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Clinical guidelines

Guidelines for preventive activities in general practice 9th edition

I. Introduction

General practice is at the forefront of healthcare in Australia and in a pivotal position to deliver preventive healthcare. More than 137 million general practice consultations take place annually in Australia and 85% of the Australian population consult a general practitioner (GP) at least once a year.1 Preventive healthcare is an important activity in general practice. It includes the prevention of illness, the early detection of specific disease, and the promotion and maintenance of health. The partnership between GP and patient can help people reach their goals of maintaining or improving health. Preventive care is also critical in addressing the health disparities faced by disadvantaged and vulnerable population groups.

Prevention of illness is the key to Australia’s future health – both individually and collectively. About 32% of Australia’s total burden of disease can be attributed to modifiable risk factors (Figure I.1 and Table I.1).2

Figure I.1. Leading risk factors contributing to the burden of disease3
Fig I1

A healthy lifestyle is vital for preventing disease, including prevention of cancer. Cancer Australia4 summarises the recommendations for adults to reduce their risk of cancer and stay healthy as the following:

  • Do not smoke
  • Maintain a healthy weight
  • Be active
  • Eat a balanced and nutritious diet
  • Limit alcohol consumption
  • Be sun smart
  • Protect against infection

The evidence of associations between behavioural and biomedical risk factors and chronic diseases is summarised in Table I.1.

Table I.1. Strong evidence of direct associations between selected chronic diseases and behavioural and biomedical risk factors5
Chronic diseaseBehavioural
Tobacco smoking
Behavioural
insufficient physical activity
Behavioural
Excessive alcohol consumption
Behavioural
Dietary risks
Biomedical
Obesity
Biomedical
High blood pressure
Biomedical
Abnormal blood lipids
CVD *
Stroke
Type 2 diabetes *
Osteoporosis
Colorectal cancer
Oral health § || #
CKD
Breast cancer (female) **
Depression
Osteoarthritis
Rheumatoid arthritis
Lung cancer
Cervical cancer ††
COPD
>Asthma

• Strong evidence in support of a direct association between the chronic disease and risk factor

— There is either not a direct association or the evidence for a direct association is not strong

*For coronary heart disease and type 2 diabetes, dietary risks relate to high intake of saturated fat

For osteoporosis, dietary risks relate to insufficient calcium and vitamin D. The recommendation is to enhance vitamin D levels through adequate sun exposure and/or supplements if required

‡ For colorectal cancer (CRC), dietary risks relate to high intakes of processed (preserved) meat. In addition, a high intake of red meat is associated with an increased risk of CRC. The Australian dietary guidelines (ADG) therefore recommend that processed meat intake should be limited (also because of its high saturated fat content). In addition, to enhance dietary variety and reduce some of the health risks associated with consuming red meat, the ADG recommend Australian adults should consume up to a maximum of 455 g per week (one serve [65 g] per day) of lean red meats

§The evidence for tobacco smoking and oral health relate to oral cancer and adult periodontal diseases

|| The evidence for excessive alcohol consumption and oral health relate to oral cancer

#For oral health, dietary risks relate to amount and frequency of free sugars for dental caries, soft drinks and fruit juices for dental erosion, excess fluoride for enamel developmental defects, and deficiency of vitamin C for periodontal disease

**The evidence for obesity and breast cancer is for postmenopausal women

††Persistent infection with the human papillomavirus (HPV) is a central cause of cervical cancer. HPV infection is not identified in Table I.1 as it only includes those risk factors that are implicated in more than one chronic disease and have the greatest prevalence within the population. It is important to recognise that the behavioural risk factors of multiple sexual partners and early age at initiation of sexual activity reflect the probability of being infected with HPV

The chronic diseases included in Table I.1 are those that currently contribute the most to burden of disease and/or are the focus of ongoing national surveillance efforts

The behavioural and biomedical risk factors included in Table I.1 are those that are implicated in more than one chronic disease and have the greatest prevalence within the population

ADG, Australian dietary guidelines; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CRC, colorectal cancer; CVD, cardiovascular disease; HPV, human papillomavirus

Reproduced with permission from Australian Institute of Health and Welfare. Chronic disease risk factors. Canberra: AIHW, 2016

The Royal Australian College of General Practitioners (RACGP) has published the Guidelines for preventive activities in general practice (Red Book) since 1989 to support evidence-based preventive activities in primary care. The Red Book is now widely accepted as the main guide to the provision of preventive care in Australian general practice.

