Download Screening for COPD in PHC Vasiliki Garmiri, Athanasios Symeonidis

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
diagnostic.
test
is
not
intended
to
be
• 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.
2.
3.
4.
5.
An important health problem
A recognizable early symptomatic/latent stage
Available facilities for diagnosis
Accepted treatment for persons with the condition
AND an agreed policy on whom to treat as patients
(*)
Suitable screening test/examination (valid, reliable,
easy, quick, with an acceptable yield)
Principles of early disease detection – prerequisites
6.
7.
8.
9.
An acceptable test
The economically balanced cost of screening and
case finding
A clear understanding of the natural history of the
condition
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.
2.
3.
4.
5.
Build healthy public policy
Create supportive environments
Strengthen community actions
Develop personal skills
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 symptombased 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.