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Guidelines for preventive activities in general practice 8th edition Guidelines for preventive activities in general practice 8th edition Disclaimer The information set out in this publication is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is this publication exhaustive of the subject matter. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates. Whilst the text is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices. Accordingly, The Royal Australian College of General Practitioners and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in this publication for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in this publication and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Recommended citation Guidelines for preventive activities in general practice, 8th edn. East Melbourne: Royal Australian College of General Practitioners, 2012. Published by The Royal Australian College of General Practitioners RACGP House 100 Wellington Parade East Melbourne VIC 3002 Australia T 03 8699 0414 F 03 8699 0400 www.racgp.org.au ISBN 978–0–86906–344–6 First edition published 1989 Second edition published 1993 Third edition published 1994 Fourth edition published 1996 Fifth edition published 2001 Fifth edition (updated) published 2002 Sixth edition published 2005 Seventh edition published 2009 This eighth edition published 2012 Cover image © istockphoto/skodonnell © 2012 The Royal Australian College of General Practitioners Guidelines for preventive activities in general practice 8th edition Acknowledgements The Royal Australian College of General Practitioners (RACGP) gratefully acknowledges the generous contribution of the following authors and reviewers of the Guidelines for preventive activities in general practice (the ‘red book’) 8th edition. Red book taskforce members Dr Evan Ackermann Chair, Red Book Taskforce, Chair, National Standing Committee for Quality Care, RACGP Professor Mark Harris Centre for Primary Health Care and Equity, University of New South Wales, National Standing Committee for Quality Care, RACGP Dr Karyn Alexander General practitioner, Victoria Dr Meredith Arcus General practitioner, Western Australia Linda Bailey Project manager, Red Book taskforce Dr John Bennett Chair, National Standing Committee for e-Health, RACGP Associate Professor Pauline Chiarelli School of Health Sciences, University of Newcastle, New South Wales Professor Chris Del Mar Faculty of Health Sciences and Medicine, Bond University, Queensland Professor Jon Emery School of Primary, Aboriginal and Rural Health Care, The University of Western Australia, National Standing Committee for Research, RACGP Dr Ben Ewald School of Medicine and Public Health, University of Newcastle, New South Wales Dr Dan Ewald General practitioner, New South Wales; Adjunct Associate Professor, Northern Rivers University Centre for Rural Health; and Clinical Advisor North Coast NSW Medicare Local Professor Michael Fasher Adjunct Associate Professor, University of Sydney; and Conjoint Associate Professor, University of Western Sydney, New South Wales Dr John Furler Department of General Practice, The University of Melbourne, Victoria Dr Faline Howes General practitioner, Tasmania Dr Caroline Johnson Department of General Practice, The University of Melbourne, Victoria, National Standing Committee for Quality Care, RACGP Dr Beres Joyner General practitioner, Queensland Associate Professor John Litt Department of General Practice, Flinders University, South Australia, Deputy Chair, National Standing Committee for Quality Care, RACGP iii iv Guidelines for preventive activities in general practice 8th edition Professor Danielle Mazza Department of General Practice, School of Primary Care, Monash University, Victoria, National Standing Committee for Quality Care, RACGP Professor Dimity Pond School of Medicine and Public Health, University of Newcastle, New South Wales Associate Professor Lena Sanci Department of General Practice, The University of Melbourne, Victoria Associate Professor Jane Smith Faculty of Health Sciences and Medicine, Bond University, Queensland Dr Tania Winzenberg Deputy Chair, National Standing Committee for Research, RACGP Reviewers Dr Stuart Aitken Gold Coast Sexual Health Clinic, Queensland Professor Adrian Bauman School of Public Health, The University of Sydney, New South Wales Dr Glenise Berry Australian & New Zealand Society for Geriatric Medicine Dr Mark Bolland School of Medicine, The University of Auckland, New Zealand Dr Chris Bourne, Sydney Sexual Health Centre, Sydney Hospital, New South Wales Robert Boyd-Boland Australian Dental Association Professor Henry Brodaty Dementia Collaborative Research Centre, University of New South Wales and Prince of Wales Hospital Kate Broun Cancer Council Victoria Leanne Burton NSW STI Programs Unit, Sydney Sexual Health Centre, Sydney Hospital, New South Wales Professor Ian Caterson Centre for Overweight and Obesity, The University of Sydney, New South Wales Samantha Chakraborty beyondblue Professor Stephen Colagiuri Institute of Obesity, Nutrition and Exercise, The University of Sydney, New South Wales Dr Michael Crampton National Immunisation Committee Dr Michael D’Emden Diabetes Australia Dr Joanne Dixon Human Genetics Society of Australasia Professor Peter Ebeling Osteoporosis Australia Associate Professor Matt Edwards Department of Paediatrics, University of Western Sydney, New South Wales Professor John Eisman Garvan Institute of Medical Research, New South Wales Guidelines for preventive activities in general practice 8th edition Shelley Evans Osteoporosis Australia Dr Linda Foreman General practitioner, Adelaide, South Australia Professor Robert Goldney Discipline of Psychiatry, The University of Adelaide, South Australia Associate Professor Jane Halliday Public Health Genetics, Murdoch Childrens Research Institute, Victoria Associate Professor Kelsey Hegarty Department of General Practice, The University of Melbourne, Victoria Kelvin Hill National Stroke Foundation Dr Elizabeth Hindmarsh General practitioner, Sydney, New South Wales Barbara Hocking Sane Australia Dr Cathy Hutton National Immunisation Committee Professor Henry Krum Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Victoria Professor Stephen Lord Neuroscience Research Australia Professor Finlay Macrae Colorectal Medicine and Genetics, The Royal Melbourne Hospital, Victoria Professor Rebecca Mason Australian & New Zealand Bone and Mineral Society Associate Professor Tim Mathew Kidney Health Australia Associate Professor Sylvia Metcalfe Genetics Education & Health Research, Murdoch Childrens Research Institute, Victoria Dr Viviene Milch National Breast and Ovarian Cancer Centre, New South Wales Carolyn Murray NSW STI Programs Unit, Sydney Sexual Health Centre, Sydney Hospital, New South Wales Professor Mark Nelson Menzies Research Institute, University of Tasmania Professor Ian Olver Cancer Council Australia Dr Rod Pearce Australian Technical Advisory Group on Immunisation Dr Carole Pinnock Repatriation General Hospital, Flinders University, South Australia Professor Ian Reid Faculty of Medical and Health Sciences, The University of Auckland, New Zealand Ann Robertson The Royal Australian and New Zealand College of Obstetricians and Gynaecologists Professor Ann Roche National Centre for Education and Training on Addiction, Flinders University, South Australia v vi Guidelines for preventive activities in general practice 8th edition Dr Jeff Rowland Australian & New Zealand Society for Geriatric Medicine Professor John Saunders Consultant Physician in Internal Medicine and Addiction Medicine, Sydney, New South Wales Associate Professor Jonathan Shaw Baker IDI Heart & Diabetes Institute, Victoria Professor James St John Cancer Council Victoria Dr Graeme Suthers South Australia Clinical Genetics Service, South Australia Shanthi Thuraisingam National Heart Foundation of Australia Professor Stephen Twigg Central Clinical School, The University of Sydney, New South Wales Dr Angela Taft Mother and Child Health Research, La Trobe University, Victoria Jinty Wilson Heart Foundation and National Vascular Prevention Disease Alliance Dr Brendan White Australian Dental Association (NSW Branch), New South Wales Dr Clive Wright Chief Dental Officer, NSW Health, New South Wales Professor Nicholas Zwar School of Public Health and Community Medicine, University of New South Wales, New South Wales Members of the Australian & New Zealand Society for Geriatric Medicine Council Members of the Australian Dental Association Oral Health Committee Members of the Paediatrics & Child Health Division, Royal Australasian College of Physicians Representatives from Cancer Council Victoria Organisational representatives Lisa Dive Royal Australasian College of Physicians Chris Enright Cancer Council Victoria Engy Henein Royal Australasian College of Physicians Ruth Hertan National Stroke Foundation and National Vascular Disease Prevention Alliance Diana Reddan National Stroke Foundation Jared Slater Optometrists Association Australia We gratefully acknowledge the expert reviewers and representatives from the above organisations who contributed scholarly feedback. Guidelines for preventive activities in general practice 8th edition Abbreviations and acronyms 13vPCV 13-valent pneumococcal conjugate vaccine 23vPPV Pneumococcal polysaccharide vaccine ABCD Asymmetry, border, colour, diameter ABI Ankle:brachial index ACE Angiotensin converting enzyme ACR Albumin-creatinine ratio AF Atrial fibrillation ALA dTPa Diphtheria,tetanus, acellular pertussis (adolescent/ adult version) DXA Dual-energy X-ray absorptiometry ECG Electrocardiograph EFG Elevated, firm, growing for more than 1 month eGFR Estimated glomerular filtration rate ESRD End stage renal disease Alpha-linolenic acid FAP Familial adenomatous polyposis AMD Aged-related macular degeneration FH Familial hypercholesterolaemia APC Adenomatous polyposis coli FOBT Faecal occult blood test ASCIA The Australasian Society of Clinical Immunology and Allergy GFR Glomerular filtration rate GP General practitioner AUSDRISK Australian Type 2 Diabetes Risk Assessment Tool HbA1c Glycated haemoglobin BCG Bacillus Calmette-Guérin HCG Human chorionic gonadotrophin BMD Bone mineral density HDL High density lipoprotein BMI Body mass index HDL-C High density lipoprotein-cholesterol BNP B-type natriuretic peptide hepA Hepatitis A BP Blood pressure hepB Hepatitis B BRCA1 Breast cancer susceptibility gene 1 HFE (gene) Haemochromatosis BRCA2 Breast cancer susceptibility gene 2 Hib Haemophilus influenzae type b CA Cancer antigen HIV Human immunodeficiency virus CA125 Cancer antigen 125 HNPCC Hereditary non-polyposis colon cancer CF Cystic fibrosis HPV Human papillomavirus CHD Coronary heart disease CKD Chronic kidney disease HSIL High grade squamous intraepithelial lesion COPD Chronic obstructive pulmonary disease IADL Instrumental activities of daily living CRC Colorectal cancer IFG Impaired fasting glucose CRP High sensitivity C-Reactive Protein IGT Impaired glucose tolerance test CT Computerised tomography IPV Inactivated poliomyelitis CVD Cardiovascular disease IS Intussuseption DBP Diastolic blood pressure LDL Low density lipoprotein DNA Deoxyribonucleic acid LDL-C Low density lipoprotein-cholesterol DLCN Dutch Lipid Clinic Network (criteria) LSIL Low grade squamous intra-epithelial lesion DPA Docosapentaenoic acid LUTS Lower urinary tract symptoms DRE Digital rectal examination LVH Left ventricular hypertrophy DT Diphtheria,tetanus MBS Medicare Benefits Schedule MMR Measles, mumps and rubella MMRV Measles, mumps, rubella and varicella DTpa Diphtheria,tetanus, acellular pertussis (child version) vii viii Guidelines for preventive activities in general practice 8th edition MMSE Mini-Mental State Examination MRI Magnetic resonance imaging MSM Men who have sex with men MSU Midstream urine MUKSB Modified UK Simon Broome criteria NAAT Nucleic acid amplification test NHMRC National Health and Medical Research Council NIP National Immunisation Program NIPS National Immunisation Program Schedule NMSC Non-melanoma skin cancer NTD Neural tube defect PCR Polymerase chain reaction PEDS Parents’ evaluation of developmental status PET-CT Positron Emission Tomography – Computed Tomography RACGP The Royal Australian College of General Practitioners RCT Randomised controlled trial PND Postnatal depression SBP Systolic blood pressure SES Socioeconomic status SIDS Sudden infant death syndrome SNAP Smoking, nutrition, alcohol, physical activity SPF Sun protection factor STIs Sexually transmitted infections TG Triglyceride TIA Transient ischaemic attack TUGT Timed up and go test UACR Urine Albumin-to-Creatinine Ratio VV Varicella Vaccination VZV Varicella Zoster Virus WHO World Health Organization Guidelines for preventive activities in general practice 8th edition Contents I. Introduction 1 The Australian experience 1 Preventive health activities 2 Screening versus case finding 2 Screening principles 3 II. Patient education and health literacy 4 Impact of patient education 4 Approaches to patient education 4 The complex needs and health problems of disadvantaged groups 5 III. Development of the red book 6 Sources of recommendations 6 Scope and limitations of the red book 6 IV. How to use the red book 7 Organisational detail 7 V. What’s new in this 8th edition? 9 1. Preventive activities prior to pregnancy 11 11 What does pre-conception care include? 2. Genetic counselling and testing 14 3. Preventive activities in children and young people 17 17 Early intervention 4. Preventive activities in middle age 26 5. Preventive activities in older age 28 5.1 Immunisation 28 5.2 Falls and physical activity 29 5.3 Visual and hearing impairment 31 5.4 Dementia 32 6. Communicable diseases 34 6.1 Immunisation 34 6.2 STIs 37 7. Prevention of chronic disease 40 7.1 Smoking 42 7.2 Overweight 43 7.3 Nutrition 45 7.4 Early detection of problem drinking 47 7.5 Physical activity 49 ix x Guidelines for preventive activities in general practice 8th edition 8. Prevention of vascular and metabolic disease 50 8.1 Assessment of absolute cardiovascular risk 50 8.2 BP 51 8.3 Cholesterol and other lipids 53 8.4 Type 2 diabetes 55 8.5 Stroke 57 8.6 Kidney disease 58 9. Early detection of cancers 60 9.1 Skin cancer 60 9.2 Cervical cancer 63 9.3 Breast cancer 65 9.4 Ovarian cancer 67 9.5 Oral cancer 68 9.6 CRC(bowel cancer) 68 9.7 Testicular cancer 71 9.8 Prostate cancer 71 10. Psychosocial 73 10.1 Depression 73 10.2 Suicide 75 10.3 Identification of intimate partner violence 76 11. Oral hygiene 78 12. Glaucoma 79 13. Urinary incontinence 80 14. Osteoporosis 82 15. Screening tests of unproven benefit 85 References87 Appendix 1: D utch Lipid Clinic Network Criteria for making a diagnosis 115 of Familial Hypercholesteroloemia (FH) in adults Appendix 2: ‘Red flag’ early intervention referral guide 117 Appendix 3: Audit-C (available for use in the public domain) 118 Appendix 4:The Australian Type 2 Diabetes Risk Assessment tool – AUSDRISK 120 Appendix 5: Australian cardiovascular risk charts 122 Appendix 6:The three incontinence questions 124 Glossary 125 Guidelines for preventive activities in general practice 8th edition I. Introduction General practice is at the forefront of healthcare in Australia and in a pivotal position to deliver preventive healthcare. More than 125 million general practice consultations take place annually in Australia and 83% of the Australian population consult a general practitioner (GP) at least once a year.1 Preventive healthcare is an important activity in general practice. Preventive healthcare includes the prevention of illness, the early detection of specific disease, and the promotion and maintenance of health. Preventive care is based on a partnership between a GP and a patient, designed to help each patient reach their goals of maintaining or improving health. Prevention is the key to Australia’s future health – both individually and collectively. It is estimated that 80% of premature heart disease, stroke and type 2 diabetes and 40% of cancer could be prevented through interventions that lead to healthy diet, regular physical activity and avoidance of tobacco products.2 Preventive care is also critical in addressing the health disparities faced by disadvantaged and vulnerable population groups. To facilitate evidence-based preventive activities in primary care, The RACGP has published the Guidelines for preventive activities in general practice (the ‘red book’) since 1989. The red book is now widely accepted as the main guide to the provision of preventive care in Australian general practice. The red book provides a comprehensive and concise set of recommendations for patients in general practice with additional information about tailoring risk and need. It provides the evidence base for which primary healthcare resources can be used efficiently and effectively while providing a rational basis to ensure the best use of time and resources in general practice. The red book’s companion publication, National guide to a preventive health assessment for Aboriginal and Torres Strait Islander peoples (2nd edition), is intended for all health professionals delivering primary healthcare to the Aboriginal and Torres Strait Islander population. The Australian experience Health reform in Australia has led to a renewed focus on preventive healthcare. The role of general practice in prevention has been recognised by the Council of Australian Governments3 and by the Australian Government’s Preventative Health Taskforce and Primary Health Care Strategy.4,5 Deaths and hospitalisations from preventable illness have continued to decline within Australia. Still, the leading causes of death and disability in Australia are preventable or able to be delayed by early treatment and intervention (Figure 1).6 Figure 1. Potentially avoidable deaths Reproduced with permission from the Australian Institute of Health and Welfare. Australia’s health 2012. Australia’s health series no. 13, cat. no. AUS 156. Canberra: AIHW, 2012.6 1 2 Guidelines for preventive activities in general practice 8th edition A recent Australian review7 concluded that lifestyle interventions could have a large impact on population health. The cardiovascular absolute 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, real and perceived barriers have meant preventive interventions in general practice remain underutilised, being the primary reason for the consultation in only seven of every hundred clinical encounters.8 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.9 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 evidencebased 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 foundation, and encourages all general practices, GPs and their teams to prioritise appropriate preventive health activities within their practices. Preventive health activities ‘Prevention is better than cure’ is an instinctive concept and its appeal is embedded in the medical and political culture. Yet we now know from the evidence that some preventive activities are not always effective or appropriate; indeed, some are quite harmful. Many preventive activities have the potential to be associated with harm. For example, screening may lead to overdiagnosis, causing needless anxiety, appointments, tests, drugs and even operations. Therefore, it is crucial that evidence clearly demonstrates that benefits outweigh those harms for each preventive activity. While greater societal awareness and attention on preventive activities is important, challenges are presented by the involvement of single-disease health groups, special interest societies and specialist groups that only visualise a refined subset of patients. These groups often utilise marketing strategies to promote their cause, and this often results in confusing messages for GPs and their patients. Determining whether a preventive activity is beneficial, harmful or of indeterminate effect (there is not enough evidence on which to base a decision) requires a consistent, unbiased, evidence-based approach. No area typifies this more clearly than the area of cancer screening. The even-handed interpretation of evidence, balancing harms and benefits, managing overdiagnosis and overtreatment, has been a goal of those drafting the prostate and breast cancer sections of the red book since the early editions. These screening activities have polarised different sectors of the health professions. The RACGP looks forward to resolving the controversies surrounding contentious areas of screening to assist GPs in caring for their patients. In these guidelines, only those screening activities where evidence demonstrates that benefits outweigh harms have been included. Section 15 of the red book provides some guidance on common tests where this is not the case. Screening versus case finding Screening has been defined as ‘the examination of asymptomatic people in order to classify them as likely or unlikely to have a disease’.10 The primary purpose of screening tests is to detect early disease in apparently healthy individuals. In these guidelines screening usually refers to early detection using questions or a test, which GPs perform either when patients present for preventive care or opportunistically when patients present for other reasons. Proactive recall of patients for screening is warranted for high-risk groups, or for conditions where population coverage has been identified by the government as a public health priority. These include immunisation and screening for cervical, breast and colorectal cancers (CRC) and diabetes. Screening tests are not ‘case finding’ or ‘diagnostic’ tests. The purpose of a diagnostic test is to establish the presence (or absence) of disease as a basis for treatment decisions in symptomatic or screen-positive individuals (confirmatory test), for example, taking a midstream urine (MSU) sample for evaluation of a urinary tract infection, or performing mammography for a suspicious breast lump. Guidelines for preventive activities in general practice 8th edition Screening and case finding carry different ethical obligations. If the practitioner initiates the screening, there needs to be conclusive evidence that the procedure can positively affect the natural history of the disorder. Moreover, the risks of screening in asymptomatic individuals 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 and, it could be argued, there is at least some implied exposure to risk (as in performing colonoscopy to investigate abdominal pain). Many health practitioners confuse the difference between screening and case-finding tests. This often obscures the arguments surrounding the benefits and harms of screening tests. Screening principles The World Health Organization (WHO) has produced guidelines11,12 for the effectiveness of screening programs. We have kept these and the United Kingdom National Health Services’ guidelines13 in mind in the development of recommendations about screening and preventive care. The 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. The 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. Outcome • There should be evidence of improved mortality, morbidity or quality of life as a result of screening and that the benefits of screening outweigh the harm. • The cost of case finding (including diagnosis and treatment of patients 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 that they can make an informed choice about participation. Screening activities in general practice are complex; they involve patients accessing care as well as general practices adopting systematic approaches to registering and recalling patients, and organising their efforts to maximise the effectiveness of each consultation in providing preventive care.14 Effective screening requires consideration of subgroups in the population who may have a higher prevalence of a disease or risk factor, or who may have difficulty accessing services.15 In Australia, there is an increasing number of Medicare items for health assessments in particular population groups: preschool children, Aboriginal children and adults, refugees, people with an intellectual disability, those aged 45–49 years (with a risk factor), and those aged 75 years or over. There is evidence that these assessments improve the likelihood of preventive care being received.16 However, it is important that such ‘health checks’ involve preventive interventions for which there is clear evidence of their effectiveness. 