Screening for COPD IN PHC WORKSHOP Vasiliki Garmiri Athanasios Symeonidis THE WHO DEFINITION OF HEALTH • Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. What is screening? • “Screening is the presumptive identification of unrecognized diseases or defects by the application of tests, examinations or other procedures which can be applied rapidly.” • “Screening tests sort out apparently well persons who probably have a disease from those who probably do not.” The CCI Conference on Preventive Aspects of Chronic Disease, 1951 • A screening test is not intended to be diagnostic. • Persons with positive or suspicious findings must be referred to their physicians for diagnosis and necessary treatment. The CCI Conference on Preventive Aspects of Chronic Disease, 1951 Why SCREENING? • Because a plethora of medical conditions have no apparent symptoms. • Because it is important to know the incidence, prevalence and natural course of disease. Principles of early disease detection – prerequisites 1. An important health problem 2. A recognizable early symptomatic/latent stage 3. Available facilities for diagnosis 4. Accepted treatment for persons with the condition AND an agreed policy on whom to treat as patients (*) 5. Suitable screening test/examination (valid, reliable, easy, quick, with an acceptable yield) Principles of early disease detection – prerequisites 6. An acceptable test 7. The economically balanced cost of screening and case finding 8. A clear understanding of the natural history of the condition 9. Casefinding should be a continuing process What are the aims of Screening? • CASE FINDING (and treatment) • SURVEYS (POPULATION/ EPIDEMIOLOGICAL) (prevalence, incidence, the natural history of the disease) • EARLY DISEASE DETECTION (secondary prevention) Screening Methodology • Physical examination by a medical practitioner • Lab tests • Medical history • Questionnaires The primary health care approach: • Equity • Universal coverage with basic services • Multisectoral approach • Community involvement • Health promotion Why PRIMARY CARE? • Access to the majority of the population • Regarded as a credible source of lifestyle advice, it improves population levels of lifestyle risk factors • Health promotion + disease prevention is a key component of the role of GPs • The unique doctor-patient relationship Why PRIMARY HEALTH CARE? • The point of first contact – it provides continuing care and a holistic approach. • GPs can guide their patients according to their findings. • GPs are familiar with the lifestyle modification approach. Why PRIMARY HEALTH CARE? • It is oriented towards the needs of the patient AND the community. • The Primary Health Care doctor engages in organized activities outside the office (alone/PHC team). THE OTTAWA CHARTER FOR HEALTH PROMOTION, WHO,1986. THE ROLE OF GPs IN HEALTH PROMOTION • Advocating for health • Enabling people to achieve their fullest health potential • Mediating with government and nongovernment agencies, industry and the media THE OTTAWA CHARTER FOR HEALTH PROMOTION, WHO, 1986. FIVE PRINCIPLES/STRATEGIES 1. Build healthy public policy 2. Create supportive environments 3. Strengthen community actions 4. Develop personal skills 5. Reorient health services SCREENING FOR COPD IN PRIMARY HEALTH CARE COPD – Statistics • It is difficult to assess the burden of COPD (the large gap between the prevalence described as airflow limitation and clinically significant disease). • The most appropriate criteria for different settings are still a matter of discussion. • Still, morbidity and mortality are significant. GOLD REPORT,2009 Estimates of prevalence • A doctor’s self-report concerning COPD diagnosis • Spirometry with/without a bronchodilator • Questionnaires about respiratory symptoms Why COPD? • Screening for COPD is quick, easy, not interventional and it can be done in PHC. • Early diagnosis and treatment can change the natural course of disease. • Smoking cessation intervention is an important preventive and health promotion measure in PHC. COPD screening • Community-based spirometric screening still of unclear benefit (the GOLD report, 2009) • High-risk group: Males > 40, smokers and ex-smokers CAN I DISCRIMINATE THROUGH SYMPTOMS? • “In a multivariate analysis, age, BMI, smoking status and pack-years, symptoms (cough, phlegm, dyspnoea, wheeze) and prior diagnosis consistent with asthma or COPD all showed