 

The Red Book

The Royal Australian College of General Practitioners (RACGP) has published the Guidelines for preventive activities in general practice (Red Book) since 1989 to support evidence-based preventive activities in primary care. The Red Book is now widely accepted as the main guide to the provision of preventive care in Australian general practice.

Purpose

The Red Book is designed to provide the general practice team with guidance on opportunistic and proactive preventive care. It provides a comprehensive and concise set of recommendations for patients in general practice with additional information about tailoring advice depending on risk and need. The Red Book provides the evidence and reasons for the efficient and effective use of healthcare resources in general practice.

The Red Book’s companion publication, National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edn, is intended for all health professionals delivering primary healthcare to Aboriginal and Torres Strait Islander peoples.

Scope

The Red Book covers primary (preventing the initial occurrence of a disorder) and secondary (preventive early detection and intervention) activities. These guidelines focus on preventive activities applicable to substantial portions of the general practice population rather than specific subgroups. This means, in general, recommendations apply to asymptomatic (low-risk) people. However, there is an emphasis on equity, with recommendations aimed at major disadvantaged groups at higher risk of disease and those who are less likely to receive preventive care.

These guidelines do not include:

  • detailed information on the management of risk factors or disease (eg what medications to use when treating hypertension)
  • information about the prevention of infectious diseases. This information has been limited largely to immunisation and some sexually transmissible infections (STIs).

There is limited advice about travel medicine. This information can be obtained from the Centers for Disease Control and Prevention or World Health Organization (WHO) International Travel and Health

The Australian experience

The role of general practice in prevention has been recognised by the Council of Australian Governments (COAG)6 and in the Australian Government’s National Preventative Health Strategy and National Primary Health Care Strategic Framework.2,7

Deaths and hospitalisations from preventable illness have continued to decline in Australia. However, the leading causes of death and disability in Australia are preventable or able to be delayed by early treatment and intervention (Figure I.2).8

Figure I.2. Age-standardised death rates for potentially avoidable deaths,
1997–2010*9

Fig I2

*Deaths among people <75 years of age that are potentially avoidable within the present healthcare system

Potentially avoidable deaths are divided into potentially preventable deaths (cases amenable to screening and primary prevention) and treatable deaths (cases from potentially treatable conditions amenable to therapeutic interventions). There were 32,919 potentially avoidable deaths in Australia in 2010; 62% were classified as potentially preventable and 38% as potentially treatable.8 Preventable death rates fell from 142 to 91 deaths per 100,000 between 1997 and 2010 (36%), and treatable death rates fell by 41% (from 97 to 57 deaths per 100,000)*Deaths among people <75 years of age that are potentially avoidable within the present healthcare system

Reproduced with permission from Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014.

An Australian review10 concluded that lifestyle interventions could have a large impact on population health. The absolute cardiovascular disease (CVD) risk approach and screening for diabetes and chronic kidney disease (CKD) were also given high priority for action.

Despite this evidence and wide acceptance of its importance, preventive interventions in general practice remain underused, being the primary reason for the consultation in only of every 100 clinical encounters.11 This is small when it is considered that preventable chronic diseases, along with biomedical risk factors, account for approximately one-fifth of all problems currently managed in Australian general practice.12

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. Much more needs to be done to support and improve proper evidence-based preventive strategies, and to minimise practices that are not beneficial or have been proven to be harmful.

The RACGP has been championing this cause since its foundation, and encourages all general practices, GPs and their teams to prioritise evidence-based preventive health activities.

Benefits and harms of preventive health activities

‘Prevention is better than cure’ makes intuitive sense. Yet there is evidence that some preventive activities are not effective, some are actually harmful. It has been said ‘all screening programs do some harm; some do good as well’.13 Screening of asymptomatic patients may lead to overdiagnosis, causing needless anxiety, appointments, tests, drugs and even operations, and may leave the patient less healthy as a consequence. Therefore, it is crucial that evidence clearly demonstrates that benefits outweigh those harms for each preventive activity.

Determining whether a preventive activity is beneficial, harmful or of indeterminate effect (ie there is not enough evidence on which to base a decision) requires a consistent, unbiased, evidence-based approach.