3 4 Guidelines for preventive activities in general practice 8th edition II. Patient education and health literacy Impact of patient education Patient education and counselling contribute to behaviour change for primary prevention of disease17. More broadly, they may also help create greater ‘health literacy’ – the knowledge and skills patients require to maintain their own health, including use of health services. The use of behavioural techniques, especially for self-monitoring, is recommended, as is the use of personal communication and written or other audiovisual materials.17 Patients view the GP as a key first contact and credible source of preventive advice. Factors that increase the effectiveness of patient education delivered by GPs include: • assessing the patient’s health literacy18 • the patient’s sense of trust in their GP19 • face-to-face delivery20 • patient involvement in decision-making21–23 • highlighting the benefits and the costs24, 25 • strategies to help the patient remember what they have been told26 • tailoring the information to the patient’s interest in change27 • strategies that address the difficulty in adherence23, 28 • the use of decision aids.29 Many prevention activities involve a change in health-related behaviour. As the patient plays a large role in making this happen, it is useful to facilitate more active inclusion of patients in their care. This process is an essential component of self-management strategies30, 31 and has the potential to increase the patient’s responsibility for their health. In addition, it: • enhances the quality of communication32, 33 • enhances the patient-doctor consultation21 • can reduce the cost of aspects of care through better informed patients22 • increases the demand and use of appropriate referral to other health professionals and agencies32 • increases adherence to recommended prevention activities and therapeutic regimens.32, 34 For those whose first language is not English, a professional interpreter should be considered. Approaches to patient education Patients need to develop their own understanding of the problem and what can be done about it. For simple behavioural changes, such as having a Pap test, patients weigh up the perceived benefits and costs.35 These benefits and costs may include answers to the following questions. • How big is the problem to the individual? • What are the consequences of not doing the test? • What are the benefits? • What are the barriers? Some health education may require more complex actions over a period of time such as changing diet, stopping smoking or increasing physical activity. The ‘stages of change model’36 identifies five basic stages of change, which are viewed as a cyclical, ongoing process during which the person has differing levels of motivation or readiness to change, and the ability to relapse or repeat a stage. Each time a stage is repeated, the person learns from the experience and gains skills to help them move to the next stage. Guidelines for preventive activities in general practice 8th edition Table II.1 Stages of change model Pre-contemplation (Not thinking about change) The person does not consider the need to change Contemplation (Thinking of change) The person considers changing a specific behaviour • Has not had sufficient experience with negative consequences. • Begins to seek relevant information. • Re-evaluates behaviour. • Obtains help from others to support future attempts. • Still weighs up options and isn’t ready to take action. Determination (Ready for change) The person makes a serious commitment to change • Is ready to take action in the next 30 days. • Needs to set goals and develop priorities in order to manage their illness. Action (Changing behaviour) Change begins (these can be large or small changes) • Makes efforts to modify habits and environment. • Increasingly uses behavioural processes of change (e.g. stimulus control and counter-conditioning). Maintenance (Maintaining change) Change is sustained over a period of time • Counter-conditioning and self-liberation peak. • Takes responsibility for actions. • Is susceptible to relapse so remain aware of environmental and internal stimuli that may trigger problem behaviours. Motivational interviewing is dealt with in more detail in the RACGP green book. The complex needs and health problems of disadvantaged groups The complex needs and health problems of disadvantaged groups and the interactions between social, psychological, environmental and physical determinants of health mean that special effort is required for patient education to be effective. In particular, GPs need to employ a range of strategies and work in collaboration with other services.37 To be effective in patient education for Indigenous communities, GPs need an understanding of the Aboriginal and Torres Strait Islander view of health, culture and history and an ability to provide services within a culturally appropriate framework. This also requires GPs to collaborate with other agencies and providers to ensure the provision of high-quality preventive healthcare for Indigenous Australians.38 5 6 Guidelines for preventive activities in general practice 8th edition III. Development of the red book These Guidelines for preventive activities in general practice, 8th edition, have been developed by a taskforce of GPs and experts to ensure that the content is the most valuable and useful for GPs and their teams. The guidelines provide an easy, practical and succinct resource. The content broadly conforms to the highest evidence-based standards according to the principles underlying the Appraisal of Guidelines Research and Evaluation.39, 40 The dimensions addressed are: • scope and purpose • clarity of presentation • rigour of development • stakeholder involvement • applicability • editorial independence. The red book maintains developmental rigour, editorial independence, relevance and applicability to general practice. The Red Book Taskforce also welcomes its companion document, the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander peoples, 2nd edition (the National guide). This publication is a collaborative effort with the National Aboriginal Community Controlled Health Organisation and the RACGP National Faculty of Aboriginal and Torres Strait Islander Health, and is intended for all health professionals delivering primary healthcare to the Aboriginal and Torres Strait Islander population. For preventive care to be most effective, it needs to be planned, implemented and evaluated. Planning and engaging in preventive health is increasingly expected by patients. The RACGP thus provides the red book and National guide to inform evidence-based guidelines, and the green book to assist in development of programs of implementation. The RACGP is planning to introduce a small set of voluntary clinical indicators to enable practices to monitor their preventive activities. Sources of recommendations The recommendations in these guidelines are based on current, evidence-based guidelines for preventive activities. We focused on those most relevant to Australian general practice. Usually this means that the recommendations are based on Australian guidelines such as those endorsed by the National Health and Medical Research Council (NHMRC). In cases where these are not available or recent, other Australian sources have been used, such as guidelines from the Heart Foundation, Canadian or United States preventive guidelines, or the results of systematic reviews. References to support these recommendations are listed. However, particular references may relate to only part of the recommendation (e.g. only relating to one of the high-risk groups listed) and other references in the section may have been considered in formulating the overall recommendation. Scope and limitations of the red book These guidelines have not included detailed information on the management of risk factors or early disease (e.g. what medications to use in treating hypertension). Similarly, they have not made recommendations about tertiary prevention (preventing complications in those with established disease). Also, information about prevention of infectious diseases has been limited largely to immunisation and some sexually transmitted infections (STIs). There is limited advice about travel medicine. Information on travel medicine can be obtained from the Centres for Disease Control and Prevention at www.cdc.gov/travel/index.htm or WHO International Travel and Health at www.who.int/ith/ These recommendations are based on the best available information at the time of writing. On past experience this means that the guidelines will remain current for no longer than 2 years. Any update information will be posted on the RACGP website. More information and guidelines can be found on the NHMRC website www.nhmrc.gov.au/ guidelines; the Australian Government clinical guidelines portal www.clinicalguidelines.gov.au; and the Cochrane Collaboration website www.cochrane.org/ Guidelines for preventive activities in general practice 8th edition IV. How to use the red book These guidelines are designed to be used in a number of ways, all of which can be useful in day-to-day general practice. The red book can be used as a: • guide to who is most at risk and for whom screening or preventive care is most appropriate • refresher to check the latest recommendations • reminder to check at a glance what preventive activities are to be performed in various age groups and how often • checklist of preventive activities used according to an individual patient’s health profile • patient education tool, to demonstrate to patients the evidence that exists for preventive activities • study guide – a comprehensive list of references is provided (links to further original sources are provided in the electronic version where appropriate). This allows more in-depth information on a particular topic. Organisational detail The information in these guidelines is organised into three levels. The first level is the lifecycle chart, which highlights when preventive activities should be performed and the optimum frequency for each activity. The lifecycle chart is organised by age and clinical topic. Simply check the column under a particular age group to see what activities should be considered for the patient. The preventive activities that are recommended for everyone within a particular age range, and for which there is sound research evidence, are shaded in red while activities to be performed only in patients with risk factors or where the evidence is not as strong are shaded in light red. A copy of this chart can be downloaded from the RACGP website and attached to the patient record as a systematic reminder for preventive activities. You can also use it as a wall chart, or keep it handy on your desk. The second level is more detailed and presents a summary of recommendations in addition to tables that identify what preventive care should be provided for particular groups in the population. This edition of the red book adopts the most recent NHMRC levels of evidence and grades of recommendations.41 Recommendations in the tables are graded according to levels of evidence and the strength of recommendation. The levels of evidence are coded by the roman numerals I–IV while the strength of recommendation is coded by the letters A–D. Practice Points are employed where no good evidence is available. In most cases a Practice Point will replace what has been classed in previous red book editions as level V evidence. 7 8 Guidelines for preventive activities in general practice 8th edition Table IV.1 Coding scheme used for levels of evidence and grades of recommendation Levels of evidence Level Explanation I Evidence obtained from a systematic review of level II studies II Evidence obtained from a randomised controlled trial (RCT) III–1 Evidence obtained from a pseudo-randomised controlled trial (i.e. alternate allocation or some other method) III–2 Evidence obtained from a comparative study with concurrent controls: • non-randomised, experimental trial • cohort study • case–control study • interrupted time series with a control group. III–3 Evidence obtained from a comparative study without concurrent controls: • historical control study • two or more single arm study • interrupted time series without a parallel control group. IV Case series with either post-test or pre-test/post-test outcomes Practice Point Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees Grades of recommendations Grade Explanation A Body of evidence can be trusted to guide practice B Body of evidence can be trusted to guide practice in most situations C Body of evidence provides some support for recommendation(s) but care should be taken in its application D Body of evidence is weak and recommendation must be applied with caution Only key references used to formulate the recommendations are included in the tables. Where the evidence is available on the internet, the web link is given to enable easy access to original materials. There is also information on how the preventive care should be implemented, for example, a brief outline of the method of screening. Finally, there is a third level of information, which is included in implementation tables, on particular disadvantaged population groups that may be at risk of not receiving preventive care and what should be done to increase their chance of preventive care. Guidelines for preventive activities in general practice 8th edition V. What’s new in this 8th edition? The format of this 8th edition of the red book is similar to the 7th edition and is designed to be used together with the other preventive resources such as the RACGP publications, the green book and SNAP (smoking, nutrition, alcohol and physical activity) guidelines. There is increased information about what should be covered in health assessments or health checks for particular groups. Levels of evidence and recommendations are now presented alongside ‘What should be done?’ and ‘How often?’. References are listed in a separate column. We have increased the amount of guidance, while trying to maintain brevity to improve clarity. Table V.1 Key changes in the 8th edition Section Change Genetic counselling and testing (Section 2) Guidance on familial hypercholesterolaemia (FH) has been added. Preventive activities in children and young people (Section 3) The Australian Government has announced a Universal Child Health Check at age 3 years. This will be introduced in 2013 and will replace the health check at age 4 years. The contents of the new check were not available prior to publication of this edition. It is expected that the new check will easily fit into the system of prevention and promotion outlined in this section. New information that describes evidence-based interventions for babies of depressed mothers (as distinct from interventions targeting the mother’s depression) has been added. As this edition was finalised, the RACGP adopted a document outlining ‘the role of general practice in the provision of healthcare to children and young adults’. It may be useful to read this document as a companion piece to Section 3: Preventive activities in children and young people. Reference to new United States Preventive Services Task Force (USPSTF) recommendations for obesity screening and screening for depression in adolescents have been included. Preventive activities in older age (Section 5) New information about possible prevention of dementia by attention to cardiovascular risk factors has been added. Information about influenza vaccination has been included. New and more detailed information about falls assessment and prevention has been included. Communicable diseases (Section 6) Chlamydia screening for both sexes up to age 29 years has been added. Human papilomavirus (HPV) vaccine for both sexes commencing in 2013 has been added. Information about combined measles, mumps, rubella, varicella (MMRV) at 18 months to be both the second dose of measles, mumps, rubella (MMR) and the first dose of varicella vaccine has been added. 9 10 Guidelines for preventive activities in general practice 8th edition Section Change Prevention of chronic disease (Section 7) New recommendations about weight management (in line with the new NHMRC guidelines) including diet and physical activity strategies have been included. Prevention of vascular and metabolic disease (Section 8) There is greater emphasis on assessment and management of cardiovascular risk for patients aged 45–74 years (in line with the new NHMRC guidelines). This includes treatment targets for blood pressure (BP) and lipids and new recommendations for screening as well as management of high-risk patients for renal disease. Early detection of cancers (Section 9) This section has been updated with new evidence; however, little has changed in the recommendations for screening for most cancers. Attention is drawn to possible changes in recommendations for cervical cancer (Pap) screening as new national guidelines are being prepared by the National Cervical Screening Program. CRC guidelines have been updated and provide more information, which may help GPs decide if a patient is at high risk. Prostate cancer screening remains controversial. New trial data do not provide unequivocal directions to screen or not screen for prostate cancer using the PSA test, with or without digital rectal examination (DRE). The medical community remains divided on the issues. From a general practice viewpoint, it is unclear whether the advantages of screening (still very uncertain) outweigh the harms (becoming more clearly defined). The updated recommendation is to not raise the issue with every eligible man, but wait until you are asked about screening. In light of many other proven preventive activities that could be more usefully addressed in men, we believe that prostate cancer screening remains low on the priority list. Oral hygiene (Section 11) Additional advice on oral health messages is included from an Australian National Consensus workshop conducted in 2011. The ‘Lift the lip’ dental check for early identification of oral problems has been added. Glaucoma (Section 12) Updated recommendations in line with new NHMRC guidelines from 2010 have been added. Osteoporosis (Section 14) Details of risk factors have been refined Changes to criteria for recommending bone mineral density (BMD) measurement have been included. Guidance on frequency of BMD measurement have been added. Recommendation to use absolute risk estimation to aid decision-making has been included. Cautionary notes on use of calcium supplementation have been included. Evidence levels have been clarified. Guidelines for preventive activities in general practice 8th edition 11 1. Preventive activities prior to pregnancy Age <2 2–3 4–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 Every woman aged 15–49 years should be considered for pre-conception care (C). Pre-conception care is a set of interventions that aim to identify and modify biomedical, behavioural and social risks to a woman’s health or pregnancy outcome through prevention and management.42 This should include smoking cessation (A)43 and advice to consider abstinence from alcohol (especially in the early stages of pregnancy),44 folic acid and iodine supplementation (A),45, 46 review of immunisation status (C),47 medications (B)48 and chronic medical conditions, especially glucose control in patients with diabetes (B).49 There is evidence to demonstrate improved birth outcomes with pre-conception healthcare in women with diabetes, phenylketonuria and nutritional deficiency50 as well as benefit from the use of folate supplementation and a reduction in maternal anxiety.51 The information below lists all the potential interventions that have been recommended by expert groups in pre-conception care (C). What does pre-conception care include? Medical issues Reproductive life plan Assist your patient in developing a reproductive life plan that includes whether they want to have children. If they do, discuss the number, spacing and timing of intended children. Reproductive history Ask if there have been any problems with previous pregnancies such as infant death, foetal loss, birth defects particularly neural tube defects (NTD), low birthweight, pre-term birth, or gestational diabetes. Are there any ongoing risks that could lead to a recurrence in a future pregnancy? Medical history Ask if there are any medical conditions that may affect future pregnancies. Are chronic conditions such as diabetes, thyroid disease, hypertension, epilepsy and thrombophilia well managed? Medication use Review all current medications including over-the-counter medications, vitamins and supplements. Genetic/family history Assess risk of chromosomal or genetic disorders, (e.g. cystic fibrosis (CF), fragile X, Tay–Sachs disease, thalassaemia, sickle cell anaemia and spinal muscular atrophy), by collection of data on family history and ethnic background. Provide opportunity for carrier screening for these and other more common genetic conditions. General physical assessment Conduct Pap test and breast examinations before pregnancy if indicated or due. Also assess body mass index (BMI), and BP and ask about periodontal disease. Substance use Ask about tobacco, alcohol and illegal drug use. ≥65 12 Guidelines for preventive activities in general practice 8th edition Vaccinations Vaccinations can prevent some infections that may be contracted during pregnancy. If previous vaccination history or infection is uncertain, testing should be undertaken to determine immunity to varicella and rubella. Women receiving live viral vaccines such as MMR and varicella should be advised against becoming pregnant within 28 days of vaccination. Recommended vaccinations are: • MMR • varicella (in those without a clear history of chickenpox or who are non-immune on testing) • influenza (recommended during pregnancy to protect against infection if in second or third trimester during influenza season) • diphtheria, tetanus, pertussis (DTpa) (to protect newborn from pertussis). Lifestyle issues Family planning Based on the patient’s reproductive life plan (see above), discuss fertility awareness and how fertility reduces with age, chance of conception, and risk of infertility and foetal abnormality. For patients not planning to become pregnant, discuss effective contraception and emergency contraceptive options. Folic acid supplementation Women should take a 0.4–0.5 mg supplement of folic acid per day for at least 1 month prior to pregnancy, and for the first 3 months after conception. In women at high risk (i.e. with a reproductive or family history of NTD, women who have had a previous pregnancy affected by NTD, women on anti-epileptics, and women who have diabetes) the dose should be increased to 5 mg per day. Healthy weight, nutrition and exercise Discuss weight management and caution against being overweight or underweight. Recommend regular, moderate-intensity exercise and assess risk of nutritional deficiencies (e.g. vegan diet, lactose intolerance, calcium or iron and vitamin D deficiency due to lack of sun exposure). Psychosocial health Provide support and identify coping strategies to improve your patient’s emotional health and wellbeing. Smoking, alcohol and illegal drug cessation (as indicated) Smoking, illegal drug and excessive alcohol use during pregnancy can have serious consequences for an unborn child and should be stopped prior to conception. Healthy environments Repeated exposure to hazardous toxins in the household and workplace environment can affect fertility and increase the risk of miscarriage and birth defects. Discuss the avoidance of TORCH infections: Toxoplasmosis, Other – such as syphilis, varicella, mumps, parvovirus and human immunodeficiency virus (HIV) – Rubella, Cytomegalovirus, Herpes simplex. • Toxoplasmosis: avoid cat litter, garden soil, raw/undercooked meat and unpasteurised milk products, and wash all fruit and vegetables. • Cytomegalovirus, parvovirus B19 (fifth disease): discuss importance of frequent handwashing, and child and healthcare workers further reducing risk by using gloves when changing nappies. • Listeriosis: avoid paté, soft cheeses (feta, brie, blue vein), pre-packaged salads, deli meats and chilled/smoked seafood. Wash all fruit and vegetables before eating. Refer to Australian food standards at www.foodstandards. gov.au/foodmatters/pregnancyandfood.cfm regarding folate, listeria and mercury. • Fish: limit fish containing high levels of mercury. Guidelines for preventive activities in general practice 8th edition 13 Table 1.1 Pre-conception: preventive interventions Intervention Technique References Folate supplementation High-risk women: 5 mg/day supplementation ideally beginning at least 1 month prior to conception and for first trimester. 45, 52–54 Most women: 0.5 mg/day supplementation ideally beginning at least 1 month prior to conception and for first trimester. Iodine supplementation All women who are pregnant, breastfeeding or considering pregnancy should take an iodine supplement of 150 micrograms (μg) each day. 46 Smoking cessation Women should be informed that tobacco affects foetal growth and all women should be advised to stop smoking. Evidence exists to suggest improved cognitive ability in children of mothers who quit smoking during gestation (III,A). Pharmacotherapy should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood and benefits of cessation outweigh the risks of pharmacotherapy and potential continued smoking. 55 Alcohol and illicit drug use For women who are pregnant or planning a pregnancy, not drinking is the safest option. The risk of harm to the foetus is highest when there is high, frequent, maternal alcohol intake. The risk of harm to the foetus is likely to be low if a woman has consumed only small amounts of alcohol before she knew she was pregnant. Women should be informed that illicit drugs may harm foetuses and advised to avoid use. 44 Interpregnancy interval There are worse perinatal outcomes with interpregnancy intervals <18 months or >59 months, namely preterm birth, low birth weight and small for gestational age. 56 Chronic diseases Optimise control of existing chronic diseases (e.g. diabetes, hypertension, epilepsy). 54 Avoid teratogenic medications. Pre-conception care resources for GPs and patients Address risk factors using Pregnancy Lifescripts (resources are in process of being updated in 2012). Health inequity About half of women in Victoria, New South Wales and South Australia supplement their diet with folate periconceptionally. This figure is lower in: 57 • women in lower socioeconomic groups • Indigenous women • rural women • younger women • multiparous women. Strategy As per general principles as discussed in Section I: Introduction and as outlined in the RACGP green book. Population health surveys in three states (New South Wales 2007–08, Australian Capital Territory 2007–08 and Tasmania 2009) showed that about half of all Australian mothers took folic acid supplements just prior to and during their first trimester of pregnancy, as recommended. Supplement use was lower in mothers without tertiary qualifications and in those living in more disadvantaged and remote areas. 14 Guidelines for preventive activities in general practice 8th edition 2. Genetic counselling and testing Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 There is evidence to recommend offering specific genetic tests to pregnant women, couples planning a pregnancy, and neonates (as part of the newborn screening program) (C). Other genetic tests are appropriate for certain conditions where the individual is considered to be at increased risk (A). In order to identify patients who may potentially benefit from genetic testing, the GP must ensure that a comprehensive family history is taken from all patients including first-degree or second-degree relatives (A) and regularly updated. A family history should ideally extend to three generations, covering both sides of the family and ethnic background. Age of onset of disease and age of death should be recorded where available. The presence of genetically determined disease may be suggested by increased frequency and early onset of cancers in families, premature ischaemic heart disease or sudden cardiac death, intellectual disability, multiple pregnancy losses, stillbirth or early death, and children with multiple congenital abnormalities. Also, patients of particular ethnic backgrounds may be at increased risk and benefit from genetic testing for specific conditions. Possible consanguinity (cousins married to each other) should be explored, for example, by asking, ‘Is there any chance that a relative of yours might be related to someone in your partner’s family?’