a significant ability to discriminate between persons with and without obstruction in the general population.” van Schayck CP, Halbert RJ, Nordyke RJ et al. Comparison of existing symptom-based questionnaires for identifying COPD in the general practice setting. Respirology 2005; 10: 323-333 What do I need to access in PHC? • Tobacco use • Pulmonary function • Patient questionnaires • Number of exacerbations • Exercise (?) Who should be screened with spirometry? • Smokers > 35(*) • Patients with symptoms suggestive of COPD • Patients testing positive on a risk evaluation questionnaire (COPD/IPCRG COPD) • *Patients ≥ 30 at high-risk (e.g. a family history of COPD, occupational or environmental risk, a smoker since childhood) Spirometry in primary care case-identification, diagnosis and management of COPD. David Price, Alan Crockett, Mats Arne, Bernard Garbe, Rupert Jones, Alan Kaplan, Arnulf Langhammer, Siân Williams, Barbara Yawn. Who should be referred for diagnostic spirometry? • FEV1 < 80% predicted or • FEV1/FVC < 0.8 (80%) or • FEV1/FEV6 < 0.8 (80%) Spirometry in primary care case-identification, diagnosis and management of COPD. David Price, Alan Crockett, Mats Arne, Bernard Garbe, Rupert Jones, Alan Kaplan, Arnulf Langhammer, Siân Williams, Barbara Yawn. COPD – Risk factors • Genes • Exposure to particles – Tobacco smoke – Occupational dusts, organic and inorganic – Indoor air pollution from heating and cooking with biomass in poorly vented dwellings – Outdoor air pollution COPD – Risk factors • Lung growth and development • Oxidative stress • Gender • Age • Respiratory infections • A previous case of tuberculosis • Socioeconomic status • Nutrition • Comorbidities (Asthma) REMEMBER! • Everyone should be asked about present or past tobacco use. • Health promotion should be directed toward everyone. PART III • TIME TO WORK IN GROUPS OF THREE! CASE • Patient, 50 years old, thin • Wants a lab. check-up “as a result of pressure from his/her spouse,” “otherwise he/she wouldn’t bother, there’s nothing wrong with me” • Occasionally measures bp – always around 120/80 mmHg CASE • Paying attention to international guidelines, you ask about tobacco use. • The patient is a smoker. DOCTORS • You have five minutes to talk to the patient and make a smoking cessation intervention. PATIENTS • After you have heard your doctor you have three minutes to tell him: 1. How you felt 2. Whatever you would like to point out (e.g. What you would like to hear, how you would have preferred to be approached, how you might be motivated, etc.) OBSERVERS – TO THE GROUP • Each observer will have one min. to focus briefly (a few words) on the following: 1. What was particularly good about the consultation. 2. The main aspect that would need improvement or was not mentioned. 3. The most interesting thing the patient said. TOBACCO USE – STATISTICS • Tobacco use is a major cause of lung cancer, CVD, and COPD. • Tobacco use causes 1 200 000 deaths each year in WHO's European region (14% of all deaths). • Unless more is done to help the 200 million European adult smokers stop smoking, the result will grow to 2 million European deaths from smoking a year by 2020. http://tobaccocontrol.bmj.com/content/11/1/44.full The European Commission published a survey on the smoking of 26 500 Europeans which took place in 28 countries (EU 27 and Norway) in December 2008. 2008 EUROBAROMETER SURVEY ON TOBACCO SUMMARY REPORT 3/10 EU citizens ≥ 15y say they smoke: 26% smoke daily, 5% occasionally, 22% of citizens say they have quit smoking. Almost half of EU citizens claim that they have never smoked. The proportion of smokers is the highest in Greece (42%), followed by Bulgaria (39%), Latvia (37%), Romania, Hungary, Lithuania, the Czech Republic and Slovakia (all 36%). The European tobacco control report 2007 • A fall in death rates from lung cancer among men across the Region. • Rates among women are still increasing. • Among young people, around 25% of 15-year-olds smoke every week and there has been no significant change in this level in recent years. • The prevalence of smoking among 15-year-old girls in many western European countries exceeds that among 15-year-old boys, while the reverse is true in eastern Europe. THE FIVE “A”s Brief strategies to help patients willing to quit smoking • ASK • ASSESS • ADVISE • ASSIST • ARRANGE THE FIVE “R”s Providing motivational interventions to patients unwilling to quit • RELEVANCE • RISKS • REWARDS • ROADBLOCKS • REPETITION A few key points to cover in a few minutes • Set a stop day and stop completely on that day. • Review past experiences and learn from them. • Make a personalized action plan. • Identify likely problems + plan on how to cope with them. • Ask family and friends for support. DON’T FORGET TO… Prevent relapse!!! 