Cancer screening, in particular, can polarise different sectors of the health profession and broader community. The objective interpretation of evidence, balancing harms and benefits, and considering overdiagnosis and overtreatment is a goal of the Red Book.

In the Red Book, the RACGP provides information to assist GPs in caring for their patients, including in areas where the evidence is uncertain or contentious. Screening activities are only recommended where evidence demonstrates that benefits outweigh harms. Chapter 15 provides some guidance on common tests where this is not the case or where the evidence is either unclear or not available.

Prevention in the practice population

The risk of illness and disease is associated with a range of factors that operate on the individual across the lifecycle. For example, poor nutrition and lack of antenatal care during pregnancy are associated with later risk of chronic diseases in the child. Risk behaviours in childhood may become entrenched, leading to progressive physiological changes that can cause chronic diseases in later life. All these factors are in turn influenced by the social determinants of health, which operate at the local community and broader societal levels; these are poverty, housing, education and economic development (Figure I.3). Thus, it is highly desirable for general practice to think beyond the preventive healthcare needs of the individual patient, towards a practice population approach to primary prevention.

Figure I.3. The determinants of health and illness9
1

Note: Bold highlights selected social determinants of health

Reproduced with permission from Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014.

General practice has a practical role to play in addressing these determinants and helping to break the cycle that may exist linking social and economic factors to illness and injury. This requires a systematic approach across the whole practice population, not just for those who seek out or are most receptive to preventive care. This 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. It will usually require teamwork within the practice as well as links with other services.

General practice also has a broader role in facilitating health improvement for vulnerable and disadvantaged groups in the local community, in association with other services and providers. In some cases, this may involve advocacy for their needs. Information on local vulnerable and disadvantaged groups and their access to healthcare can be obtained from local Primary Health Networks (PHNs) or state and territory health networks. 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 to preventive health assessment for Aboriginal and Torres Strait Islander people, 2nd edn.

Screening versus case finding

Many clinicians confuse screening and case-finding tests. Screening is defined as ‘the examination of asymptomatic people in order to classify them as likely or unlikely to have a disease’.14 The primary purpose of screening tests is to detect early disease in apparently healthy individuals.

Case finding is the examination of an individual or group suspected of having, or at risk of, the condition. Case finding is a targeted approach to identifying conditions in select patients who may already have symptoms.15

A diagnostic test is any kind of medical test performed to establish the presence (or absence) of disease as a basis for treatment decisions in symptomatic or screen-positive individuals (confirmatory test). Examples include taking a mid-stream urine (MSU) sample for evaluation of a urinary tract infection and performing a mammogram for a suspicious breast lump.

Screening and case finding carry different ethical obligations. If a clinician initiates screening in asymptomatic individuals, there needs to be conclusive evidence that the procedure can positively affect the natural history of the disorder. Moreover, the risks of screening must be carefully considered as the patient has not asked the health professional for assistance.

This situation is somewhat different from case finding, where the patient has presented with a particular problem or has asked for some level of assistance. In this situation, there is no guarantee of benefit of the tests undertaken. It could be argued that there is at least some implied exposure to risk (eg performing colonoscopy to investigate abdominal pain).

Opportunistic versus systematic prevention

Most preventive activities are undertaken in Australia opportunistically – that is when patients present for other reasons, and the preventive activity is an add-on.16 This approach is supported by evidence, which shows that visits just for ‘a general check-up’ are not effective or necessary.17

However, systematic approaches to register and recall patients for some specific targeted conditions are worthwhile – including childhood immunisations; and screening for cervical, breast and colorectal cancers (CRC), and diabetes. Proactive recall of patients for screening is warranted for high-risk groups, those who may have difficulty accessing services and for conditions where population coverage has been identified by the government as a public health priority.15

Screening principles

The World Health Organization (WHO) has produced guidelines18,19 for the effectiveness of screening programs. These and the National Health Service’s (NHS) guidelines20 in the UK have been kept in mind in the development of recommendations about screening in the Red Book.

Condition

  • It should be an important health problem.
  • It 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.

Test

  • It should be simple, safe, precise and validated.
  • It 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 they should be treated.