. GPs should consider referral to or consultation with a genetic service (general or cancer genetics) for testing because test results, (which rely on sensitivity, specificity and positive predictive value) are not straightforward. Testing often involves complex ethical, social and legal issues. Waiting lists for genetic services are usually more than 1 month, so direct consultation and liaison by telephone are necessary when the genetic advice could affect a current pregnancy. Table 2.1 Genetic testing: identifying risks Who is at risk? What should be done? How often? Assess their probability of having FH using the Dutch Lipid Clinic Network (DLCN) criteria or Modified UK Simon Broome (MUKSB) criteria (III,B) (Appendix 1) At first presentation References Breast and ovarian cancer See Section 9.3: Breast cancer Colon cancer See Section 9.6: CRC (bowel cancer) FH Increased risk • Premature ischaemic heart disease (men aged <55 years, women aged <60 years) • First-degree relative with premature ischaemic heart disease (men aged <55 years, women aged <60 years) • Total cholesterol >7.5 or LDL-C >4.9 • First-degree relative with a total cholesterol >7.5 or LDL-C >4.9 • Tendon xanthomata or arcus cornealis at age <45 years Offer referral to a lipid disorders clinic if DLCN score >3 or the MUKSB suggests possible FH 58–60 Guidelines for preventive activities in general practice 8th edition Who is at risk? What should be done? How often? References Offer referral for genetic counselling and testing (III,B) Test couple prior to pregnancy or in first trimester 61–63 In first or second trimester 63–67 In first or second trimester 64 At first presentation 63, 68–70 Cystic fibrosis Increased risk • Northern European or Ashkenazi Jewish ancestry • Family history of CF, or a relative with a known CF mutation • Where partner is affected or is a known carrier of CF • Partners from Northern European, Ashkenazi Jewish backgrounds who are consanguineous (cousins married to each other) If patient is pregnant, contact genetic services to organise screening in first trimester • Men with infertility suspected or due to congenital absence of the vas deferens Down syndrome At risk • All pregnant women Combined maternal serum and ultrasound screening in first trimester Maternal serum screening in second trimester* (C) Significantly increased risk • Women who have had a previous Down syndrome pregnancy • Women with positive maternal serum screening/nuchal translucency ultrasound in first trimester or maternal serum screening in second trimester Foetal diagnostic genetic testing (C) Offer referral for genetic counselling • Parent with a chromosomal rearrangement (e.g. balanced translocation of chromosome 21) Hereditary haemochromatosis (HFE) Increased risk • Patients with liver disease of unknown cause, including those with suspected alcoholic liver disease • All first-degree relatives of patients with haemochromatosis, known mutation in HFE gene • Patients with conditions that could be a complication of HFE (diabetes mellitus, atypical arthritis, cardiomyopathy, erectile dysfunction or chronic fatigue) 15 Test for transferrin saturation and serum ferritin concentration. If fasting transferrin saturation >45% or fasting ferritin >250 µg/L on more than one occasion, test for HFE mutations (II,A). If HFE mutation identified, discuss options for genetic testing and referral for genetic counselling of at-risk family. Children of C282Y heterozygotes should only be tested if the other parent has the C282Y mutation. Testing children in affected families is generally not recommended until age 18 years unless symptomatic. Other first-degree relatives of C282Y heterozygotes should be tested with iron studies. If these are positive, discuss genetic testing and referral for genetic counselling. 16 Guidelines for preventive activities in general practice 8th edition Who is at risk? What should be done? How often? References Mean corpuscular volume, mean corpuscular haemoglobin, ferritin Test couple prior to pregnancy or in first trimester 70, 71 Haemoglobinopathies and thalassaemias Increased risk • People from any of the following ethnic backgrounds: Southern European, African (including Americas and Caribbean), Middle Eastern, Chinese, Indian subcontinent, Central and South East Asian, Pacific Islander, New Zealand Maori, South American and some northern Western Australian and Northern Territory Indigenous communities Haemoglobin electrophoresis (III,B) Seek advice from haematology or genetic services about deoxyribonucleic acid (DNA) testing especially for alphathalassaemia carriers Fragile X syndrome Increased risk Children or adults of either sex with one or more of the following features: • developmental delay including intellectual disability of unknown cause • autistic-like features • attention deficit hyperactivity disorder Karyotype/comparative genomic hybridisation by microarray and DNA test for fragile X Refer to genetic services for genetic counselling and testing at-risk family (I,A) Any age for diagnosis 73, 74 Prior to pregnancy to ascertain reproductive risk • speech and language problems • social and emotional problems, such as aggression or shyness • a female with a history of primary ovarian insufficiency or premature menopause (age <40 years) (IV,B) 72, 75 • adults with ataxia, balance problems and Parkinsonism (IV,A) 76 • relative with a fragile X mutation * First trimester Down syndrome screening: • free beta human chorionic gonadotrophin (HCG), pregnancy associated plasma protein at 10–12 weeks (this also provides risk for trisomy 18, Edwards syndrome) • nuchal translucency screen at 11 weeks 3 days–13 weeks 6 days. Second trimester serum screening: • beta HCG, unconjugated oestriol, alpha-fetoprotein and inhibin A ideally at 15–17 weeks; also gives risk for Edward syndrome and NTDs. Guidelines for preventive activities in general practice 8th edition 3. Preventive activities in children and young people Early intervention Prevention and promotion in the early years, from conception to age 5 years, is important for an individual’s lifelong health and wellbeing.77 It may also be an opportunity to redress health inequalities.78, 79 In adolescence, neurodevelopmental studies support the value of early intervention to prevent ongoing harm.80 Many infants and children visit their GP frequently and adolescents visit at least once a year.81 This frequent contact provides opportunities for disease prevention and health promotion. Evidence provides moderate support for the hypothesis that ‘accessible, family-centred, continuous, comprehensive, coordinated, compassionate and culturally effective care improves health outcomes for children with special healthcare needs’.82 There is also evidence that supports the beneficial impact of similar care for children without special healthcare needs.83 There is little Australian research investigating interventions based in general practice. Recommendations in this section are largely drawn from expert consensus and parental values. Health inequity Compared with non-Indigenous Australians, Aboriginal and Torres Strait Islander children are three times more likely to die before their first birthday, five times more likely to succumb to sudden infant death syndrome (SIDS), twice as likely to be born premature or with low birthweight, and nearly four times as likely to be hospitalised with respiratory infection. Indigenous Australian mothers are eight times more likely than non-Indigenous mothers to receive inadequate antenatal care and rates of breastfeeding are lower in Indigenous than non-Indigenous communities.84 There is a socioeconomic gradient in the health of Australian children and young people, both Indigenous and nonIndigenous, which has an impact that is both immediate and lifelong. There are large numbers of vulnerable children in the mid-socioeconomic range of the population and it is the size of this group that justifies universal intervention. On the other hand, the magnitude of the ill-health experienced by the smaller number at the bottom of the spectrum justifies targeted intervention. Michael Marmot has attempted to resolve this tension by arguing for ‘proportionate universalism’.78 Maternal smoking during pregnancy is more prevalent among women of lower socioeconomic status (SES) and single mothers, and is strongly associated with low birthweight. Mothers from lower socioeconomic backgrounds have fewer and less regular antenatal visits. Lower rates of breastfeeding and shorter duration of breastfeeding have been reported for mothers in a variety of disadvantaged backgrounds including single, low income, migrant, unemployed families, poorly educated parents and disadvantaged communities. Higher mortality rates in infancy and childhood including deaths from neonatal hypoxia, SIDS, prematurity-related disorders, and accidental and non-accidental injury are reported for lower socioeconomic children and children living in disadvantaged neighbourhoods.84 Health inequity present at school entry gets worse thereafter. The Australian data was summarised in Alan Hayes in 2011.79 17 18 Guidelines for preventive activities in general practice 8th edition Table 3.1 Age-related health checks in children and young people Age What should be done? Neonatal • Vitamin K and immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A) References Assessment • Metabolic screen (IV,B) 85 • Nutrition assessment: review feeding method. Support and appropriately promote breastfeeding (C) (see Table 3.3 comment a). New NHMRC guidelines expected in 2012 86 • Universal hearing assessment see www.health.nsw.gov.au/initiatives/swish/index.asp and www.aussiedeafkids.org.au/newborn-hearing-screening.html • Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comment b) 87 • Identify family strengths, elicit concerns and promote parental confidence, competence and mental health (C) 88 Preventive counselling and advice • Injury prevention: promote safety from accidental and non-accidental injury. This includes the risks to baby of passive smoking, SIDS and UV exposure (III,B) 87 • Settling (Practice Point) • Maternal health (Practice Point) 2, 4, 6 months • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A) Assessment • Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comment b) 87 • Nutrition assessment: promote breastfeeding appropriately. Introduction of solids: be aware of conflicting expert advice concerning the best age at which to introduce solids (B) (see Table 3.3 comment a) New NHMRC guidelines expected in 2012 86, 89 • Developmental progress including vision and hearing (see Table 3.3 comment c) 88 • Quality of child-parent relationship (C) 88, 90 • When the baby is presented as a ‘problem’ assess parental mental health, family functioning (including the possibility of domestic violence) and social support (C) (see Table 3.3 comment d) 91 • Encourage discussion related to physical activity recommendations (B) (see Table 3.3 comment e) Preventive counselling and advice • Injury prevention – promote safety from accidental and non-accidental injury, includes the risks to baby of passive smoking, SIDS, UV exposure, water, home environment (III,B) 87, 92, 93 • Settling (Practice Point) • Maternal health (Practice Point) • Teething (Practice Point) • Play (Practice Point) 12 & 18 months Assessment • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f) • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 2012 94, 95 • Risk of iron depletion and vitamin D deficiency (C) 86, 91 • Developmental progress including vision and hearing (see Table 3.3 comment c) 96, 97 • Family functioning, dysfunction (including domestic violence) and the social environment (C) (see Table 3.3 comments h and i) 88, 90 Preventive counselling and advice • Social and emotional wellbeing (Practice Point) • Toilet training (Practice Point) • Behaviour and behaviour management techniques (Practice Point) 88, 90 Guidelines for preventive activities in general practice 8th edition 2 years 19 • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A) Assessment • Physical exam as outlined in the Child Health Record (C) (see Table 3.3 comments b and g) 87 • Developmental progress including vision and hearing (see Table 3.3 comment c) • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f) 94, 95 • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 2012 86, 91 • Emerging behavioural or emotional problems (C) • When the child presents with behavioural or emotional problems consider family functioning (including the possibility of domestic violence) and the family environment more generally (C) (Practice Point explanatory comments h and i) 88, 90 Preventive counselling and advice • Injury prevention (III,B) 3 years • Sun protection (Practice Point) 87, 92, 93 • Social and emotional wellbeing (C) 88, 90 Assessment • Check vision (B) (see Table 3.3 comment j) 98 The Universal Child Health Check at age 3 years will replace the current Healthy Kids check at age 4 years. To be introduced by the Australian Government in 2013. Details not available at the time of publication. 4 years • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A) Healthy Kids Check see Table 3.3 comment k 99–102 Assessment • Physical assessment (B) (see Table 3.3 comment k) Also recommended • Developmental and emotional progress (see Table 3.3 comment c) • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f) 94, 95 • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 2012 86, 91 • Assess the quality of family functioning when there are emotional or behavioural problems (C) (see Table 3.3 comments h and i) 88, 90 Preventive counselling and advice • Injury prevention (III,B) 92, 93 • Sun protection (Practice Point) • Social and emotional wellbeing (C) 88, 90 20 Guidelines for preventive activities in general practice 8th edition Age What should be done? 6–13 years Assessment References • Growth velocities including BMI opportunistically (B) 103 • Discussion relating to progress at school (C) 88 • ‘Lift the lip’ dental check (C) (see Table 3.3 comment f). Encourage regular dental reviews 94, 95 • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 2012 86, 91 • Family functioning and family environment (C) (see Table 3.3 comments h and i) 88, 90 • Anticipate and look for emerging behavioural or emotional problems (C) 88, 90 Preventive counselling and advice • Injury prevention (II) 92, 93 • Sun protection • Social and emotional wellbeing (C) 14–19 years 88, 90 • Immunisation as per the Australian Government Department of Health and Ageing Australian Immunisation Handbook at www.immunise.health.gov.au (A) Assessment • Growth velocities including BMI opportunistically (B) (see Table 3.3 comment l) 103, 104 • Nutrition and physical activity (B) (see Table 3.3 comment e). New NHMRC guidelines expected in 2012 86, 91 • Screen sexually active young people for chlamydia (Section 6.2.1: Chlamydia and other STIs) • Screening of adolescents (age 12–18 years) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive–behavioural or interpersonal), and follow-up (B) (see Table 3.3 comment m) 105 Preventive counselling and advice • Injury prevention – harm minimisation (C) (see Table 3.3 comment n) 88, 92, 93 • Sun protection • Social and emotional wellbeing (II,C) 88, 90 • Oral health 94, 95 • Advocate for models of care that facilitate the transition of young people with chronic disease or disability from tertiary paediatric care to effective primary care with access to adult specialist care Guidelines for preventive activities in general practice 8th edition Table 3.2 Age-related physical assessment in children and young people Age Required physical assessment Neonatal • Weight • Length • Head circumference • Head shape, including fontanelle • Mouth/palate, facies and ears • Eyes: observation, appearance and red reflexes • Neurological and developmental status, including responsiveness and tone • Cardiovascular status • Umbilicus • Skin • Femoral pulse (for radio-femoral delay) • Hips (Barlow and Ortolani), limbs, joints, hands (palmar creases), feet (for talipes) • Genitalia, testes, anal region • Any parental concerns? 2, 4 & 6 months • Weight • Length • Head circumference • Eyes: observation, fixation and following • Cardiovascular status • Umbilicus • Skin • Femoral pulse • Hips, limbs, joints • Genitalia, testes, anal region • Oral health, ‘lift the lip’ from age 6 months • Developmental progress • Any parental concerns? 12 & 18 months • Weight velocity • Height velocity • Head circumference velocity • Eyes and vision: observation, fixation and following, corneal light reflex • Testes • Oral health, ‘lift the lip’ • Developmental progress • Any parental concerns? 2 years • Weight velocity • Length velocity • Head circumference velocity • Evaluate gait • Oral health, ‘lift the lip’ • Assess development and behaviour • Any parental concerns? 21 22 Guidelines for preventive activities in general practice 8th edition Age Required physical assessment 3 years • Vision screening • The Universal Child Health Check at age 3 years will replace the current Healthy Kids check at age 4 years. To be introduced by the Australian Government in 2013. Details not available at the time of publication. 4 years • As outlined by the Health Kids Check: –– height and weight (plot and interpret growth curve/calculate BMI) –– eyesight –– hearing –– oral health (teeth and gums) –– toileting –– allergies. 6–13 years • Weight and height (plot and interpret growth curve and calculate BMI) 14–19 years • Weight and height (plot and interpret growth curve and calculate BMI) Table 3.3 Explanatory notes for Practice Points Practice Point Comment a The Australasian Society of Clinical Immunology and Allergy or (ASCIA) issued a position paper (2008) that supports ‘the introduction of solids that the family usually eats after 4 months regardless of whether the food is thought to be highly allergenic’89 The ASCIA position is in conflict with the current policy of the RACGP on breastfeeding, based on the NHMRC guideline,86 which recommends exclusive breastfeeding until age 6 months. This uncertainty merits frank discussion. b Physical exam: • complete the Child Health Record (also known as the Parent Held Record), which is given at birth87 • see outline in Table 3.2 Age-related physical assessment in children and young people. Note: Parents value reviewing completed growth charts. Velocities are more important than the centile position of single measurements. Multiple measurements have the further advantage of allowing inaccurate measurements to become evident as outliers. c Developmental progress Evidence continues to build that early intervention can counteract biological and environmental disadvantage and set children on a more positive developmental trajectory.106 Early intervention presupposes early detection. Prior to age 3 years the rate of attaining developmental milestones varies so much that the simple application of screening ‘tools’ would excessively detect developmental delay (false positive). This risk is reduced after age 3 years. In the earliest years, guides to developmental progress can be used to initiate an ongoing conversation with parents to elicit their concerns about their child’s progress. ‘Asking repeatedly should help reluctant parents gain confidence in their observations and facilitate their willingness to share concerns. The value of such discussions is clear; children with disabilities are 11 times more likely to be enrolled in needed interventions.’107 There is little evidence available; however, early detection is known to help reduce disability in some instances, and also allows for referral to community services, which can potentially decrease family stress. Developmental milestone assessments are outlined in the Child Health Record, which is provided at birth. Acknowledging that parents are the best source of information about their own children, a parent-completed screening tool, such as the Parent Evaluation of Developmental Status (PEDS), can be used to identify any concerns about their child’s development. The information gathered helps the GP gain a better understanding of the progress of each child. Further information on the PEDS questionnaire can be accessed at www.rch.org.au/ ccch/resources_and_publications/Monitoring_Child_Development/ Prompts to assist assessment of development include: • Learn the Signs – Act Early at www.cdc.gov/ncbddd/actearly/index.html • Red Flags Early Intervention Guide at www.health.qld.gov.au/rch/professionals/brochures/red-flag.pdf See also Appendix 2. Further information on the Ages and Stages Questionnaire is at http://agesandstages.com Guidelines for preventive activities in general practice 8th edition d • At present there is insufficient evidence for either benefit or harm in screening for postnatal depression (PND). However, PND is known to have an unfavourable impact on the quality of attachment and family functioning. Further, there are evidence-based interventions for both PND108 and for improving the quality of mother-infant interaction adversely affected by PND.109, 110 e Physical activity recommendations for children aged 0–5 years 23 • Being physically active every day is important for the healthy growth and development of infants, toddlers and preschoolers. • For infants (birth to 1 year) physical activity – particularly supervised floor-based play in safe environments – should be encouraged from birth. • Before infants begin to crawl, encourage them to be physically active by reaching and grasping; pulling and pushing; moving their head, body and limbs during daily routines and during supervised floor play, including tummy time. Once infants are mobile, encourage them to be as active as possible in a safe, supervised and nurturing play environment. • Toddlers (age 1–3 years) and preschoolers (age 3–5 years) should be physically active every day for at least 3 hours, spread throughout the day. • Young children don’t need to do their 3 hours of physical activity all at once. It can be accumulated throughout the day and can include light activity such as standing up, moving around and playing, as well as more vigorous activity like running and jumping. Active play is the best way for young children to be physically active. • Children aged younger than 2 years should not spend any time watching television or using other electronic media (DVDs, computer and other electronic games) and for children aged 2–5 years these activities should be limited to less than 1 hour per day. • Watching television and DVDs and playing computer games usually involve sitting for long periods – time that could be spent playing active games or interacting with others. • Infants, toddlers and preschoolers should not be sedentary, restrained or kept inactive for more than 1 hour at a time, with the exception of sleeping. Physical activity recommendations for children aged 5–12 years • A combination of moderate and vigorous activities for at least 60 minutes a day is recommended. Examples of moderate activities are a brisk walk, a bike ride or any sort of active play. • More vigorous activities will make kids ‘huff and puff’. Physical activity recommendations for young people aged 12–18 years • At least 60 minutes of physical activity every day is recommended. This can be built up throughout the day with a variety of activities. • Physical activity should be done at moderate to vigorous intensity. f ‘Lift the lip’ screening tool for the prevention and early detection of tooth decay in children: • complete and also teach parents to simply lift the top lip of child, looking for signs of tooth decay (e.g. white lines on top of teeth below gumline or discolouration of the teeth that cannot be brushed off). Encourage parents to complete once a month • encourage dental hygiene twice a day: no toothpaste under 17 months and low fluoride toothpaste up to age 5 years • encourage dental visits annually after age 12 months. See also NHMRC research at www.nhmrc.gov.au/national_register_public_health_research/29331 and Section 11: Oral hygiene. g The American Academy of Paediatrics has recommended the annual plotting of BMI for all patients aged 2 years and older, and parent-held records produced by Australian jurisdictions follow this recommendation. This is not supported by the United States Preventive Services Task Force (USPSTF). There is potential for causing harm by either inappropriate diagnosis of ‘overweight’ or inappropriate reassurance of ‘healthy weight’. The risk will be minimised if clinicians remember that in the preschool years, small errors in measuring either height/length or weight cause large errors in the position of the calculated BMI on the BMI centile chart. This is because centile lines are crowded together in the preschool ages. h An Australian RCT demonstrated that a coordinated cross agency system of parenting support, which included general practice, produced meaningful effects at the population level.90 24 Guidelines for preventive activities in general practice 8th edition Practice Point Comment i ‘For pre-school children, family support and parenting programs continue to be the most effective method of preventing the onset of emotional and behavioural problems, which predispose to mental illness in later childhood and adolescence’.88, 106 j The USPSTF concludes with moderate certainty that vision screening for all children at least once between the ages of 3–5 years to detect the presence of amblyopia or its risk factors has a moderate net benefit.98 The USPSTF concludes that the benefits of vision screening for children aged <3 years are uncertain and that the balance of benefits and harms cannot be determined for this age group. Various screening tests that are feasible in primary care are used to identify visual impairment among children. These include visual acuity tests, stereoacuity tests, the cover–uncover test, and the Hirschberg light reflex test (for ocular alignment/strabismus), as well as the use of autorefractors (automated optical instruments that detect refractive errors) and photoscreeners (instruments that detect amblyogenic risk factors and refractive errors). The Universal Child Health Check at age 3 years will replace the current Healthy Kids Check at age 4 years – this is to be introduced by the Australian Government in 2013 (details not available at the time of publication). k Australian Government Department of Health and Ageing Medicare Benefits Schedule (MBS) Primary Care Items: • Healthy Kids Check for children aged at least 3 years and less than 5 years, who have received or who