare, and explains the risks and what the GP’s approach should be to address the patient’s risks and take a preventive approach.
‘The Red Book is a comprehensive document unlike anything else that’s available in Australia, and that’s what makes it the gold standard for prevention and preventive care in this country.’