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					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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