are receiving their age 4-year immunisation • once only to an eligible patient • the Healthy Kids Check is an assessment of a patient’s physical health, general wellbeing and development with the purpose of initiating medical interventions as appropriate. The Healthy Kids Check must include the following basic physical examinations and assessments: a.height and weight (plot and interpret growth curve/calculate BMI) b.eyesight c.hearing d.oral health (teeth and gums) e.toileting f.allergies. The medical practitioner is required to note if a copy of the department’s publication Get Set 4 Life – habits for healthy kids has been provided to the patient’s parent(s)/guardian at www.health.gov.au/internet/main/publishing. nsf/content/47B8A7F882590379CA25759B001EE259/$File/GetSet4LifeBrochure.pdf The medical practitioner is also required to note that the age 4-year immunisation has been given (including evidence provided). See also www.health.gov.au/internet/main/publishing.nsf/Content/Health_Kids_Check_Factsheet l The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioural interventions to promote improvement in weight status (B).103 • There is a moderate net benefit for screening children aged 6–18 years. • As a screening tool, BMI is an ‘acceptable measure for identifying children and adolescents with excess weight’103 • The definitions used by the USPSTF have changed since the 2005 report. Overweight is now defined as having a BMI between the 85th and 94th percentiles for the individual’s age and gender, and obesity is defined as having a BMI at ≥95th percentile for age and gender. BMI-for-age percentile is not a direct measure of adiposity, but it correlates fairly well with percentile rankings of directly measured per cent body fat (with correlations generally between 0.78 and 0.88) in children. Because BMI changes with age, percentile scores based on agespecific and gender-specific norms are used to monitor growth. National Institute of Clinical Excellence (also known as NICE)104 • BMI (adjusted for age and gender) is recommended as a practical estimate of overweight in children and young people, but needs to be interpreted with caution because it is not a direct measure of adiposity • Waist circumference is not recommended as a routine measure, but may be used to give additional information on the risk of developing other long-term health problems. • Bio-impedance is not recommended as a substitute for BMI as a measure of general adiposity. Guidelines for preventive activities in general practice 8th edition m 25 Mental, emotional, behavioural disorder in Australian young people • Fifty per cent of adult disorders have onset by age 14 years. • Fourteen per cent to 18% of children and young people experience mental health problems of clinical significance. • Depression and coping with stress are priorities for: –– 16% of those aged 11–14 years –– 21% of those aged 15–19 years.111 • The USPSTF recommends screening of adolescents (aged 12–18 years) for major depressive disorder when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive–behavioural or interpersonal), and follow-up105 (B). • Risk factors for major depressive disorder include parental depression, having comorbid mental health or chronic medical conditions, and having experienced a major negative life event.105 n • Promoting health and minimising harm is a whole-of-community opportunity and responsibility. Celebrating strengths, explaining confidentiality (including its limits) and using the HEADSS framework (below) to explore with young people the context in which they live are strategies likely to improve the clinician’s capacity to promote health and minimise morbidity112 (C). –– Home –– Education/Employment –– Activities –– Drugs –– Sexuality –– Suicide • Young people who present frequently are at higher risk of having a mental health problem.113 • Provide messages that encourage delay in initiation of potentially risky behaviours, and, at the same time, promote risk-reduction strategies if adolescents choose to engage or are already engaging in the behaviour. • Use principles of motivational interviewing in the assessment and discussion of risky health behaviours with adolescent patients (including safe practice for the sexually active). • Be familiar with the resources in the community that provide harm reduction programs for substance abuse, pregnancy prevention and injury prevention. • Be familiar with resources in the community that provide parenting skills training for parents of young people. • Advocate for the introduction, further development and evaluation of evidence-based prevention and treatment programs that use a harm reduction philosophy in schools and communities (C). 26 Guidelines for preventive activities in general practice 8th edition 4. Preventive activities in middle age Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 The recommended specific activities for low-risk patients in the 45–64 years age group are listed below. Patients should be offered these opportunistically, or at 2–5-year intervals. Planned health checks in middle-aged adults have been demonstrated to improve the frequency of management of smoking, nutrition, alcohol and physical activity (SNAP) behavioural risk factors; screening for cervical and CRC and hyperlipidaemia, in general practice.16, 114, 115 There is also evidence that Indigenous health checks improve early detection of diabetes and provision of preventive care.116 However, there is mixed evidence for the effectiveness of interventions to address multiple risk factors.117 These checks may be facilitated by involvement of practice nurses.118–120 Interventions should be tailored to level of risk and use of the 5As framework (Ask, Assess, Advise, Assist and Agree, Arrange follow-up) is recommended as a guide to their delivery in primary healthcare.121 Table 4.1 Age-related health checks in middle age Age What should be done? 45–49 years Ask about: Pages • SNAP and readiness to change 40–49 • risk of diabetes using Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) 55–574 Appendix 4 • depression in increased risk groups (past history, physical illness, other mental problems, etc.) 73–74 • risk factors for osteoporosis 82–83 • skin cancer. 60–62 Measure: • weight, height (calculate BMI) and waist circumference 43–44 • BP 51–53 • fasting lipids 53–55 • fasting blood glucose in patients at high risk of diabetes. 55–57 Perform: • Pap test every 2 years 63–65 • mammography if family history indicates high risk. 65–67 Calculate: • absolute cardiovascular risk. Appendix 5 Guidelines for preventive activities in general practice 8th edition 50–59 years 27 Ask about: • SNAP and readiness to change 40–49 • risk of diabetes using AUSDRISK 55–574 Appendix 4 • depression in increased risk groups (past history, physical illness, other mental problems, etc.) 73–74 • risk factors for osteoporosis 82–83 • skin cancer. 60–62 Measure: • weight, height (calculate BMI) and waist circumference 43–44 • BP 51–53 • fasting lipids 53–55 • fasting blood glucose in patients at high risk of diabetes 55–57 • urinalysis for protein. 58–59 Perform: • Pap test every 2 years 63–65 • CRC screening with faecal occult blood testing (FOBT) at least every 2 years 68–70 • mammography every 2 years 65–67 • vaccination for dTpa. Consider influenza and pneumococcal vaccination if high risk. 35–36 Calculate: • absolute cardiovascular risk. Appendix 5 Table 4.2 Preventive interventions in middle age Intervention Technique References Health education Tailor health advice or education to the patient’s risk, stage of change and health literacy (see Section II Patient education and health literacy). 36 Practice organisation Use clinical audit to identify patients who have not had preventive activity. Recall to practice or opportunistically arrange a health check. 122 Implementation Health inequity Individual behavioural counselling is most likely to be effective for patients from disadvantaged backgrounds if linked to community resources and if financial and access barriers are addressed. Provider attitudes are also important in building self-efficacy among patients from these groups. Aboriginal and Torres Strait Islander and low SES patients have higher risk of disease, but are less likely to be offered preventive interventions. Strategies Strategies to increase screening and effective motivational and behavioural interventions in this group are discussed in the RACGP green book. 28 Guidelines for preventive activities in general practice 8th edition 5. Preventive activities in older age Older people are at increased risk of multiple chronic conditions that may impair their function and quality of life. Those living alone are particularly vulnerable. Their health problems may be exacerbated by poor nutrition, lack of physical activity and lack of sun exposure. Older people may rely on the help and support of family and carers. Carers, particularly carers for people with dementia or depression, are at risk of depression, anxiety, emotional distress, loneliness and isolation but their healthcare needs are often overlooked.123–127 Their need for support should be assessed when possible128 (C). Carer support resources are helpful for carer wellbeing and may delay the need for the older person to be relocated to a residential facility.123, 129–131 People should be advised to plan for their care as they get older. This includes organising wills, power of attorney and an advance care plan. Medication-related problems may cause unnecessary hospital admission, adverse drug reactions and other adverse outcomes for people living in the community.132 GPs should review medications in older people, particularly for vulnerable groups. Vulnerability factors include: • recent discharge from hospital • high-risk drug groups (e.g. anticoagulants) • confusion/cognitive impairment or dementia • history of falls • currently taking five or more regular medications • target disease states where medication management is an important process of care (CKD, congestive cardiac failure)133 • multiple chronic medical problems • regular use of alcohol • previous adverse drug reaction. GPs may consider a pharmacist medication review. The most successful interventions have been delivered by small numbers of pharmacists working in close liaison with primary care doctors (III,C).134 The review should include consideration of the need for each medication; issues around patient compliance and understanding of the medication; screening for side effects, particularly falls and cognitive impairment; and consideration of the use of aids such as dosette boxes and Webster packaging. A review of the combined anticholinergic load and sedative load of the medications may also be done, as anticholinergic and sedative loads increase the rate of confusion and other adverse side effects. 5.1 Immunisation Immunisation is recommended for adults aged 65 years and over, according to the Australian Government Department of Health and Ageing Australian Immunisation Handbook. Table 5.1 Immunisation: preventive interventions in older age Intervention Technique References Vaccination: influenza Annual influenza vaccination in the pre-flu season months (III,C). 135 Vaccination: pneumococcal Pneumococcal polysaccharide vaccination (23vPPV) is recommended for the prevention of invasive pneumococcal disease (II,B). 136 Vaccination should be done opportunistically. One dose is currently recommended except for those who have a condition that predisposes them to an increased risk of invasive pneumococcal disease. See http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/ pneumo23-atagi-statement-cnt.htm Vaccination: herpes zoster A single dose of zoster vaccine is recommended for adults aged 60 years and over (II,B) See also Section 6.1: Immunisation. 137 29 Guidelines for preventive activities in general practice 8th edition 5.2 Falls and physical activity Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Advice about moderate physical activity is recommended for all older people138, 139 (A). Approximately 30% of people aged 65 years or older report one or more falls in the last 12 months.140 For the older person, physical activity provides many benefits, as well as minimising some of the limitations of later life (e.g. reduced mobility, tendency to fall and reduced interaction with the environment).141 Table 5.2.1 Falls: identifying risks Who is at risk of falls? What should be done? How often? References Average risk Screen for falls and risk factors for falls* (I,A) Every 12 months 139, 142, 143 Screen for risk factors and involve in preventive activities* (I,A) Every 6 months 140, 142 • All people aged 65 years or more Moderately high risk • Older people presenting with one or more falls, who report recurrent falls or with multiple risk factors (see Table 5.2.2) * If the person has inadequate sun exposure, Vitamin D supplement should be recommended to reduce the risk of fracture.144 30 Guidelines for preventive activities in general practice 8th edition Table 5.2.2 Falls: preventive interventions Intervention Technique References Screening for falls risk Ask the following three screening questions: 140, 142, 145–150 1.Have you had two or more falls in the past 12 months? 2.Are you presenting following a fall? 3.Are you having difficulty with walking or balance? If the answers to any of these are positive: • obtain relevant medical history, complete a physical examination, and perform cognitive and functional assessments • determine multifactorial fall risk: 151 –– history of falls –– multiple medications, and specific medications (e.g. psychotropic medications and opiate-containing analgesic agents) –– impaired gait, balance and mobility –– impaired visual acuity, including cataracts –– issues with bifocal or multifocal spectacle use –– reduced visual fields –– other neurological impairment –– muscle weakness –– cardiac dysrhythmias –– postural hypotension –– foot pain and deformities and unsafe footwear –– home hazards –– vitamin D deficiency. There are many fall risk-assessment tools. However, reports from researchers are variable, so no single tool can be recommended for implementation in all settings or for all subpopulations within each setting. A quick screening tool is the ‘timed up and go test’ (TUGT), which involves looking for unsteadiness as the older person gets up from a chair without using his or her arms, walks 3 metres and returns. The usefulness of timing this test as a predictor of falls has been questioned. 152 Simple alternatives to the TUGT are the repeated chair standing test and the alternate step test. The repeated chair standing test measures how quickly an older person can rise from a chair five times without using the arms. A time of >12 seconds indicates an increased fall risk. The alternate step test measures how quickly an older person can alternate steps (left, right, left, etc.) onto an 18 cm high step a total of eight times. A time >10 seconds indicates an increased fall risk. The Quickscreen assessment tool, developed and validated for use in an Australian population, includes these tests as well as simple assessments of medication use, vision, sensation and balance. 153 See also Section 13: Urinary incontinence 154 Guidelines for preventive activities in general practice 8th edition Falls risk reduction • Prescribe or refer for a home-based exercise program and/or encourage participation in a community-based exercise program. In either case, exercise for preventing falls needs to include medium-intensity to high-intensity balance training (i.e. exercises must be undertaken while standing and challenge balance), and be of long duration, preferably ongoing. Exercise programs targeting nonEnglish speaking patients may need to address cultural norms about appropriate levels of physical activity. 31 155–161 162 163 • Physical activity recommendations for older adults from the American College of Sports Medicine and American Heart Association are: –– do moderately intense aerobic exercise 30 min/day, 5 days/week or vigorous aerobic exercise 20 min/day, 3 days/week and –– do 8–10 muscle strength training exercises, 10–15 repetitions of each exercise 2–3 times/week and –– if at risk of falling, perform balance exercises and have a physical activity plan. • Review medications and discontinue centrally acting medications where clinically appropriate. • Consider prescribing vitamin D for people with vitamin D levels <50 nmol/L for older people living in the community (III,C) and consider routinely prescribing vitamin D (unless contraindicated) for all older people living in residential aged care (I,B), as routine sun exposure in residential aged care may not be feasible. 164 • See also Section 14: Osteoporosis. • Refer people with painful feet or foot deformities to podiatry for intervention. • Provide advice on the dangers of bifocal and multifocal glasses when walking outdoors (as these blur ground-level obstacles) and recommend the wearing of single lens glasses when outdoors. • Identify cataracts and refer for cataract extraction. • Refer people with a history of recent falls for an occupational therapy home assessment. 5.3 Visual and hearing impairment Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Visual acuity should be assessed from age 65 years using the Snellen chart (B) in those with symptoms or who request it. There is no evidence that screening of asymptomatic older people results in improved vision.165 Hearing loss is a common problem among older individuals and is associated with significant physical, functional and mental health consequences. Annual questioning about hearing impairment is recommended with people aged 65 years and over (B). In some states and territories, there are legal requirements for annual assessment (e.g. driving over age 70 years).166 Eye disease and visual impairment increase threefold with each decade of life after age 40 years. They are often accompanied by isolation, depression and poorer social relationships, and are strongly associated with falls and hip fractures.167 It should be determined whether the patient is wearing an up-to-date prescription, and whether there is a possibility of falls because they are no longer capable of managing a bifocal, trifocal or multifocal prescription. People at greater risk of visual loss are older people and those with diabetes and a family history of vision impairment. Cataracts are the most common eye disease (42% of cases of visual impairment), followed by agerelated macular degeneration (AMD) (30%), diabetic retinopathy and glaucoma. The leading causes of blindness in those aged >65 years are AMD (55%), glaucoma (16%) and diabetic retinopathy (16%).168 ≥80 32 Guidelines for preventive activities in general practice 8th edition Table 5.3.1 Visual and hearing impairment: identifying risks Who is at higher risk of hearing loss? What should be done? How often? References People ≥65 years Screen for hearing impairment (II,B) Every 12 months 169 Table 5.3.2 Visual and hearing impairment: preventive interventions Intervention Technique References Visual impairment: case finding • Use a Snellen chart to screen for visual impairment in the elderly if requested or if indicated by symptoms. There is no evidence that screening asymptomatic older people results in improvements in vision. 165, 170 • See also Section 12: Glaucoma. Hearing impairment screening • A whispered voice out of field of vision (at 0.5 metre) or finger rub at 5 cm has a high sensitivity for hearing loss, as does a single question about hearing difficulty. 169, 171 5.4 Dementia With people aged over 65 years, clinicians should be alert to the symptoms and signs of dementia. These may be detected opportunistically and assessed using questions addressed to the person and/or their carer (C). Depression and dementia may co-exist. When a person has dementia, adequate support is required for the person, carer and family. Counselling and education are important. Management priorities will vary from patient to patient, but there may be a need to consider medical management of dementia, behaviour and comorbidity, legal and financial planning, driving and advance care planning.172 Table 5.4.1 Dementia: identifying risks Who is at risk? What should be done? How often? References Average risk No evidence of benefit from screening (II,C) n/a 173, 174 Case finding and early intervention (III,C) n/a 175–177 • Those without symptoms Moderate risk • Risk increases with increasing age • A family history of Alzheimer disease • People with history of repeated head trauma 178 • People with Down syndrome • Those with elevated cardiovascular risk (heart disease, stroke, hypertension, obesity, diabetes, elevated homocysteine, elevated cholesterol) • Those with depression or a history of depression • Those with symptoms (see Table 5.4.2) 179–184 177 Guidelines for preventive activities in general practice 8th edition 33 Table 5.4.2 Dementia: preventive interventions Intervention Technique References Case finding and confirmation • Ask ‘How is your memory?’ and obtain information from others who know the person (e.g. repeating questions, forgetting conversations, double buying, unpaid bills, social withdrawal). 185 • Other symptoms may include a decline in thinking, planning and organising and reduced emotional control or change in social behaviour affecting daily activities. Not everyone with dementia has memory problems as an initial symptom (C). Other clues are missed appointments (receptionist often knows), change in compliance with medications and observable deterioration in grooming, dressing. 186, 187 • Over several consultations, obtain the history from the person and family/carer, and perform a comprehensive physical examination. Undertake cognitive assessment using: – Mini-Mental State Examination (MMSE) at www.minimental.com – General Practitioner Assessment of Cognition at www.gpcog.com.au 186 – clock drawing test 188 – R owland Universal Dementia Assessment Scale at www.fightdementia.org.au/ understanding-dementia/rowland-universal-dementia-assessment-scale.aspx is a multicultural cognitive assessment scale that has been used to detect dementia across cultures. 189 • The MMSE is the most widely used and evaluated scale. • Assess functional status. The Instrumental Activities of Daily Living at www.abramsoncenter.org/PRI/documents/IADL.pdf assessment tool may be used. All screening instruments used to assess dementia in general practice have high rates of overdiagnosis (false positives) and underdiagnosis (false negatives), so the full clinical presentation needs to be taken into account. Early intervention and prevention • Evidence is growing that attention to cardiovascular risk factors may improve cognitive function and/or reduce dementia risk. A 2012 review has suggested that there is sufficient evidence now for clinicians to recommend the following strategies for early intervention and prevention of dementia: increased physical activity (e.g. 150 minutes per week of moderate-intensity walking or equivalent), social engagement (increased number of social activities per week) and cognitive training and rehabilitation. See also Section 7: Prevention of chronic disease, Section 8: Prevention of vascular and metabolic disease and Section 10: Psychosocial 179–184 190 34 Guidelines for preventive activities in general practice 8th edition 6. Communicable diseases GPs have an important role in the prevention and management of communicable diseases. This includes advice on prevention, immunisation, early detection and treatment. Updates on communicable diseases and notification requirements are available from the Australian Department of Health and Ageing at www.health.gov.au/internet/main/publishing.nsf/Content/cda-surveil-nndss-casedefs-distype.htm GP’s laboratories and hospitals are required by law to notify particular infectious diseases to their local or state public health units (this law overrides all privacy regulations). A list of state-specific notifiable infectious diseases is also available from state health department websites. This role has become almost completely automated by pathology laboratories as a result of advances in information technology. The GP may still need to ensure notification has occurred on occasions where a clinical diagnosis is made, or where clinical information is required. Please note that varicella and zoster are notifiable diseases with or without the need for pathology testing. 