Outcome

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

Consumers

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

In Australia, there is an increasing number of Medicare Benefits Schedule (MBS) items for health assessments in particular population groups: Aboriginal and Torres Strait Islander children and adults, refugees, people with an intellectual disability, those aged 45–49 years (with a risk factor), and those aged ≥75 years. There is evidence that these assessments improve the likelihood of preventive care being received.21 However, it is important that such ‘health checks’ involve preventive interventions where there is clear evidence of their effectiveness.

References

  1. Britt H MG, Henderson J, Bayram C, et al. General practice activity in Australia 2014–15. Sydney: Sydney University Press, 2015.
  2. Australian Government Preventative Health Taskforce. Australia: The healthiest country by 2020 – National preventative health strategy. Canberra: Commonwealth of Australia, 2009. Available at www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/content/AEC223A781D64FF0CA2575FD00075DD0/$File/nphs-overview.pdf [Accessed 15 December 2015].
  3. Begg S, Vos T BB, Stevenson C, Stanley L, Lopez AD. The burden of disease and injury in Australia 2003. Canberra: AIHW, 2007.
  4. Cancer Australia. Cancer Australia position statements. Surrey Hills, NSW: Cancer Australia, 2016. Available at https://canceraustralia.gov.au/publications-and-resources/position-statements/lifestyle-risk-factors-and-primary-prevention-cancer [Accessed 5 May 2016].
  5. Australian Institute of Health and Welfare. Chronic disease risk factors. Canberra: AIHW, 2016. Available at www.aihw.gov.au/chronic-diseases/risk-factors [Accessed 3 May 2016].
  6. Council of Australian Governments Health Services. Promoting good health, prevention and early intervention. Canberra: COAG, 2006. Available at www.health.gov.au/internet/budget/publishing.nsf/Content/budget2006-hfact37.htm [Accessed 15 December 2015].
  7. Department of Health. National Primary Health Care Strategic Framework. Canberra: DOH, 2013. Available at www.health.gov.au/internet/main/publishing.nsf/Content/nphc-strategic-framework[Accessed 18 March 2016].
  8. Steering Committee for the Review of Government Service Provision. National agreement performance information 2011–12: National healthcare agreement. Canberra: Productivity Commission, 2011.
  9. Australian Institute of Health and Welfare. Australia’s health 2014. Canberra: AIHW, 2014.
  10. Vos T, Carter R, Barendregt J, et al. Assessing cost-effectiveness in prevention (ACE–Prevention): Final report. Herston, Qld: University of Queensland; and Burwood, Vic: Deakin University, 2010.
  11. Mazza D, Shand LK, Warren N, Keleher H, Browning CJ, Bruce EJ. General practice and preventive health care: A view through the eyes of community members. Med J Aust 2011;195(4):180–83.
  12. Australian Institute of Health and Welfare. Chronic diseases and associated risk factors in Australia. Canberra: AIHW, 2006. Available at www.aihw.gov.au/publication-detail/?id=6442467914 [Accessed 5 May 2016].
  13. Gray JA, Patnick J, Blanks RG. Maximising benefit and minimising harm of screening. BMJ 2008;336(7642):480–83.
  14. Morrison AS. Screening. In: Rothman KJ, Greenland S, Lash TL, editors. Modern epidemiology, 2nd edn. Philadelphia: Lippincott-Raven,1998.
  15. Aldrich R, Kemp L, Williams JS, et al. Using socioeconomic evidence in clinical practice guidelines. BMJ 2003;327(7426):1283–85.
  16. The Royal Australian College of General Practitioners. Smoking, nutrition, alcohol, physical activity (SNAP): A population health guide to behavioural risk factors in general practice. 2nd edn. East Melbourne, Vic: RACGP, 2015.
  17. Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease: Cochrane systematic review and meta-analysis. BMJ 2012;345:e7191.
  18. World Health Organization. Screening for various cancers. Geneva: WHO, 2008. Available at www.who.int/cancer/detection/variouscancer/en [Accessed 3 May 2016].
  19. Wilson J, Jungner Y. Principles and practices of screening for disease. Geneva: World Health Organization, 1968.
  20. UK National Health Services. What is screening? London: UK National Screening Committee, 2015. Available at www.nhs.uk/Livewell/Screening/Pages/screening.aspx#what-is [Accessed 6 January 2016].
  21. Bouleware LE, Barnes GJ, Wilson RF, et al. Systematic review: The value of the periodic health evaluation. Ann Intern Med 2007;146:289–300.
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