1. Open-ended questions 2. Active discussion 3. Help patients identify coping mechanisms to address threats DON’T FORGET… • The young • Ex-smokers • Secondhand smokers Top 5 secondary losses when someone quits smoking • Friends • Feelings of loneliness • Low self-esteem • Boredom • Indulgence Recommendations for smoking cessation specialists – Intensive Support Treatment as back-up to brief opportunistic interventions. • Individually/in groups • Coping skills training + social support • Around five one-hour sessions over approx. one month + follow up • NRT/bupropion/varenicline as appropriate PHARMACOTHERAPY • Bupropion and varenikline • NRT products: the patch, gum, nasal sprays, inhalators, tablets, lozenges Smokers of 10 or more cigarettes a day who are ready to stop should be encouraged to use NRT or bupropion/varenikline as a cessation aid. References • Wilson JMG, Jungner G. Principles and practice of screening for disease. WHO, Public Health Papers No. 34. Geneva: WHO, 1968 • Braveman PA, Tarimo E. Screening in primary health care. Setting priorities with limited resourses. Geneva: WHO, 1994 • Price DB, Tinkelman DG, Halbert RJ et al. Symptom-based questionnaire for identifying COPD in smokers. Respiration 2006; 73: 285-295 • Tinkelman DG, Price DB, Nordyke RJ et al. Symptom-based questionnaire for differentiating COPD and asthma. Respiration 2006; 73: 296-305 • Calverley PMA, Nordyke RJ, Halbert RJ et al. Development of a population-based screening questionnaire for COPD. J COPD 2005; 2: 225-232 • van Schayck CP, Halbert RJ, Nordyke RJ et al. Comparison of existing symptom- based questionnaires for identifying COPD in the general practice setting. Respirology 2005;10: 323-333 • David Price, Alan Crockett, Mats Arne, Bernard Garbe, Rupert Jones, Alan Kaplan, Arnulf Langhammer, Siân Williams, Barbara Yawn. DISCUSSION PAPER. Spirometry in primary care case-identification, diagnosis and management of COPD. Primary Care Respiratory Journal 2009; 18(3): 216-223 • http://www.copdguidelines.ca/guidelines-lignes_e.php • http://www.theipcrg.org/resources/ipcrg_copd_opinion_5.pdf • http://www.thepcrj.org/journ/view_article.php?article_id=654 • WWW.THEIPCRG.ORG • WWW.CCQ.NL • www.ginastma.org • www.copdgold.org • https://fhs.umr.com/oss/export/sites/default/FiservHealthServices/SharedFiles/F H0060_Adult.pdf • http://www.euro.who.int/document/e88698.pdf • http://www.apa.org/pubs/videos/4310588-scale.aspx • http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2519083/ DICTIONARY OF USED TERMS AND DEFINITIONS Screening is the presumptive identification of unrecognized diseases or defects by the application of tests, examinations or other procedures which can be applied rapidly. Screening tests sort out apparently well persons who probably have a disease from those who probably do not. A screening test is not intended to be diagnostic. Persons with positive or suspicious findings must be referred to their physicians for diagnosis and necessary treatment. Mass screening is the large scale screening of whole population groups. Selective screening is screening in selected high-risk groups in a certain population. It can be large-scale. Multiple (or multiphasic) screening is the application of two or more screening tests in combination to large groups of people. Surveillance is a long-term process (close and continuous observation) similar to the application of screening examinations repeatedly at selected regular intervals of time. It is often used as a synonym of the word screening. Case-finding is a form of screening aimed at detecting disease and bringing patients to treatment. Population or epidemiological surveys are surveys that primarily aim at elucidating the prevalence, incidence and natural history of the variable/s under study rather than bringing patients to treatment (although case-finding is a by-product of surveys). Early disease detection is the detection of disease at a primary stage by any means.
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