6.1 Immunisation Age <2 2–3 4–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 Immunisation is recommended for all children and adults at particular ages, according to the Australian Immunisation Handbook (A). GPs should advocate immunisation and counter the common misunderstandings and antivaccine campaigns. The National Immunisation Program Schedule (NIPS) lists the recommended funded vaccines. There may be other vaccines that are not funded but are recommended in the Australian Immunisation Handbook. There may be variability in vaccines recommended/funded, for example, hepatitis A vaccine (hep A). Vaccination for special high-risk groups Adults or children who develop asplenia, HIV infection or a haematological malignancy, or who receive a bone marrow or other transplant (following recovery), may not be fit for some vaccinations, or may require additional vaccinations, including the need for repeat vaccinations at http://immunise.health.gov.au Health inequity For immunisation to be effective there needs to be high coverage. Thus GPs need to be aware of groups with lower levels of age-appropriate immunisation including:191 • families with young parents under age 25 years192, 193 • single-parent families and families with more than one child194 • migrant families, particularly in the first years of their arrival in Australia, or if a language other than English is spoken at home192–196 • families where the parents are unemployed,191, 195 on low incomes192, 195 or have very high or very low education levels193, 194, 197 • families who move frequently196 • Aboriginal children in rural and urban areas.198, 199 For young people with a chronic illness, cost may be a barrier to achieving appropriate immunisation against influenza and pneumococcal infection.200 ≥65 Guidelines for preventive activities in general practice 8th edition Table 6.1.1 The National Immunisation Program Schedule Sequence Age Vaccine 1 Birth* • Hepatitis B (hep B) 2 6–8 weeks • hep B 1 • DTPa 1 • Haemophilus influenzae type b (Hib) 1 • Inactivated poliomyelitis (IPV) 1 • 13-valent pneumococcal (13vPCV) 1 • Rotavirus† 3 4 months • hep B 2 • DTPa 2 • Hib 2 • IPV 2 • 13vPCV 2 • Rotavirus† 4 6 months • hep B 3 • DTPa 3 • Hib 3 • IPV 3 • 13vPCV (3) • Rotavirus† (Rotateq only) 5 6 months to <5 years • Influenza (for all Aboriginal and Torres Strait Islander peoples) annually 12 months • hep B (fifth dose for those born <32 weeks or <2000 g birthweight) 4 • Hib 1 • MMR first dose 1 • Meningococcal C (MenCCV) 4 • 13vPCV booster for high-risk groups 1 12–18 months • hep A (for Aboriginal and Torres Strait Islander peoples in the Northern Territory, Queensland, South Australia and Western Australia only) 2 18 months‡ • MMR and varicella, or MMRV instead of separate varicella at 18 months and MMR at age 4 years (when available) 2 18–24 months • hep A (for Aboriginal and Torres Strait Islander peoples in the Northern Territory, Queensland, South Australia and Western Australia only) 4 24 months • 13vPCV booster (for Aboriginal and Torres Strait Islander children) 4 4 years • DTPa 4 • IPV 2 • MMR (to be superseded by combined MMRV at 18 months by 2016) 1 • 23vPPV (only for high-risk groups ) 1&2 12–13 years • hep B (2 adult doses for those not vaccinated against hepatitis B) 1 • Varicella (catch up until all immunised) 1, 2 & 3 • HPV (three doses over 6 months, for both sexes – catch-up 2013–15) 5 15 years • dTpa is the adult/adolescent vaccine 15–49 years • Influenza (for all Aboriginal and Torres Strait Islander peoples) annually • 23vPPV (only at-risk Aboriginal and Torres Strait Islander peoples) 35 36 Guidelines for preventive activities in general practice 8th edition Sequence Age Vaccine 50 years and over§ • Influenza (Aboriginal and Torres Strait Islander peoples) • 23vPPV (Aboriginal and Torres Strait Islander peoples) 65 years and over • Influenza • 23vPPV * hep B vaccine (dose 1 or 0) should be given to all infants within 24 hours of birth ideally, but at most within 7 days of birth. Infants whose mothers are hepatitis B surface antigen positive should be given hepatitis B immunoglobulin within 12 hours of birth. † Rotavirus vaccines are contraindicated in infants with a history of intussusception (IS), or predisposing abnormality to IS, or severe combined immunodeficiency. Rotavirus vaccines are time limited and differ in number of doses and timing: • Dose 1 must be given before age 12 weeks (Rotateq) or 14 weeks (Rotarix) or not at all. • Dose 2 must be given before age 24 weeks (Rotarix) or before 28 weeks (Rotateq) or not at all. • Dose 3 ONLY for Rotateq must be given before age 32 weeks or not at all. ‡ MMR dose 2, previously at age 4 years, and separate varicella at 18 months, is to be replaced by combined MMRV at 18 months and predicted to be available by July 2013. § It is recommended that all people aged 50 years should be given DT. dTpa is preferred instead of DT to protect from pertussis. This is funded for parents and ‘carers of infants’ under age 6 months in some states. It can be given regardless of timing of previous DT. Table 6.1.2 Recommended vaccines in the Australian Immunisation Handbook not in the NIPS Age Vaccine Soon after birth Bacillus Calmette–Guérin (or BCG) (for Aboriginal and Torres Strait Islander peoples in the Northern Territory, Queensland, and parts of Northern South Australia) From 6 months Annual influenza vaccination is recommended for any person aged ≥6 months where there is a wish to reduce the likelihood of becoming ill with influenza. Only Influvac or Vaxigrip influenza vaccines are suitable for use from the age of 6 months. Under 14 years Varicella: a second dose improves protection from varicella from 94% to 98% Parents and carers of infants under age 6 months DTpa is recommended to protect the infant from pertussis. To maximise the protection of infants, the options are to give before, immediately after, or in the third trimester of pregenancy. The dTpa vaccine can be given at any time after DT and dTpa may be given again 10 years after previous dTpa. Please refer to the Australian Immunisation Handbook for details. 50 years dTpa is preferred to DT (This booster dose is recommended if no tetanus immunisation was received in the previous 10 years)* From 60 years Zoster virus live vaccine (e.g. Zostavax) for prevention of shingles All healthcare workers hep B (and hep A in some jurisdictions) Annual influenza dTpa MMR (if not immune) Varicella (if not immune) Men who have sex with men hep B and hep A Injecting drug users * It is recommended that all 50-year-olds should be given DT. dTpa is preferred instead of DT to protect from pertussis. This is funded for parents and ‘carers of infants’ under age 6 months in some states. It can be given regardless of timing of previous DT. Guidelines for preventive activities in general practice 8th edition Immunisation information resources include: • the Australian Government Immunisation Handbook is online at http://immunise.health.gov.au • the Australian Childhood Immunisation Register enquiry line is available on telephone 1800 653 809. This phone number can be used to obtain information on the vaccination history of individuals from birth–7 years of age given since 1 January 1996 • the National Centre for Immunisation Research & Surveillance is at www.ncirs.usyd.edu.au Notification of adverse events The reporting of adverse events following vaccinations varies geographically. It is possible to report direct to the Therapeutic Goods Administration from anywhere in Australia by telephoning 1800 044 114, or visiting its website at www.tga.gov.au/hp/problem-medicine-reporting-reactions.htm 6.2 STIs STIs are frequently seen in general practice, especially chlamydia, which is typically asymptomatic. It is important to detect it early in order to minimise potential complications, such as infertility, and to prevent transmission to others. It may also be appropriate to screen for other STIs. The individual’s age and sexual behaviour and community STI prevalence all influence the level of risk, and should influence the choice of STI screening tests. Sexual health consultation Many patients and doctors do not like discussing sexual histories even when the patient is requesting STI testing, or it is indicated. While taking a sexual history is an important part of the assessment and management of STIs, it should not be a barrier to offering STI testing. The patient may not disclose the truth to avoid embarrassment.201 A non-judgemental attitude and environment will maximise patient disclosures on sexual matters.202 It is important to ask open questions and to avoid terms that make assumptions about sexual behaviour or orientation (e.g. by using the term ‘partner’). Issues to cover include current sexual activity, gender and number of partners, contraception (including use of condoms), immunisation status and other risk factors for blood-borne viruses (such as injecting drug use, tattooing and piercing). Investigations should be explained, and patients should be counselled and asked for consent before ordering tests such as HIV or hepatitis C. Contact tracing is an important part of the management of most STIs, and it is the responsibility of the diagnosing clinician to facilitate the process of notifying current and past partners. This may be by a direct approach from the patient or their treating health professional, or by using online partner notification services such as: • www.letthemknow.org.au • www.thedramadownunder.info/notify (for males with male partners) • www.bettertoknow.org.au (for Aboriginal youth). For more information and to determine ‘how far back to trace’ see the contact tracing manual at www.ashhna.org. au/documents/STIContact_tracing_toolMay2011.pdf In the case of a notifiable condition, the patient should be informed that case notification to public health authorities will occur. Notification should be made as prescribed by the department of health in your state or territory. 37 38 Guidelines for preventive activities in general practice 8th edition 6.2.1 Chlamydia and other STIs Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Screening for chlamydia infection in all sexually active people aged 15–29 years is recommended because of increased prevalence and risk of complications.203 Younger sexually active youth should not be excluded from case finding, or identifying any safety or abuse issues. Women with untreated chlamydia infections have a 2–8% risk of infertility.204 Other STIs to consider screening for in higher risk individuals are gonorrhoea, HIV and syphilis.205 The risk for gonorrhoea, HIV and syphilis is low for heterosexuals in all major cities in Australia and New Zealand206 but rates of gonorrhoea and syphilis may be higher in remote community settings. The individual’s age and sexual behaviour and community STI prevalence influence the level of risk and should guide STI testing recommendations for patients. (Please refer to tables for guidance.) Men who have sex with men (MSM) should be screened for gonorrhoea, chlamydia, syphilis and HIV every 12 months. Men who have multiple sexual contacts should be screened more often. Most MSM with STIs have no symptoms.207 Screening for hepatitis C should be provided if the patient is HIV positive or there is a history of injecting drug use. There is good evidence that all pregnant women at risk should be screened for hepatitis B, HIV and syphilis;205 screen for chlamydia and possibly gonorrhoea if the patient is considered to be particularly at risk.208, 209 Table 6.2.1.1 STIs: identifying risks Who is at higher risk of infection and complications? What should be done? How often? References • All sexually active young people aged 15–29 years, particularly if: Urine or genital swab for chlamydia (II, A) Every 12 months 203, 210–215 – under age 20 years Consider other infections based on risk assessment such as gonorrhoea, hepatitis B, syphilis and HIV High-risk asymptomatic – Aboriginal or Torres Strait Islander – inconsistent or no condom usage – recent change in sexual partner A good opportunity is at same time as Pap test or presentation for other reasons 216 Consider trichomonas in remote communities (III) Asymptomatic men who have sex with men • Higher risk in those who:217 –– have unprotected anal sex –– have had >10 partners in past 6 months –– participate in group sex or use recreational drugs during sex Urine and rectal swab for chlamydia polymerase chain reaction (PCR) Every 12 months and 3–6 monthly in higher risk men 217, 218, 219 If chlamydia infection found (and treated), repeating testing to check for reinfection after 3–12 months may be appropriate 220–223 Throat and rectal swab for gonorrhoea PCR (III, B) Serology for HIV, syphilis and hepatitis A and B serology if not vaccinated or immune Also offer hepatitis A and B vaccination (III,B) Sexual contacts from the last 6 months of infected women and men Test and treat contacts presumptively (II,A) For how far back to trace, see www.ashhna.org. au/documents/STIContact_tracing_toolMay2011. pdf Consider other infections based on risk assessment such as gonorrhoea, hepatitis B (if not vaccinated), syphilis and HIV (III,B) Low risk heterosexual asymptomatic requesting ‘STI check-up’ Urine PCR or genital swab for chlamydia, serology for hepatitis B (if not vaccinated or immune), syphilis and HIV (III, B) 219 Guidelines for preventive activities in general practice 8th edition 39 Table 6.2.1.2 Tests to detect STIs Test Technique Site References Nucleic acid amplification test (NAAT) most commonly by PCR • Should be (20 mL) first void urine (passed at least 1 hour after last having urinated, (i.e. not midstream) (I,B) Urine, endocervix or vagina 206, 222, 224 • PCR endocervical or vaginal swab (patient can self-collect) also possible in females (I,B) 219 • This technique has also been validated for anal or throat swabs: – r ectal swab should be inserted ~3 cm into anus and rotated (asymptomatic men who have sex with men can be taught to perform this test themselves, with the aid of a visual diagram. See www.stipu. nsw.gov.au/icms_docs/117569_Self_Collected_Specimen_Chart.pdf – throat swab should sample the posterior pharyngeal wall and tonsillar crypts • NAATs are highly sensitive and specific for chlamydia and gonorrhoea from all specimens. False positive gonorrhoea results can occur, especially if testing low-risk individuals. However, laboratories usually perform supplemental assays to confirm results for gonorrhoea. Gonorrhoea microscopy, culture and sensitivity (MCS) • Rectal swab should be inserted 3 cm into anus and rotated 225 • MCS is of use to guide treatment where resistance to antibiotics is a problem Implementation Chlamydia is the most common and curable STI in Australia. Notification rates per 100 000 have increased from 35.4 in 1993 to 319 in 2010, mostly in those aged 15–29 years.226 Estimated infection rates of the sexually active population in this age group vary from 4–12%. Young Aboriginal and Torres Strait Islander peoples have the highest infection rates, which are 12–34% in some locations. There is also an increased risk of gonorrhoea and syphilis among Aboriginal and Torres Strait Islander peoples. Screening of sexually active women under age 25 years for chlamydia on an annual basis has been shown to halve the infection and complication rates204, 227 All partners of those infected should be tested and treated presumptively. A systematic review has shown that providing patient-delivered partner therapy to index cases is more effective in reducing infection rates than paper-based methods of contact tracing.228 It is important to ensure current sexual partners are treated simultaneously. Referral to a sexual health clinic may provide improved contact tracing and should be considered for problematic repeated infections.229 Untreated pregnant women infected with chlamydia have a 20–50% chance of infecting their infant at delivery.230 40 Guidelines for preventive activities in general practice 8th edition 7. Prevention of chronic disease The SNAP risk factors are common among patients attending general practice.231 They contribute significantly to the burden of disease, largely due to their effect on the incidence and complications of chronic diseases such as diabetes, cardiovascular disease (CVD), chronic respiratory disease and some cancers.2, 232 While there is some debate about the impact and effectiveness of GPs and practice nurses on a patient’s lifestyle,233–235 most accept that GPs and their teams have a role and can be effective in each of the SNAP lifestyle areas. including smoking,55, 236, 237 hazardous drinking,44, 238 physical activity239–241 and dietary change.239, 242 Each of these risk factors may interact with each other throughout the lifecycle and need to be considered together rather than separately. Behavioural counselling approaches such as motivational interviewing243 may be tailored to the patient’s readiness to change their behaviour (see the RACGP green book for more details)244 and should consider the patient’s literacy and health literacy.243 The 5As121, 245–249 is an internationally accepted framework for organising the assessment and management of all the behavioural risk factors in primary healthcare. It consists of: • Ask – a systematic approach to all patients regarding their smoking, nutrition, alcohol or physical activity, which may occur opportunistically as they present for other conditions and/or by recall for health checks • Assess – assess readiness to change, and dependence (for smoking and alcohol) • Advise – provide brief, non-judgemental advice with patient education materials (such as Lifescripts) and work with the patient to set agreed goals • Assist – provide motivational interviewing; refer to telephone support services, group lifestyle programs or individual providers (e.g. dietitian or exercise physiologist); and consider pharmacotherapy • Arrange – regular follow-up visits to monitor maintenance and prevent relapse. A systematic approach to identifying chronic disease can be more effective as a larger number of eligible subjects are identified and assisted.244, 250, 251 Guidelines for preventive activities in general practice 8th edition Health inequity Disadvantaged people (low incomes and/or education) have higher rates of smoking and alcohol use, poorer diets and lower levels of physical activity. These higher rates are a product of social, environmental factors and individual factors, which interact. Individual behavioural counselling is most likely to be effective for patients from disadvantaged backgrounds if linked to community resources and if financial and access barriers are addressed. Smoking is one of the preventable risk factors to show the greatest inequities across groups. Most disadvantaged groups have significantly higher smoking rates. Smoking status varies by education level, employment status, SES, geographic location and Indigenous status.252 While the proportion of people smoking across all of these groups either declined significantly or remained relatively stable between 2007 and 2010, significant inequities remain. In 2010, 24.6% of people aged over 14 years in the lowest SES areas smoked, compared with 12.5% in people from the highest SES areas. People living in remote and very remote areas are about 1.7 times as likely to smoke as those living in major cities. While the proportion of Aboriginal and Torres Strait Islander current daily smokers aged 15 years and over fell from 49% to 45% between 2002 and 2008, Aboriginal and Torres Strait Islander peoples are still nearly twice as likely as non-Indigenous people to be current daily smokers.253, 254 The Centre for Excellence in Indigenous Tobacco Control provides resources and strategies at www.ceitc.org.au Smoking is also more prevalent in patients with long-term mental illness, who are more prone to nicotine addiction.255 Overweight and obesity rates are higher in socioeconomically disadvantaged people and the gap between these and other socioeconomic groups is widening.256 Aboriginal and Torres Strait Islander peoples and those from the Pacific Islands have higher rates of overweight and obesity as well as a higher incidence of vascular disease.257 Aboriginal and Torres Strait Islander communities in remote regions face significant access barriers to nutritious and affordable food.258, 259 Nutritious food tends to cost more in rural and remote areas, and cost may also be an issue in low socioeconomic groups.260 Low income groups are less likely to be offered interventions to prevent being overweight261 (see Section 1: Introduction.) Interventions to improve physical activity among socially disadvantaged patients need to be linked to community programs that improve the physical environment and opportunities to exercise and to programs that remove cost barriers.262 Provider attitudes are also important in building self-efficacy among patients from these groups.262, 263 Improvements in physical activity for Aboriginal and Torres Strait Islander patients may be achieved by linking health advice with locally available and appropriate community sport and recreation programs as well as social support programs (such as group activities).264 Risky alcohol use is also frequently associated with mental health issues.265, 266 Having both risk factors may not be readily recognised and may reduce access to and receipt of treatment services.267 Alcohol has tended to produce a greater burden of harms in more socially disadvantaged groups268, 269 partly through the more hazardous pattern of drinking270 and partly through the associated poverty associated with lower SES.271 Recognition and treatment is also impeded by the social stigma associated with problematic use of alcohol.271, 272 41 42 Guidelines for preventive activities in general practice 8th edition 7.1 Smoking Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Smoking status and interest in quitting should be assessed for every patient over age 10 years.55, 237, 273–275 All patients who smoke, regardless of the amount they smoke, should be offered smoking cessation advice. This should include: • asking about their interest in quitting (B) • advising to stop smoking (A), agreeing on quit goals and offering pharmacotherapy if appropriate275, 276 (A) • offering referral to a proactive telephone callback cessation service (e.g. the Quitline 13 7848)277 (A) • following up to support maintenance and prevent relapse using self-help or pharmacotherapy278(A). To assess nicotine dependence: • ask about the time to first cigarette and the number of cigarettes smoked a day. There is a high likelihood of nicotine dependence if the person smokes within 30 minutes of waking and smokes more than 10–15 cigarettes a day • explore whether the patient had withdrawal symptoms when they previously attempted to quit. Table 7.1.1 Smoking: identifying risks Who is at risk? What should be done? How often? References Average risk Ask about quantity and frequency of smoking (I,A). Offer smoking cessation advice, set quit goals, offer pharmacotherapy, referral and follow-up as appropriate (II,A). Opportunistically* (III,C) 55, 237, 274, 279–282 • Everyone over age 10 years High risk (people who smoke and who have the following characteristics) • Aboriginal and Torres Strait Islander peoples Offer smoking cessation advice. Agree on quit goals, offer pharmacotherapy and culturally appropriate referral and support (II,A). Opportunistically, ideally at every visit* (III,C) 280 • People with mental illness Offer smoking cessation advice and make careful use of pharmacotherapy given significant impact of nicotine and nicotine withdrawal on drug metabolism† (I,A). Opportunistically, ideally every visit* (III,C) 55, 273, 279, 281, 282 • Pregnant women Offer smoking cessation advice, agree on quit goals, offer referral to a quit program (I,A). At each antenatal visit (III,C) 273, 283–285 • People with other drug-related dependencies Offer smoking cessation advice and make careful use of pharmacotherapy given significant impact of nicotine and nicotine withdrawal on drug metabolism† (I,A). Opportunistically, ideally every visit* (III,C) 55, 279, 282, 286, 287 • People with smoking-related disease Offer smoking cessation advice highlighting specific disease-related benefits of quitting; refer to smoking programs (I,A). Opportunistically, ideally every visit* (III,C) 55, 274, 282, 283 • Parents of young babies and children Offer smoking cessation advice. If the parent is unable to quit advise to: Opportunistically, ideally every visit* (III,C) 55, 198, 274, 284, 288 • smoke away from children • not smoke in confined spaces with children (e.g. when driving) (I,A). * See Effect of smoking abstinence on medications, Appendix 9, New Zealand smoking cessation guidelines 2007 at www.treatobacco. net/en/uploads/documents/Treatment%20Guidelines/New%20Zealand%20treatment%20guidelines%20in%20English%202007.pdf † While enquiry about smoking should occur at every opportunity, be aware of patient sensitivity. Non-judgemental enquiry about smoking is associated with greater patient satisfaction.283, 286, 289 Guidelines for preventive activities in general practice 8th edition 43 Implementation At an individual patient level, GPs and their teams can influence smoking rates by systematically providing opportunistic advice and offering support to all attending patients who smoke.44, 168, 259, 290, 291 GPs tend to underutilise effective treatment strategies for example, referral to the Quitline,292–294 pharmacotherapy,284, 288, 295, 296 and motivational interviewing.284, 288, 297 There is a lack of evidence for greater effectiveness of stage-based approaches,298 and interest in quitting fluctuates over time.299 The stages of change model provides a useful framework to help clinicians identify smokers and provide tailored support for a smoker’s level of interest in quitting in a way that is time efficient and likely to be well received.300–302 Pregnant women find it especially difficult to quit: pregnancy alters nicotine metabolism and heightens withdrawal symptoms and the support from partners is an important element in quitting.240, 241 Higher smoking rates in disadvantaged individuals reflect greater neighbourhood disadvantage, less social support, greater negative affect and lower selfefficacy.303 Removing access barriers and providing incentives to motivate patients to quit may improve quit rates.304, 305 A whole-of-practice approach that includes a supportive infrastructure has a big impact on GP effectiveness in smoking cessation.236, 237, 244, 306, 307 The RACGP green book outlines a range of effective implementation strategies in smoking cessation.244 7.2 Overweight Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 BMI and waist circumference should be measured every 2 years (A). BMI on its own may be misleading, especially in older people and muscular individuals, and classifications may need to be adjusted for some ethnic groups.308 Waist circumference is a strong predictor of health problems.309, 310 Patients who are overweight or obese should be offered individual lifestyle education (A).121, 311, 312 Restrictive dieting is not recommended for children and adolescents. A modest loss of 5% of starting body weight in adults who are overweight is sufficient to achieve some health benefits.312–315 Table 7.2.1 Obesity-related complications: identifying risks Who is at risk? What should be done? How often? References Average risk Assess BMI and waist circumference in all adults aged over 18 years (I,A). Every 2 years (IV,D) 311, 313 Every 12 months (IV,D) 264, 311 • All patients In children and adolescents use age-specific BMI charts (see Section 3: Preventive activities in children and young people) (III,C). Offer education on nutrition* and physical activity† (I,A). Increased risk • Aboriginal and Torres Strait Islander peoples and those from Pacific Islands Assess BMI and waist circumference in all adults over age 18 years (I,B). Offer individual or group-based education on nutrition and physical activity (II,A). 313, 316 • Patients with existing diabetes or CVD, stroke, gout or liver disease Identified risk • Patients who are overweight or obese Assess weight and waist circumference (I,B). Develop weight management plan‡ (II,B). Every 6 months§ (III,C) 311 317, 318 Consider referral for self-management support or coaching in an individual or group-based diet or physical activity program or allied health provider (e.g. dietitian, exercise physiologist, psychologist). * For more information see the NHMRC Dietary guidelines for Australian adults. † For more information see the NHMRC Physical activity guidelines. ‡ See Obesity management guidelines: the plan should include frequent contact (not necessarily in general practice), realistic targets, and monitoring for at least 12 months. § Review impact on changes in behaviour in 2 weeks. 44 Guidelines for preventive activities in general practice 8th edition Table 7.2.2 Overweight and obesity: assessment and preventive interventions Assessment Technique References BMI BMI = body weight in kilograms divided by the square of height in metres. BMI of 25 or greater conveys increased risk 311, 319 Waist circumference An adult’s waist circumference is measured halfway between the inferior margin of the last rib and the crest of the ilium in the mid-axillary plane over bare skin. The measurement is taken at the end of normal expiration. 311, 319 • ≥94 cm in males and ≥80 cm in females conveys increased risk. • ≥102 cm in males and ≥ 88 cm in females conveys high risk. Weight reduction 1.Advise that weight loss can have health benefits, including reduced BP and prevention of diabetes in high-risk patients. 2.Start a lifestyle program that includes reduced caloric intake (aiming for 600 Kcal or 2500 KJ energy deficit) and increased physical activity (increasing to 60 minutes of moderate-intensity 5 days per week) supported by behavioural counselling. 320, 321 3.Agree on goals, including a realistic initial target of 5% weight loss. Make contact (visits, phone, etc.) 2 weeks after commencing the program to determine adherence and if goals are being met. 322, 323 4.If no response (<1 kg weight or 1 cm waist) after 3 months, consider alternative approaches, including the addition of medication such as Orlistat. 324 5.After achieving initial weight loss, advise that patients may regain weight after 2 years without a maintenance program that includes support, monitoring and relapse prevention. 325–329 Bariatric surgery may be considered in patients who fail lifestyle interventions and who have a BMI of 35+ with comorbidities, such as poorly controlled diabetes, who are expected to improve with weight reduction. Table 7.2.3 Obesity and risk of CVD and type 2 diabetes in Australian adults Classification BMI (kg/m2) Disease risk (relative to normal measures) Underweight <18.5 – Healthy weight 18.5–24.9 – Overweight 25.0–29.9 Increased Obesity 30.0–39.9 High to very high Severe obesity >40 Extremely high Reproduced from National Health and Medical Research Council. Overweight and obesity in adults – a guide for general practitioners. Canberra: NHMRC, 2003311 Implementation Strategy Body weight is associated with the balance between levels of dietary intake and physical activity. Environmental, cultural, genetic and lifestyle factors all contribute to overweight and obesity. Changes in the balance between energy intake (increasing) and energy expenditure (decreasing) have been identified as major contributors to rising obesity. There is little consensus on the relative importance of dietary intake compared with physical activity.319, 330 Regular physical activity is protective against unhealthy weight gain and reduces CVD risk as well as CVD risk factors such as overweight, high BP, levels of high density lipoprotein (HDL) and total blood cholesterol, and type 2 diabetes.331–333 Dietary behaviour influences the risk of coronary heart disease (CHD) and stroke due to the combined effects of individual dietary factors and total energy intake – if this leads to excess weight.331 Strategies to increase screening in this group are discussed in the RACGP green book and the National guide to a preventive health assessment in Aboriginal and Torres Strait Islander people, 2nd edition. Guidelines for preventive activities in general practice 8th edition 45 7.3 Nutrition Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Ask adults how many portions of fruits or vegetables are eaten in a day and advise to follow the Dietary guidelines for Australian adults.334 (B). Brief lifestyle advice should be given to reduce saturated fat and sodium and increase fruit and vegetable portions (2 + 5 portions) as these are associated with a lower risk of CVD and diabetes.335 Breastfeeding should be promoted as the most appropriate method for feeding infants and one that offers protection against infection and some chronic diseases.336 See Section 3: Preventive activities in children and young people for nutrition-related recommendations. Table 7.3.1 Nutrition-related complications: identifying risk Who is at risk? What should be done? How often? References Average risk Ask about number of portions of fruits and vegetables eaten per day, amount of sodium, and amount of saturated fat eaten (II,B). Every 2 years (IV,D) 292, 337, 338 Every 6 months (III,C) 338–341 • All patients All patients should be advised to follow the NHMRC Dietary guidelines for Australian adults and the Heart Foundation guidelines (see Table 7.3.2). High risk • Overweight or obese • High cardiovascular absolute risk (>15%) • A past or first-degree family history of CVD (including stroke) before age 60 years. For personal history the age doesn’t matter. • Type 2 diabetes or high risk for diabetes Provide lifestyle advice to reduce dietary saturated fat, sodium and increase fruit and vegetables. (See Section 7.2: Overweight for dietary recommendations for overweight and obesity) (II,B). Provide self-help nutrition education materials and refer to a dietitian or group diet program (II,B). 46 Guidelines for preventive activities in general practice 8th edition Table 7.3.2 Nutrition-related complications: preventive interventions Intervention Technique References Vitamin supplements Vitamin supplementation is not of established value in asymptomatic individuals* (with the exception of folate and iodine in pregnancy). Routine screening for vitamin D deficiency is not recommended in low-risk populations. 342 Dietary recommendations Enjoy a wide variety of foods each day: 334 • five portions of vegetables and two portions of fruit343, 344 • three portions of cereals (including breads, rice, pasta and noodles) • one to two portions of lean meat, fish, poultry and/or alternatives • at least 2 g per day alpha-linolenic acid by including foods such as canola-based or soybean-based oils and margarine spreads, seeds (especially linseeds), nuts (particularly walnuts), legumes (including soybeans), eggs and green leafy vegetables • drink plenty of water. Take care to: • limit saturated fat and moderate total fat intake338 but consume about 500 mg per day of combined docosahexaenoic acid and eicosapentaenoic acid through a combination of the following:345 two or three serves (150 g serve) of oily fish per week, fish oil capsules or liquid, food and drinks enriched with marine omega-3 polyunsaturated fatty acids346 • limit salt intake347 to less than 6 g of salt a day (approximately 2300 mg of sodium a day), which is approximately 1½ teaspoons of salt • limit alcohol intake • consume only moderate amounts of sugars and foods containing added sugars. • prevent weight gain: be physically active and eat according to energy needs • care for food: prepare and store it safely • encourage and support breastfeeding. Note: There are also dietary guidelines for children and adolescents: Dietary guidelines for children and adolescents in Australia, incorporating the infant feeding guidelines for health workers.86 For specific advice, especially patients with specific conditions, refer to a dietitian. The Heart Foundation has a number of nutrition position statements at www.heartfoundation.org.au/information-for-professionals/food-professionals/Pages/ guides-policies-position-statement.aspx Encourage breastfeeding Encourage and support exclusive breastfeeding for 4–6 months, then the introduction of complementary foods and continued breastfeeding thereafter. It is recommended that breastfeeding continue until age 12 months and thereafter as long as mutually desired. 334 * Prevalence of nutritional deficiency is high in certain groups such as people with alcohol dependence and elderly living alone or in institutions. 47 Guidelines for preventive activities in general practice 8th edition Implementation Strategy Refer to general principles as discussed in Section 1: Introduction and Section 7: Prevention of chronic disease and as outlined in the RACGP green book. Lifescripts provide guidance on portions and what foods to eat at www.health. gov.au/internet/main/publishing.nsf/Content/lifescripts-clinical It is important to consider cultural and religious beliefs in recommending dietary changes. A full range of Lifescripts resources have been produced for use with Aboriginal and Torres Strait Islander peoples at www.healthinfonet.ecu. edu.au/key-resources/promotion-resources?lid=16071 7.4 Early detection of problem drinking Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 All patients should be asked about the quantity and frequency of alcohol intake from age 15 years (A). Those with at-risk patterns of alcohol consumption should be offered brief advice to reduce their intake348 (A). Provide interventions using brief motivational interviewing targeted at high-risk use (I,B).349–351 The lifetime risk of harm from drinking alcohol increases with the amount consumed. For healthy men and women, drinking no more than two standard drinks on any day reduces the lifetime risk of harm from alcohol-related disease or injury. Short-term risks stem from the risks of accidents and injuries occurring immediately after drinking. Table 7.4.1 Alcohol-related complications: identifying risk Who is at risk? What should be done? How often? References Low risk Ask about the quantity and frequency of alcohol intake (II,B). Every 2–4 years (III,C) 44 Opportunistically (III,C) 44 Opportunistically (III,C) 352–354 • All patients aged 15 years and over Increased risk • Children and adolescents Advise if drinking alcohol to drink two drinks per day or less and no more than four drinks on any one occasion (II,B). Advise children aged under 15 years not to drink (III,B). Advise young people aged 15–17 years to delay drinking as long as possible (III,B). • Older people* • Young adults, who have a higher risk of accidents and injuries Inform that there is an increased risk of potential harm from drinking (III,B). 355 • People with a family history of alcohol dependence 356–358 • Individuals who are participating or supervising risky activities (e.g. driving, boating, extreme sports, diving, using illicit drugs) Advise that non-drinking is the safest option: driving (I,A), other areas (III,C). • Woman who are pregnant or planning a pregnancy Advise that non-drinking is the safest option (I,A). Opportunistically (III,C) Driving 359, 360 361–364 Opportunistically or at each antenatal visit (III,C) 44, 365, 366 48 Guidelines for preventive activities in general practice 8th edition Who is at risk? What should be done? How often? References • People with a physical condition made worse by alcohol: Advise that non-drinking is the safest option but weigh up pros and cons for each individual (I,A). Opportunistically (III,C) 44, 367 – pancreatitis Advise those with hypertension, or taking antihypertensive medication, to limit alcohol intake to no more than two (for men) or one (for women) standard drinks per day (II,B). Opportunistically (III,C) 368–370 Opportunistically (III,C) 371, 372 – diabetes –h epatitis/chronic liver disease – peptic ulcer – hypertension – sleep disorders – sexual dysfunction – other major organ disease • People with a mental health problem made worse by alcohol (e.g. anxiety and depression) Assess whether there are possible harmful interactions between their medications and alcohol (II,A). • People taking medications * Older people who have a higher risk of falls and are more likely to be taking medication.354 Table 7.4.2 Alcohol-related complications: preventive interventions Intervention Technique References Brief intervention • Brief interventions for problem drinkers halve the mortality rate in this group. 44, 373 • Brief advice in general practice has been demonstrated to have resulted in a reduction in drinking of about six standard drinks per week for men. 238, 348, 356, 374, 375 • The impact of brief advice on reduction in consumption for women is less clear. 356–358, 374, 375 • While there is no clear dose–response curve for spending more time counselling subjects who are drinking at risky levels, the minimum time to achieve some impact is between 5 and 15 minutes. • While some have argued that screening of itself constitutes a brief intervention, the impact of interventions of less than 5 minutes is less clear. 358, 375, 376 238 377 356, 376, 378 Implementation Strategy In the Australian setting, fewer than one in three females and one in six males with documented alcohol dependence seek any form of treatment.379 The barriers to identifying and treating patients with risky or problematic drinking are numerous380–385 and include: stigma associated with diagnosis, gender (females less likely to receive treatment), shorter consultations, self-perceived skills and scepticism about the benefit of treatment. Nevertheless, the number needed to treat (return on effort) using brief interventions is one in eight: eight hazardous drinkers need to be treated to produce one who will reduce drinking to low risk levels.238, 356, 358, 374, 375, 386 Implementation is improved through: • screening/routine enquiry of all patients in the target group, especially using non-confrontational tools (e.g. computerised screening).387–389 Alternatively, embed enquiry about drinking in opportunistic assessment of lifestyle or use a structured questionnaire, for example the AUDIT-C (Appendix 3).390, 391 (Note that the risk assessment should use the NHMRC guidelines and not other structured questionnaires, e.g. AUDIT-C.) • addressing barriers,392, 393 for example, ensuring that there is a supportive organisational practice infrastructure387, 394, 395 and adequate training for clinicians394–396 and practice nurses.381, 394, 397 Guidelines for preventive activities in general practice 8th edition 49 7.5 Physical activity Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 All adults should be advised to participate in 30 minutes of moderate activity on most, preferably all, days of the week (at least 2.5 hours per week)398 (A) and to avoid prolonged sitting, which is a cardiovascular risk factor.399 While moderate physical activity is recommended for health benefit, more vigorous exercise may confer additional cardiovascular health and cancer prevention benefits if carried out for a minimum of 30 minutes three to four times a week.400 The amount of physical activity can be accumulated over several bouts. The amount of activity for weight loss is greater. It is recommended that at least 60 minutes of moderate-intensity physical activity (such as brisk walking) every day may be required, in addition to reducing energy intake, in order to achieve measurable weight loss over a number of months and prevent weight regain.401 Even without weight loss, physical activity can accrue health benefits.402 Table 7.5.1 Physical inactivity: identifying risk Who is at risk? What should be done? How often? References Average risk Question regarding current level of activity (II,A). Consider use of pedometer to assess step count per day (III,C). Every 2 years (III,C) 403 Question regarding current level of activity and readiness to be more active (III,C). Every visit (IV,D) • Those already performing moderate levels of activity for 30 minutes daily on at least 5 days of the week. Increased risk • Those not performing moderate levels of activity for 30 minutes daily on at least 5 days of the week. • Others at higher risk include teenage girls, office workers, Aboriginal or Torres Strait Islander peoples, and people from low socioeconomic backgrounds and non-English speaking backgrounds. • Those with a chronic condition or other CVD risk factors (see Section 8: Prevention of vascular and metabolic disease). • Patients at high risk of CVD or diabetes (including impaired glucose tolerance). 404 405 Provide brief advice and written physical activity materials (III,C). Refer to an exercise or physical activity program: programs with additional behaviour change support may be more beneficial (III,C). Table 7.5.2 Physical inactivity: assessment and intervention Assessment and intervention Determine level of physical activity Brief interventions to increase levels of physical activity Technique References • Moderate physical activity is associated with a moderate, noticeable increase in the depth and rate of breathing while still being able to whistle or talk comfortably. 406 • Question regarding current level of activity and readiness to be more active. 407 • Consider use of pedometer to assess current number of steps per day over 1 week; 10 000 steps per day is regarded as sufficient although health benefits also accrue at lower levels. 408 Interventions in general practice that have been shown to have short-term benefit in changing behaviour related to physical activity include: 407 • patient screening to identify current level of activity (including use of a pedometer) and 404 readiness to be more active • provision of brief advice or counselling on exercise • supporting written materials and/or written prescription for exercise (e.g. Physical Activity Lifescript). • pedometer step target of 10 000 steps per day, or 2000 more than at baseline. Physical activity program • Structured programs of physical activity education and exercise may be delivered as individual or group program and over several sessions. The Heart Foundation is at http:// heartmoves.heartfoundation.org.au and some local councils have information on local physical activity programs. Exercise physiologists are listed at www.essa.org.au 50 Guidelines for preventive activities in general practice 8th edition 8. Prevention of vascular and metabolic disease CVDs occur in 18% of the population, with 6.9% of the population estimated to have disability associated with them.168 They account for 36% of all deaths. Most of the risk of these conditions can be attributed to smoking, raising BP, dyslipidaemia obesity, physical inactivity and poor diet.409 The majority of these can be prevented by changing behavioural and physiological risk factors. The behavioural risk factors include smoking, poor nutrition, hazardous alcohol consumption and physical inactivity as outlined in Section 7: Prevention of chronic disease. In addition to these, depression, social isolation and lack of quality social support are risk factors for CHD.410 These risk factors are common in the Australian population: 90% of adults aged over 45 years have at least one modifiable risk factor and two-thirds have three or more risk factors for CVD.411 Absolute CVD risk combines risk factors in a calculation of the probability that an individual will develop a cardiovascular event (myocardial infarction, stroke) or other vascular disease within a specified timeframe (usually 5 years). Health inequity Aboriginal and Torres Strait Islander peoples, people living in rural and remote areas and lower socioeconomic groups all have an increased risk of cardiovascular disease.252 Both biological and behavioural risk factors play a part (see Section 7: Prevention of chronic disease for a discussion of the relationship between behavioural risk factors and social disadvantage). Low income and education are generally associated with worse biological risk factors for CVD, including BP, lipid profiles, waist circumference, fasting glucose and insulin levels. This is only partly mediated by behavioural risk factors and is more consistently observed for women.412 Diabetes is three to four times more common in Aboriginal and Torres Strait Islander peoples and about twice as common in the most disadvantaged compared to the most socioeconomically advantaged groups.413 Higher prevalence is found in people born in North Africa, the Middle East, South-East Asia, the Pacific Islands and Southern and Eastern Europe. Little regional variation occurs within Australia. The incidence of end-stage renal disease (ESRD) among Aboriginal and Torres Strait Islander peoples varies from up to 30 times the national incidence in some remote areas to around double in some urban areas.414–416 Factors that affect rates of ESRD in the Aboriginal and Torres Strait Islander population include low birthweight, poor nutrition, infections such as scabies, smoking, other behavioural risk factors and socioeconomic disadvantage.417–419 There is also a threefold variation within urban areas among non-Indigenous Australians, with higher ESRD incidence in more disadvantaged areas.420 The role of socioeconomic disadvantage in preventive activities for CVD is complex. Preventive care may be more commonly offered to low socioeconomic groups, but may be less likely to be followed up421 or it may be less comprehensive or complete422 suggesting additional targeted strategies may be needed for these groups. There is evidence that men from socioeconomically disadvantaged backgrounds may be less likely to be offered statins.423 8.1 Assessment of absolute cardiovascular risk Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Aboriginal and Torres Strait Islander peoples Absolute cardiovascular risk assessment should be conducted at least every 2 years in all adults aged 45 years and older who are not known to have CVDs or to be at clinically determined high risk (B).424 This calculation requires information on the patient’s age, sex, smoking status, total and HDL cholesterol, systolic blood pressure (SBP) and if the patient is known to have diabetes or left ventricular hypertrophy (LVH). ≥80 51 Guidelines for preventive activities in general practice 8th edition Table 8.1.1 Cardiovascular disease: identifying risk Population group What should be done? How often? References Adults aged 45 years and older not known to have CVD or not clinically determined to be at high risk Calculate absolute cardiovascular risk* 45–74 years (II,B) Every 2 years† (IV,C) 424 ≥75 years (Practice Point) Aboriginal and Torres Strait Islander peoples aged 35 years and older not known to have CVD or not clinically determined to be at high risk Assess absolute CVD risk (may underestimate risk) (IV,C) Every 2 years (IV,C) * Calculate risk using the National Vascular Prevention Disease Alliance charts (Appendix 5) or online at www.cvdcheck.org.au Blood lipid results within 5 years can be used in the calculation of absolute CVD risk, but BP should be measured at the time of assessment. On-therapy measures of BP and cholesterol may underestimate absolute risk and thus recently recorded pre-treatment measures may be more appropriate to use if available. An electrocardiograph (ECG) is not required to determine LVH if not previously known. † Adults with any of the following do not require absolute CVD risk assessment using the Framingham Risk Equation because they are already known to be at clinically determined high risk of CVD (IV,D): • diabetes and age >60 years • diabetes with microalbuminuria (>20 μg/min or urine albumin:creatinine ratio (UACR) >2.5 mg/mmol for males, >3.5 mg/mmol for females) • moderate or severe CKD (persistent proteinuria or estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2) • previous diagnosis of FH • SBP ≥180 mmHg or diastolic blood pressure (DBP) ≥110 mmHg • serum total cholesterol >7.5 mmol/L • Aboriginal or Torres Strait Islander peoples aged over 74 years (Practice Point). Adults aged older than 74 years may have their absolute risk assessed with age entered as 74 years. This is likely to underestimate 5-year risk but will give an estimate of minimum risk.425 Patients with a strong family history of CVD (first-degree relatives) or obesity (BMI above 30 kg/m2 or more) may be at greater risk.310, 426, 427 Similarly patients with depression and atrial fibrillation (AF) may be at increased risk.424 See Appendix 5 or www.cvdcheck.org.au 8.2 BP Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 BP should be measured in all adults from age 18 years (A) at least every 2 years. BP should be interpreted in the context of an absolute cardiovascular risk assessment after age 45 years (35 years of age for Aboriginal and Torres Strait Islander peoples) (B). Secondary causes of hypertension and ‘white coat’ hypertension should be considered. 52 Guidelines for preventive activities in general practice 8th edition Table 8.2.1 Hypertension: identifying risk Who is at risk? What should be done? How often? References Low absolute risk Provide lifestyle advice and education (I,B). BP every 2 years (III,C) 424, 428–430 BP every 6–12 months (III,C) 310, 424, 426–428, 431 BP every 6–12 weeks (III,C) 424, 429 • <10% CVD risk Offer pharmacotherapy if BP persistently over 160/100 mmHg Moderate risk • 10–15% absolute cardiovascular risk Provide intensive lifestyle advice (II,B). Consider pharmacotherapy if risk factors have not reduced after 3–6 months of lifestyle intervention. Offer pharmacotherapy simultaneously with lifestyle intervention if BP persistently over 160/100 mmHg or if family history of premature CVD or South Asian, Middle Eastern, Maori, Aboriginal or Pacific Islander descent (III,C). High risk • >15% absolute cardiovascular risk • Clinically determined high risk: – diabetes and age >60 years – diabetes with microalbuminuria (>20 μg/min or UACR >2.5 mg/mmol for males, >3.5 mg/mmol for females) – moderate or severe CKD (persistent proteinuria or eGFR <45 mL/min/1.73 m2) – previous diagnosis of FH – SBP ≥180 mmHg or DBP ≥110 mmHg – serum total cholesterol >7.5 mmol/L Provide intensive lifestyle advice (II,B) Commence pharmacotherapy (simultaneously with lipid therapy unless contraindicated) 432, 433 Treatment goal is BP <140/90 mmHg in adults without CVD including those with CKD (I,B–III,D)* (≤130/80 in people with diabetes or micro or macroalbuminuria (UACR >2.5 mg/mmol in males and >3.5 mg/mmol in females)) – Aboriginal and Torres Strait Islander peoples aged over 74 years High risk Lifestyle risk factor counselling Existing CVD (previous event, symptomatic CVD), stroke or transient ischaemic attacks (TIAs) or CKD Pharmacotherapy to lower risk (I,A) * D recommendation for clinically determined high risk. Every 6 months (III,C) 429 Guidelines for preventive activities in general practice 8th edition 53 Table 8.2.2 Hypertension: preventive interventions Intervention Technique References Measure BP Measure BP on at least two separate occasions with a calibrated mercury sphygmomanometer, or automated device that is regularly calibrated against a mercury sphygmomanometer. At the patient’s first BP assessment, measure BP on both arms. Thereafter, use the arm with the higher reading. In patients who may have orthostatic hypotension (e.g. the elderly, those with diabetes), measure BP in sitting position and repeat after the patient has been standing for at least 2 minutes. 424, 429 If possible, use ambulatory BP monitoring or self-measurement for patients with any of thefollowing: • unusual variation between BP readings in the clinic • suspected white coat hypertension • hypertension that is resistant to drug treatment • suspected hypotensive episodes (e.g. in elderly or diabetic patients) Risk calculation should be performed using clinical BP measurements (as the algorithms are based on these). Ambulatory BP readings are considered to be better predictors of outcomes than clinic BP measurements, and therefore should be used to monitor BP lowering therapy. Lifestyle modification Lifestyle risk factors should be managed at all risk levels. 424, 429 All people, regardless of their absolute risk level, should be given dietary advice. Those at low to moderate absolute risk of CVD should be given dietary and other lifestyle advice. (See Section 7: Prevention of chronic disease) Advise to aim for healthy targets: • at least 30 minutes of moderate-intensity physical activity on most, if not all, days • smoking cessation • waist measurement <94 cm for men and <80 cm for women, BMI <25 kg/m2 • dietary salt restriction ≤4 g/day (65 mmol/day sodium) • limit alcohol intake to ≤2 standard drinks per day for males and ≤1 standard drink per day for females. Medications BP treatment should aim to lower BP towards (while balancing risks and benefits): 424 • ≤140/90 for adults without CVD (including those with CKD) • ≤130/80 for adults with diabetes or with micro- or macro-albuminuria (UACR >2.5 mg/ mmol for males, >3.5 mg/mmol for females). Treatment may commence with an ACE inhibitor, angiotensin II antagonist, calcium channel blocker or a low-dose thiazide or thiazide-like diuretic. A second or third agent from a different class may be added to treat towards targets. 8.3 Cholesterol and other lipids Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Aboriginal and Torres Strait Islander peoples Adults should have their fasting blood lipids assessed starting at age 45 years, every 5 years (A for males, C for females). Lipid levels should be interpreted in the context of an absolute cardiovascular risk assessment after age 45 years (35 years for Aboriginal and Torres Strait Islander peoples) (B). Aboriginal and Torres Strait Islander adults should have fasting lipid tests performed every 5 years from age 35 years (B). ≥80 54 Guidelines for preventive activities in general practice 8th edition Table 8.3.1 Cholesterol and lipids: identifying risk Who is at risk? What should be done? How often? References Low risk Provide lifestyle advice (I,A). Repeat fasting lipids every 5 years* 424 Provide intensive lifestyle advice (II,B). Repeat fasting lipids every 2 years 310, 424, 426, 427 Every 12 months (III,C) 424 Every 12 months (III,C) 434 • Absolute CVD risk <10% Moderate risk • Absolute CVD risk 10–15% Consider pharmacotherapy if not reaching target after 6 months (I,A) or if family history of premature CVD, or Aboriginal or Torres Strait Islander, South Asian, Middle Eastern, Maori or Pacific Islander descent (II,C). High risk • Absolute cardiovascular risk >15% • Patient with the following clinically determined highrisk factors: – diabetes and age >60 years – diabetes with microalbuminuria (>20 µg/min or UACR >2.5 mg/mmol for males, >3.5 mg/mmol for females) Provide intensive lifestyle advice (II,C). Commence cholesterol lowering therapy (simultaneously with antihypertensive unless contraindicated) (II,C-III,D).† – CKD (persistent microalbuminuria or Stage 4 renal failure eGFR <30 mL/min/1.73 m2) or Stage 3a renal failure eGFR <45 mL/min/1.73 m2) – previous diagnosis of FH – SBP >180 mmHg or DBP >110 mmHg – serum total cholesterol >7.5 mmol/L – Aboriginal and Torres Strait Islander peoples aged over 74 years See Section 8.2: BP High risk Lifestyle risk factor counselling Existing CVD (previous event, symptomatic CVD) Pharmacotherapy to lower risk (I,A) * Lipid blood test results within 5 years can be used to calculate absolute CVD risk every 2 years. Patients with diabetes, cardiac disease, stroke, hypertension or kidney disease should have their lipids tested every 12 months (III,C). † D recommendation for clinically determined high risk. Guidelines for preventive activities in general practice 8th edition 55 Table 8.3.2 Cholesterol and lipids: preventive interventions Intervention Technique References Fasting blood lipids Fasting total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides (TG). If lipid levels are abnormal, a second confirmatory sample should be taken on a separate occasion (as levels may vary between tests) before a definitive diagnosis is made. 435 436, 437 Screening tests using capillary blood samples produce total cholesterol results that are slightly lower than on venous blood. These may be used, providing they are confirmed with full laboratory testing of venous blood for patients with elevated levels and there is good follow-up. In adults at low absolute risk of CVD, blood test results within 5 years may be used for review of absolute cardiovascular risk unless there are reasons to the contrary. Lifestyle modification Lifestyle risk factors should be managed at all risk levels. 424, 429 All people, regardless of their absolute risk level, should be given dietary advice Those at low to moderate absolute risk of CVD should be given dietary and other lifestyle advice (see Section 7: Prevention of chronic disease). Advise to aim for healthy targets: • at least 30 minutes of moderate-intensity physical activity on most, if not all, days • smoking cessation • waist measurement <94 cm for men and <80 cm for women, BMI <25 kg/m2 • dietary salt restriction ≤4 g/day (65 mmol/day sodium) • limit alcohol intake to ≤2 standard drinks per day for men and ≤1 standard drink per day for women. Pharmacotherapy Lipid lowering therapy for primary prevention should (while balancing risks and benefits) aim towards: 424 • Total cholesterol <4.0 mmol/L • HDL-C ≥1.0 mmol/L • LDL-C <2.0 mmol/L • Non-HDL-C <2.5 mmol/L • TG <2.0 mmol/L Treatment should commence with a statin. If LDL-C levels are not sufficiently reduced on maximally tolerated dose of a statin, add one of ezetimibe, bile acid binding resin or nicotinic acid. These agents may be used as monotherapy if statins cannot be tolerated at all. If TG levels remain elevated, consider use of one of fenofibrate, nicotinic acid or fish oil. 8.4 Type 2 diabetes Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Aboriginal and Torres Strait Islander peoples Patients should be screened for diabetes every 3 years from age 40 years using AUSDRISK (B). Aboriginal and Torres Strait Islander peoples should be screened from age 18 years. Those with a risk score of 12 or more should be tested by fasting plasma glucose (C). ≥80 56 Guidelines for preventive activities in general practice 8th edition Table 8.4.1 Type 2 diabetes: identifying risk Who is at risk? What should be done? How often? References Increased risk AUSDRISK (III,B) (Appendix 4) Every 3 years (III,C) 438 Fasting blood sugar (III,B) Every 3 years (III,C) 439, 440 Fasting blood sugar (III,B) Every 12 months (III,C) 439 • Age >40 years • Aboriginal and Torres Strait Islander peoples High risk • Any one of following risk factors: –– AUSDRISK score of 12 or more –– all people with a history of a previous cardiovascular event (acute myocardial infarction or stroke) –– women with a history of gestational diabetes mellitus –– women with polycystic ovary syndrome –– patients on antipsychotic drugs High risk • Those with impaired glucose tolerance test or impaired fasting glucose (not limited by age) Table 8.4.2 Tests to detect diabetes Test Technique References Fasting blood sugar Measure plasma glucose levels on a fasting sample. 439 • <5.5 mmol/L: diabetes unlikely • 5.5–6.9 mmol/L fasting: may need to perform an oral glucose tolerance test • 7.0 mmol/L or more fasting (>11.1 non-fasting): diabetes likely, repeat fasting blood sugar to confirm on a separate day. The test should be performed on venous blood and tested in a laboratory to confirm a diagnosis. Oral glucose tolerance test Before and 2 hours after a 75 gram oral glucose load is taken orally, the plasma glucose is measured. If this is greater than 11.1 mmol/L, diabetes is likely. If the 2 hour plasma glucose is between 7.8 and 11.0 mmol/L, there is impaired glucose tolerance. If it is less than 7.8 mmol/L, diabetes is unlikely. 439 Diabetes risk Diabetes risk may be calculated using AUSDRISK. This calculates a score related to the risk of developing diabetes over a 5-year period (Appendix 4). 441 HbA1c may be used to as a diagnostic test for diabetes. HbA1c of 6.5% is the diagnostic cut-off. However, this is not currently approved by the MBS as a test to diagnose diabetes in Australia. 442 (AUSDRISK) Glycated haemoglobin (HbA1c) 443 57 Guidelines for preventive activities in general practice 8th edition Table 8.4.3 Type 2 diabetes: preventive interventions Target group Intervention References Pre-diabetes (impaired glucose tolerance, impaired fasting glycaemia, gestational diabetes) and those with an elevated AUSDRISK score or with other specific risk factors with negative screening test • Increasing physical activity (e.g. 30 minutes brisk walking five times a week) and/or weight loss reduces risk of developing diabetes by 40–60% in those at high risk. 444–447 • Give advice on healthy low fat diet (<30% kcal or kilojoules from fat and <10% from saturated fat; high fibre, low glycaemic index with cereals, legumes, vegetables and fruits), weight loss and increased physical activity (see RACGP SNAP: A population health guide to behavioural risk factors in general practice). • Refer patients to a dietitian and a physical activity program. • Provide pre-conception advice to women with a history of gestational diabetes. 8.5 Stroke Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 GPs should be alert to symptoms of TIAs in those aged 45 years and older and assess early in order to prioritise those needing urgent investigation and management. Adults with AF should have their absolute cardiovascular risk assessed. Patients with AF are at additional risk of thromboembolic disease and stroke.448 Table 8.5.1 Stroke: identifying risk Who is at risk? What should be done? How often? References High absolute risk Question about symptoms of TIA. If TIA, stratify risk of stroke and consider anticoagulation* (I,A). Every 12 months (IV,C) 424, 434, 449–451 for stroke/TIA • Either calculated >15% absolute risk, clinical determined high risk or pre-existing CVD or • Previous stroke (especially with coexistent AF or high grade (70–99%) symptomatic carotid stenosis) If AF, determine cause of AF and treat according to cardiovascular and thromboembolic risk (II,B). Manage behavioural and physiological risk factors actively. Treat with antihypertensive and lipidlowering medications unless contraindicated or clinically inappropriate (II,B). • Previous TIA Auscultation for carotid bruit Auscultating for carotid bruits in asymptomatic people is not recommended in the general adult population as a screening tool for stroke risk. Screening with duplex ultrasonography in this population is not cost- effective (yields many false positive results) coupled with the fact that the overall benefit of surgery is at best small, hence very careful selection of patients is needed to justify surgery in those with severe (>60%) but asymptomatic stenosis.† However, the presence of a carotid bruit has been shown to be associated with increased risk of myocardial infarction and cardiovascular death, so may be a useful prognostic marker when assessing cardiovascular risk generally. Screen patients with known asymptomatic carotid artery stenosis for other treatable causes of stroke and treat these intensively. * Anticoagulation with warfarin should be considered in patients with documented ischaemic stroke or TIAs due to AF. † Antiplatelet therapy should be considered for non-cardioembolic stroke or TIA. 452, 453 449 454 449 58 Guidelines for preventive activities in general practice 8th edition Table 8.5.2 Tests to detect stroke risk Test Technique Question about TIA Question patient or carer regarding symptoms of sudden onset of loss of focal neurological function such as weakness or numbness of arms or legs, speech disturbance, double vision or vertigo. ABCD2 tool References All patients with suspected TIA should have stroke risk assessment including the ABCD2 tool: 434 • Age: >60 years (1 point) • BP: >140/90 mmHg (1 point) • Clinical features: unilateral weakness (2 points), speech impairment without weakness (1 point) • Duration: >60 min (2 points), 10–59 min (1 point) • Diabetes (1 point) Important additional information also required: • Presence of AF, signs that might indicate carotid disease (e.g. anterior circulation signs) who are candidates for carotid surgery or two or more TIAs within previous 7 days (crescendo TIA) For those deemed high risk (ABCD2 tool 4–7 and/or AF, potential carotid disease or crescendo TIA): urgent brain and carotid imaging (‘urgent’ is considered immediately, but certainly within 24 hours). If carotid territory symptoms, consider duplex ultrasound for patients who are potential candidates for carotid revascularisation. For those deemed high risk (ABCD2 tool 0–3 without AF, potential carotid disease or crescendo TIA): CT brain (and carotid ultrasound where indicated) as soon as possible (i.e. within 48–72 hours) For further information about secondary prevention after stroke or TIA, see www.strokefoundation.com.au See also Section 15: Screening tests of unproven benefit. 8.6 Kidney disease Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Those at high risk Patients should be screened for kidney disease if they are at high risk (B). Table 8.6.1 Kidney disease: identifying risk Who is at risk? What should be done? How often? References High risk BP, ACR and eGFR (III,A) Every 1–2 years* 419, 455–462 (IV,C) 440, 463–466 • Smoking ≥40 years • Hypertension 419, 439, 463, 465, 467 • Obesity • Family history of kidney disease • Diabetes • Aboriginal or Torres Strait Islander aged >30 years * 1 year for patients with hypertension or diabetes. If ACR positive, arrange two further samples for urine ACR over 2 months (III,B) 468 469 Guidelines for preventive activities in general practice 8th edition 59 Table 8.6.2 Tests to detect kidney disease Test Technique References Albuminuria Spot, untimed collection of urine for calculation UACR, preferably on a first morning void. 463, 465 Note: dipstick urine test is not adequate to identify microalbuminuria. Albumin:creatinine ratio (ACR) Normal Females Microalbuminuria Macroalbuminuria GFR <3.5 mg/mmol Males <2.5 mg/mmol 3.5–35 mg/mmol >35 mg/mmol 2.5–25 mg/mmol >25 mg/mmol This is currently automatically reported with every test for serum creatinine using the abbreviated modification of diet in renal disease formula (staging is based on both GFR level and UACR (normoalbuminuria, microalbuminuria or macroalbuminuria): • Stage 1 >90 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria • Stage 2 (mild) 60–89 mL/min/1.73 m2 with microalbuminuria, proteinuria or haematuria • Stage 3a (mod) 45–59 mL/min/1.73 m2 • Stage 3b (mod) 30–44 mL/min/1.73 m2 • Stage 4 (severe) 15–29 mL/min/1.73 m2 • Stage 5 (end-stage) <15 mL/min/1.73 m2 Refer patients with stage 4 or 5 to renal unit or nephrologist, and consider referral at stage 3 or earlier if: • persistent significant albuminuria (ACR ≥30 mg/mmol, approximately equivalent to protein:creatinine ratio ≥50 mg/mmol, or urinary protein excretion ≥500 mg/24 hours, • rapidly declining eGFR (average (of at least three readings) decline >5 mL/min/1.73 m2 in 6 months) • CKD and hypertension that is hard to get to target despite at least three anti-hypertensive agents • unexplained anaemia (<100 g/L) with eGFR <60mL/min/1.73m2 See www.racgp.org.au/Content/NavigationMenu/ClinicalResources/RACGPGuidelines/ ChronicKidneyDiseaseCKDManagementinGeneralPractice/CKDManagement.pdf The eGFR may be unreliable in the following situations: • acute changes in renal function • dialysis patients • certain diets (e.g. vegetarian, high protein, recent ingestion of cooked meat) • extremes of body size • muscle diseases (may overestimate) or high muscle mass (may underestimate) • children <18 years • severe liver disease. It has not been validated in all ethnic groups. 466, 468, 470 60 Guidelines for preventive activities in general practice 8th edition 9. Early detection of cancers 9.1 Skin cancer General population screening for melanoma or non-melanoma skin cancer (NMSC) is not recommended as the prerequisite (evidence to show this reduces death) is not available.471 Providing education that raises awareness of early detection of skin cancer or its prevention is recommended. Assess people opportunistically or when the patient is concerned (about skin lesions or their skin cancer risk) and plan appropriate strategies for their level of risk. People generally should be encouraged to become familiar with their skin, including skin not normally exposed to the sun, and be alert for new or changing skin lesions, particularly people aged over 40 years. 9.1.1 Melanocytic skin cancer Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Advise on sun protection and prevention Assess risk and advise Screen high risk only Skin self-examination should be encouraged for high-risk individuals every 3 months (B). All people, particularly children, should be advised to adopt protective measures when UV levels are 3 and above (C). Sunscreen may prevent melanoma in adults,472 and generally minimising sun exposure may reduce the risk of melanoma.472–477 Table 9.1.1.1 Melanocytic skin cancer: identifying risk Who is at risk? What should be done? How often? References Average risk Primary preventive advice (III,B) Opportunistically 471 Primary preventive advice and examination of skin (III,B) Opportunistically 471, 478 Preventive advice, Examination of skin (with or without photography) and advice on selfexamination (III,C) Every 3–12 months (Practice Point) 479 Light skin without past history of risk Increased risk (Risk 2–5 times normal) • Family history of melanoma in first-degree relative • Fair complexion, a tendency to burn rather than tan, the presence of freckles, light eye colour, light or red hair colour • Age over 30 years (over 50 years most at risk) • Presence of solar lentigines • Past history of NMSC (age <40 years higher risk) • People with childhood high levels of UV exposure and episodes of sunburn in childhood High risk (Risk >6 times normal) • Those with multiple atypical or dysplastic naevi and who have a history of melanoma in themselves or in a firstdegree relative ≥80 61 Guidelines for preventive activities in general practice 8th edition Table 9.1.1.2 Melanocytic skin cancer: preventive interventions Intervention Technique References Sun protection advice All people (especially children aged ≤10 years) should be advised to adopt protective measures when UV levels are 3 and above. These measures include use of shade; broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and sun protection factor (SPF) 30+ sunscreens, (which need to be reapplied every 2 hours). 471, 480 Times when the UV is forecast to reach 3 and above and sun protection is recommended are available from the Bureau of Meteorology. ‘SunSmart’ applications for smart phones or desktops provide real-time electronic alerts on recommended sun protection times, maximum UV levels, and information on recommended exposure for vitamin D. They are adjustable to specific geographic locations around Australia at www.sunsmart.com.au Skin examination Before examining the skin, it is worth asking about any new, or changes in old lesions. Characteristics of suspicious naevi include asymmetry, border irregularity, variable colour (including a surrounding coloured halo) and diameter >6 mm elevation (mnemonic ‘ABCD’). Naevi that stand out from the others (‘ugly duckling’) are also suspicious. 471, 484–486 Nodular melanomas (with a much worse prognosis) are characteristically elevated, firm, growing over the past month (mnemonic ‘EFG’). Excision biopsy or referral should be considered. Examination under surface magnification (x 10) (after appropriate training) can assist in diagnosis. Photography aids in monitoring skin lesions by detecting changes over time, and may reduce the excision rate of benign lesions.481, 482 Full body skin examination has been shown in general and dermatology practice, with and without dermatoscopy, to take on average 2–3 minutes.483 Self-examination People should be advised on the specific changes that suggest melanoma, be encouraged to become familiar with their skin, and be alert for new or changing skin lesions. High-risk individuals should be encouraged to perform self-examination, especially of naevi. Those at high risk can benefit from use of self-photography. 478, 487 Implementation GPs over-excise pigmented lesions in people who are younger (age <40 years), or female, in whom they excise relatively more benign lesions.482 GPs should be more suspicious of skin lesions in men aged over 50 years.482 9.1.2 NMSC (basal cell and squamous cell carcinoma) Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Opportunistic case finding Prevention advice High-risk individuals from age 40 years should be examined for NMSC opportunistically (B). Skin self-examination should be encouraged for high-risk individuals (B). The most common preventable cause of NMSC is UV exposure. All people, especially children, should be advised to use protective measures when UV levels are 3 or above (A). Use of sunscreen helps prevent squamous cell skin cancer (B).488 ≥80 62 Guidelines for preventive activities in general practice 8th edition Table 9.1.2.1 NMSC: identifying risk Who is at risk? What should be done? How often? References Average risk Preventive advice (III,B) Opportunistically 489 Preventive advice, education to present if changes occur in a skin lesion, and examination of skin (III,B) Opportunistically 489 Preventive advice, education to present if changes occur in a skin lesion, examination of skin, and advice on selfexamination (III,B) If initial opportunistic assessment indicates the need. Every 12 months, or when patient develops new skin lesion (Practice Point) • Those with fair to lighter than olive skin colour, under age 40 years without any risk factors Increased risk • Fair complexion, a tendency to burn rather than tan, the presence of freckles, light eye colour, light or red hair colour • Family history of skin cancer • Age over 40 years • Male sex • Presence of multiple solar keratoses • People with high levels of UV exposure such as outdoor workers High risk • Fair complexion, a tendency to burn rather than tan, the presence of freckles, light eye colour, light or red hair colour 490 • Age over 40 years • Previous NMSC (up to 60% grow another in 3 years) • Past exposure to arsenic • Immunosuppressed (e.g. post-renal or heart transplant) Table 9.1.2.2 Non-melanocytic skin cancer: preventive interventions Intervention Technique References Sun protection advice All people (particularly children) should be advised to adopt protective measures when UV levels are 3 or above, especially between the hours of 10 am and 3 pm. These measures include use of shade; broad-brimmed, bucket or legionnaire-style hats; protective clothing; sunglasses; and SPF 30+ sunscreens (which need to be reapplied every 2 hours). 491 Skin examination Skin examination should be preceded by enquiry for relevant history (e.g. of lesions of concern to patient or recent appearance or change in any lesions in the past few months or years). Examination should identify skin lumps, ulcers or scaly patches, particularly growing, scarred or inflamed lesions. Incision, shave or excision biopsy for histology (or referral) should be considered. There are many suitable means to treat NMSC; these include the use of surgery, cryotherapy, curettage and cytotoxic and immune modulating creams. Examination under magnification can assist in diagnosis. Full body skin examination has been shown to take on average 2–3 minutes in general and dermatology practice, with and without dermatoscopy. 482, 486 Self-examination People should be advised to be alert for skin lesion changes. 489 Guidelines for preventive activities in general practice 8th edition 63 9.2 Cervical cancer Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Pap test screening is recommended every 2 years for women who have ever had sex and have an intact cervix, commencing from age 18–20 years (or up to 2 years after first having sexual intercourse, whichever is later). These recommendations are under review because evidence is challenging some of the following recommendations,492 and may change in the National Cervical Screening Program renewal. Currently, in 2012, this is in a consultation process. Go to www.msac.gov.au/internet/msac/publishing.nsf/Content Australia has the lowest mortality rate and the second lowest incidence of cervical cancer in the world. The success of the cervical screening program is dependent upon the recruitment of women: 85% of women in Australia who develop cervical cancer have either not had a Pap test or been inadequately screened in the past 10 years. Women aged >50 years still represent an underscreened group. The introduction of the HPV vaccine as part of the National Immunisation Program (NIP) 2007 may reduce the future incidence of cervical cancer, but is not a substitute for a continuing screening program. Table 9.2.1 Cervical cancer: identifying risk Who is at risk? What should be done? How often? References Average risk Pap test (III–2,B) Women who have ever had sex and still have an intact cervix should undergo Pap test screening. 493 • All women who have ever been sexually active Routine screening with Pap tests should be carried out every 2 years for women who have no symptoms or history suggestive of cervical pathology (Practice Point). All women who have ever been sexually active should start having Pap tests between age 18 and 20 years, or 1–2 years after first having sexual intercourse, whichever is later. Pap tests may cease at age 70 years for women who have had two normal Pap tests within the last 5 years. Women over age 70 years who have never had a Pap test, or who request a Pap test, should be screened. Women with female sex partners are also at risk of developing cervical cancer and should be screened as above. HPV vaccination (B) For maximal effect the vaccination should be given prior to the onset of sexual activity. It has no modifying effect on already acquired HPV infections. It is available as part of the NIP for girls in year 7. 47, 494 64 Guidelines for preventive activities in general practice 8th edition Who is at risk? What should be done? How often? References Increased risk Pap test (Practice Point) It is important to ensure the patient always receives the results of her test. 495, 496 • Persistent infection with high-risk HPV types is necessary for the development of cervical cancer. Other risk factors include: –– immunosuppression –– cigarette smoking –– use of combined oral contraception >5 years. Low-grade squamous intraepithelial lesions (LSIL) • A woman with a Pap test report of possible/ definite LSIL should have a repeat Pap test in 12 months (Practice Point). If the repeat test at 12 months shows LSIL (definite or possible) the woman should be referred for colposcopy. • A woman aged 30 years or more with a Pap test report of LSIL, without a history of negative smears in the preceding 2–3 years, should be offered either colposcopy or a repeat Pap smear at 6 months (Practice Point). High-grade squamous intraepithelial lesion (HSIL) • Refer for colposcopic assessment and targeted biopsy where indicated. Glandular abnormality or adenocarcinoma • Refer for colposcopy by an experienced gynaecologist or gynaecological oncologist. • If the woman is symptomatic or if she has a clinically abnormal cervix, referral for colposcopy is recommended. Table 9.2.2 Tests to detect cervical cancer risk Test Technique References Pap test A sample of the ectocervix – using an extended tip spatula – then the endocervix, using a cytobrush, provides the best method of sampling and can be used in all age groups of women. (The cytobrush is not recommended for use during pregnancy.) The cervical broom can be used on its own in premenopausal women if it is possible to sample from both sides of the transformation zone. In postmenopausal women the transformation zone tends to be higher in the endocervical canal. The cervical cells should be placed onto a glass slide and fixed with spray within 5 seconds. If the smear is reported as technically unsatisfactory, it should not be repeated before 6 weeks. In postmenopausal women with atrophic changes, it may be necessary to use vaginal oestrogen for 14–21 days prior to the test. See also Section 15: Screening tests of unproven benefit regarding evidence related to bimanual vaginal examination. 497 HPV testing As a primary screening tool: • Current national guidelines do not support the use of HPV testing as a primary screening tool for cervical cancer. 493, 498, 499 In triage of LSIL: • The use of HPV testing in the triage of LSIL remains under investigation and is not currently recommended by the National Cervical Cancer Screening guidelines. 493, 500–502 In follow-up of HSIL: • In women treated for HSIL, cervical cytology plus HPV testing should be performed 12 months post-treatment and annually thereafter until both tests are negative on two consecutive occasions, at which point women can return to the routine cervical screening interval. Liquid-based cytology Liquid-based cytology can be used as an additional test to the conventional smear but not as a substitute. Its addition may be useful when repeating an unsatisfactory smear, or added if requested by the woman. 503, 504 Guidelines for preventive activities in general practice 8th edition 65 Implementation Strategy Methods of encouraging women to undergo cervical screening include invitations, reminders, education, message framing, counselling, risk-factor assessment, procedures and economic interventions. Evidence supports the use of invitations and, to a lesser extent, educational materials. It is likely other methods are advantageous, but the evidence is not as strong. Further research is required.505 9.3 Breast cancer Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 It is recommended that women aged 50–69 years attend the BreastScreen Australia Program every 2 years for screening mammograms (A). Women should be aware that a recommendation for clinical breast examination is not possible because there is insufficient evidence that this offers benefits to women of any age (C). However, it is recommended that all women, whether or not they undergo mammographic screening, are aware of how their breasts normally look and feel, and promptly report any new or unusual changes (such as a lump, nipple changes, nipple discharge, change in skin colour, or pain in a breast) to their GP.506 Table 9.3.1 Breast cancer: identifying risk Who is at risk? What should be done? How often? References Average or only slightly higher* risk Every 2 years from age 50–69 years‡ 507 (>95% of women) Clarify risk at www. nbocc.org.au/fraboc • No confirmed family history of breast cancer Mammogram Regular (Practice Point) • One first-degree relative diagnosed with breast cancer at age 50 years or older • One second-degree relative diagnosed with breast cancer at any age Breast awareness (I,A) • Two second-degree relatives on the same side of the family diagnosed with breast cancer at age 50 years or older • Two first- or second-degree relatives diagnosed with breast cancer, at age 50 years or older, but on different sides (i.e. on each side) of the family As a group, risk of breast cancer up to age 75 years is between 1:11 and 1:8. Moderately increased risk† (<4% of the female population) • One first-degree relative diagnosed with breast cancer before the age of 50 (without the additional features of the potentially high-risk group) • Two first-degree relatives, on the same side of the family, diagnosed with breast cancer (without the additional features of the potentially high-risk group) • Two second-degree relatives, on the same side of the family, diagnosed with breast cancer, at least one before age 50 years (without the additional features of the potentially high-risk group) As a group, the relative risk of breast cancer up to age 75 years is between 1:8 and 1:4. Clarify risk at www. nbocc.org.au/fraboc Mammogram (III,C) Breast awareness Consider referral to or consultation with a family cancer clinic for further assessment and management plan At least every 2 years from age 50–69 years‡ Annual mammograms from age 40 may be recommended if the woman has a first-degree relative <age 50 years diagnosed with breast cancer (Practice Point) 507 66 Guidelines for preventive activities in general practice 8th edition Who is at risk? What should be done? How often? References Potentially high risk§ Clarify risk at www. nbocc.org.au/fraboc Individualised surveillance program. This may include regular clinical breast examination, and annual breast imaging with mammography, MRI or ultrasound 507 (<1% of the female population) • Women who are at potentially high risk of ovarian cancer • Two first- or second-degree relatives on one side of the family diagnosed with breast or ovarian cancer plus one or more of the following features on the same side of the family: –– additional relative(s) with breast or ovarian cancer –– breast cancer diagnosed before age 40 years –– bilateral breast cancer –– breast and ovarian cancer in the same woman –– Ashkenazi Jewish ancestry –– breast cancer in a male relative. • One first- or second-degree relative diagnosed with breast cancer at age 45 years or younger plus another first- or second-degree relative on the same side of the family with sarcoma (bone/soft tissue) at age 45 years or younger • Member of a family in which the presence of a high-risk breast cancer gene mutation has been established Advise referral to a cancer specialist or family cancer clinic for risk assessment, possible genetic testing and management plan Ongoing surveillance strategies may include regular clinical breast examination, breast imaging with mammography, magnetic resonance imaging (MRI) or ultrasound and consideration of ovarian cancer risk (III,C) (Practice Point) See the National Breast and Ovarian Cancer Centre guidelines at www.nbocc.org.au/fraboc for further information. As a group, risk of breast cancer up to age 75 years is between 1:2 and 1:4. * About 1.5 times the population average. † About 1.5–3 times the population average. ‡ Population-based screening using mammography is the best early detection method available for reducing deaths from breast cancer.508 Evidence of the benefit is strongest for women aged 50–69 years. For all women there is a chance that mammography will either miss breast cancer (false negative) or detect a change not caused by breast cancer (false positive). The chance of a false negative or false positive result is higher in younger women because their breast tissue is denser, making it more difficult to detect changes. Women aged 40–49 years are eligible for free 2-yearly screening mammograms through BreastScreen Australia, although they are not targeted by the program. In deciding whether to attend for screening mammography, women in this age group should balance the potential benefits and downsides for them, considering the evidence that screening mammography is less effective for women in this age group than for older women. Generally, breasts become less dense as women get older, particularly after menopause, which is why mammograms become more effective as women get closer to age 50 years. Mammographic screening is not recommended for women aged <40 years because the reduced accuracy of mammography produces a high risk of false positive and false negative results.506 Women aged ≥70 years are eligible for free 2-yearly screening mammograms through BreastScreen Australia, although they are not targeted by the program because there is limited evidence available from randomised control trials about the benefits of screening them.509 Women in this age group should balance the potential benefits and downsides of screening, considering their general health and whether they have other diseases or conditions.506 § More than 3 times the population average. Individual risk may be higher or lower if genetic test results are known. Guidelines for preventive activities in general practice 8th edition 67 Table 9.3.2 Breast cancer: clinical breast examination and breast awareness Other tests Comment References Clinical breast examination Clinical trials in Russia and China showed that population-based screening using clinical breast examination did not reduce the number of deaths from breast cancer. New RCTs trials are underway in India and Egypt. 506 Breast awareness In Australia, despite our fully implemented mammographic screening program, most breast cancers are diagnosed after the woman develops symptoms, or by her doctor. If women are aware of the normal look and feel of their breasts, and report unusual symptoms, breast cancer might be detected earlier. 506 In the past, regular ‘breast self-examination’ (women examining their own breasts) was promoted and taught. However, this is not supported by evidence of the size or stage of tumours at diagnosis or in the number of deaths from breast cancer. Therefore, teaching women breast self-examination is no longer recommended (I,B). Implementation Strategies A systematic review of strategies for increasing the participation of women in community breast cancer screening found five favourable active strategies: letter of invitation, mailed educational material, letter of invitation plus phone call, phone call, and training activities plus direct reminders for the women.510 Physical activity during leisure time and at work is associated with a reduced risk of breast cancer,511 estimated as a 20–40% reduction in both premenopausal and postmenopausal women.512 9.4 Ovarian cancer Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Not recommended as a preventive activity Routinely screening for ovarian cancer using blood tests for cancer antigen (CA) 125, or transabdominal or transvaginal ultrasound provides no benefit. Three large trials have been started: the United Kingdom Collaborative Trial of Ovarian Cancer Screening will report in 2014; a European equivalent was commenced in 2005 and has not reported yet; and the United States Prostate Lung Colorectal and Ovarian trial reported in 2011 with no benefits from CA125 or transvaginal ultrasound screening.513 Table 9.4.1 Ovarian cancer: identifying risk Who is at risk? What should be done? How often? References Lower risk No screening 514 Higher risk No screening 515 • Family history of ovarian cancer, especially first-degree relatives and more than one relative (risk of about 3 times the population average) Consider increased frequency of screening for breast and CRC • Those who have used the oral contraception, or carried a pregnancy to term (risk of about half the population average) • Presence of the breast cancer susceptibility gene 1 (BRCA1) or breast cancer susceptibility gene 2 (BRCA2) 516 68 Guidelines for preventive activities in general practice 8th edition 9.5 Oral cancer Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Not recommended as a preventive activity There is insufficient evidence to recommend screening by visual inspection or by other screening methods.517, 518 Table 9.5.1 Oral cancer: identifying risk Who is at risk? What should be done? How often? References Average risk Education regarding prevention (Practice Point) Every 2 years (Practice Point) 519 Increased risk Opportunistic examination of the mouth and lips (Practice Point) Every 12 months (Practice Point) 519, 520 • Smokers aged >50 years, heavy drinkers, patients chewing tobacco or areca/betel nut • Patients exposed to excessive amounts of sunlight (at risk of lip cancer) Table 9.5.2 Oral cancer: preventive care Method Technique References Education All patients should be advised about the hazards of smoking or chewing tobacco, excessive alcohol consumption and sunlight exposure 519 Oral examination 1.Examination of the extra oral areas – neck, lips and facial areas – looking for lumps and swellings 521 2.Inspection of the oral cavity – buccal mucosa, gums, tongue (lateral borders and dorsum), floor of mouth and palate (looking for white or red patches, ulceration or induration) 9.6 CRC(bowel cancer) Age High risk 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 10 years prior to age of onset of affected family member Organised screening by FOBT is recommended for the asymptomatic average risk population from age 50 years every 2 years (A) until age 75 years with repeated negative findings.522, 523 Increased risk is determined by family history; this should include determining the number of relatives affected by CRC, side of family and age at diagnosis. DRE is not recommended as a screening tool (D), (but is important in evaluating patients who present with symptoms such as rectal bleeding). A GP recommendation can positively influence participation in bowel cancer screening using FOBT.524–526 Regular FOBT can reduce CRC mortality by up to 16%.527 ≥80 Guidelines for preventive activities in general practice 8th edition 69 Table 9.6.1 CRC: identifying risk Who is at risk? What should be done? How often? References Category 1: Average or slightly increased risk FOBT (I,A) Every 2 years from age 50 years (Practice Point) 491, 522, 527, 528 Category 2: Moderately increased risk Colonoscopy 522, 529, 530 (1–2% of the population) Sigmoidoscopy plus double-contrast barium enema or CT colonography (performed by an experienced operator) acceptable if colonoscopy is contraindicated Every 5 years from age 50 years, or at an age 10 years younger than the age of first diagnosis of CRC in the family, whichever comes first (Practice Point) Asymptomatic people with: • no personal history of bowel cancer, colorectal adenomas or ulcerative colitis and no confirmed family history of CRC, or • one first- or second-degree relative with CRC diagnosed at age 55 years or older Asymptomatic people with: • one first-degree relative with CRC diagnosed before age 55 years, or • two first-degree or one first- and one seconddegree relative/s on the same side of the family with CRC diagnosed at any age (without potentially high-risk features as in Category 3) Category 3: High risk (relative risk of ~4–20) (<1% of the population)* Asymptomatic people with: • three or more first- or second-degree relatives on the same side of the family diagnosed with CRC (suspected Lynch syndrome, also known as hereditary non-polyposis CRC or HNPCC) or other Lynch syndrome-related cancers† or • two or more first- or second-degree relatives on the same side of the family diagnosed with CRC, including any of the following high-risk features: Consider offering FOBT (III,B) In intervening years Refer for genetic screening of affected relatives Those at risk for: Refer to bowel cancer specialist to plan appropriate surveillance (III,B) FAP: flexible sigmoidoscopy or Colonoscopy in attenuated FAP‡ –– multiple CRC in the one person • FAP (no APC mutation defined): every 12 months from age 12–15 years to age 30–35 years and every 3 years after age 35 yearsII • Lynch syndrome: 1–2 yearly from age 25 years or 5 years earlier than the youngest affected member of the family (whichever is earliest). Aspirin 100 mg/day is effective prophylaxis –– CRC before age 50 years –– a family member who has or had Lynch syndrome-related cancer or • at least one first- or second-degree relative with CRC, with a large number of adenomas throughout the large bowel (suspected familial adenomatous polyposis: FAP) or • somebody in the family in whom the presence of a high-risk mutation in the adenomatous polyposis coli (APC) or one of the mismatch repair genes has been identified Members of proven FAP§ and Lynch syndrome families who are shown not to carry the family mutation are no longer at high risk and revert to the average-risk group and still require populationbased screening. HNPCC: In intervening years – colonoscopy Consider offering FOBT (III,B) (Practice Point) 529, 530 70 Guidelines for preventive activities in general practice 8th edition *Age of starting screening varies in high-risk groups: age 25 years for those with Lynch syndrome or 5 years earlier than the earliest age of onset in the family. † Lynch syndrome criteria can be found at www.ncbi.nlm.nih.gov/pubmed/14970275 531 ‡ Attenuated FAP is characterised by a significant risk for colon cancer but fewer colonic polyps (average of 30), more proximally located polyps, and diagnosis of colon cancer at a later age. Patients with 10–100 adenomas have an attenuated form of FAP, which can be due to APC mutation (dominantly inherited) or MUTYH bi-allelic mutations (recessive). In each case the CRC risk is high. § FAP is an autosomal disorder caused by a germline mutation in the APC gene. APC mutation, as manifested by the development of CRC, approaches 100% by the age of 50 years in untreated subjects. FAP, however, accounts for less than 1% of all CRC cases. HNPCC, also known as Lynch syndrome, is due to an inherited mutation (abnormality) in a gene that normally repairs the body’s DNA. Both disorders have an autosomal dominant mode of transmission within families and carry a very high risk for cancer. As the HNPCC gene mutation is present in every cell in the body, other organs can also develop cancer. In untreated FAP, mutation carriers have a lifetime risk for CRC close to 100%. In HNPCC, their risk for colorectal or other syndrome cancers is 70–90%.522 Aspirin at 600 mg/day reduced Lynch syndrome cancer incidence by 50–68% in the CAPP2 trial.532 Follow-up of the low-dose aspirin RCTs.533, 534 suggests low-dose aspirin (100 mg/day) also reduces cancer incidence by half. A dose–response RCT in Lynch syndrome is open for recruitment at www.CAPP3.org II Bi-annual (6-monthly) or annual sigmoidoscopy for APC gene carriers of diagnosed FAP (colonoscopy in attenuated FAP). Table 9.6.2 Test to detect CRC Test Technique References FOBT screening Two main types of FOBT are available: guaiac and faecal immunochemical tests. Immunochemical tests are preferred as they have greater sensitivity and higher uptake535 (A). Two or three serial stools should be tested, depending on the type and brand of test being used. Follow the manufacturer’s instructions. It is essential that any positive FOBT (including just one of the samples) is appropriately investigated by diagnostic tests (such people being at least 12 times more likely to have CRC than those with a negative test). With guaiac tests, even if a subject fails to follow dietary restrictions, it is dangerous to assume that a positive result is a result of dietary non-compliance. 535, 536 Implementation Strategy Measures to increase screening in these groups include organised approaches such as employing recall and reminders;536, 537 recommendations by the GP for the screening;537, 538 addressing capacity issues, including convenience;537, 538 and minimising barriers such as cost.537–539 See the RACGP green book. The National Bowel Cancer Screening Program commenced in 2006 targeting specific age groups. GPs are critical, not just in maximising participation, but managing participants with a positive FOBT.540, 541 Participation is underrepresented by Aboriginal and Torres Strait Islander peoples,198 who have lower survival rates from CRC.542, 543 71 Guidelines for preventive activities in general practice 8th edition 9.7 Testicular cancer Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Not recommended as a preventive activity There is insufficient evidence to routinely screen for testicular cancer using clinical or self-examination.544, 545 Those performing testicular self-examination are not more likely to detect early-stage tumours or have better survival than those who do not (C). Table 9.7.1 Testicular cancer: identifying risk Who is at risk? What should be done? How often? References High risk Testicular examination (Practice Point) Opportunistically (Practice Point) 544, 546, 547 • Those with a history of cryptorchidism (relative risk above average of 3.5–17), orchidopexy, testicular atrophy, or previous testicular cancer (relative risk 25–28) 9.8 Prostate cancer Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Screening for prostate cancer is not recommended unless: 1. the man specifically asks for it; and 2. he is fully counselled on the pros and cons. Routine screening for prostate cancer with DRE, PSA or transabdominal ultrasound is not recommended.548–550 DRE has poor ability to detect prostate disease.551 Yet some cancers missed by PSA testing alone are detected by DRE,551 which is why those recommending screening advocate DRE as well as PSA. The recommendation is contentious. Two large RCTs552, 553 found none or marginal benefit. However, analysis of the data from one centre contributing to one of these554 showed an increased survival from prostate cancer (but not mortality from any cause) beyond 10 years. Two recent systematic reviews concluded that screening is not effective.555, 556 Even if we were to conclude there was a survival benefit (from current or future trial data), this survival would need to be balanced against the harms of cancer overdetection and treatment. GPs need not raise this issue, but if men ask about prostate screening they need to be fully informed of the potential benefits, risks and uncertainties of prostate cancer testing.556 When a patient chooses screening, both PSA and DRE should be performed. ≥80 72 Guidelines for preventive activities in general practice 8th edition Table 9.8.1 Prostate cancer: identifying risk Who is at risk? What should be done? How often? References Average risk Respond to requests for screening by informing patients of risks and benefits of screening (I,A) On demand (Practice Point) 557–559 Respond to requests for screening by informing patients of risks and benefits of screening (Practice Point) On demand (Practice Point) 558–560 • The risk of developing prostate cancer increases with age and positive family history. However, because prostate cancer is normally slow growing, men older than age 75 years or with a life expectancy of less than 10 years are at reduced threat of dying from a diagnosis of prostate cancer. • Men with uncomplicated lower urinary tract symptoms (LUTS) do not appear to have an increased risk of prostate cancer. The most common cause of LUTS is benign prostate enlargement. Early prostate cancer often does not have symptoms. High risk • Men with one or more first-degree relatives diagnosed under age 65 years • Men with a first-degree relative with familial breast cancer (BRCA1 or BRCA2) Table 9.8.2 Screening for prostate cancer Not recommended Justification References PSA screening The most common adverse effect of radical prostatectomy is erectile dysfunction, which affects most men (it is less common in younger men, those with a lower PSA, and when nerve-sparing surgical techniques are used). 548–550, 555, 561 Other complications are common as well, including urinary incontinence (which is very common in the months after treatment, but returns to normal in 75–90% men after 2 years, depending on treatment type), and to a lesser extent, urinary irritation and bowel symptoms. General feelings of ‘vitality’ are lost in about 10% of men. 562 Both suicide and CVD increase enormously (8 and 11 times more, respectively) in the week after men are given their diagnosis of prostate cancer. 563 Even diagnostic procedures following positive screening are harmful, with Australian data showing that the risk of life-threatening sepsis needing intensive care admission is not uncommon after biopsy. Despite large trials, their meta-analysis suggests that prostate cancer screening does not save lives. 564 555, 556 Implementation Strategy Patients who request testing should be informed about the risks and benefits of tests for prostate cancer, and assisted to make their own decision.565 Written material, particularly decision aids, may be useful for this purpose: see the RACGP green book and a free book providing a balanced presentation of facts566 at http://ses.library.usyd. edu.au/bitstream/2123/6835/3/Let-sleeping-dogs-lie.pdf Responding to the patient’s concerns and fulfilling medico-legal responsibilities are considerations in discussion with patients. Guidelines for preventive activities in general practice 8th edition 73 10. Psychosocial GPs have an important role in the detection and management of mental illness, especially high-prevalence conditions such as depression and anxiety. In the most recent Australian National Survey of Mental Health and Wellbeing, the prevalence of any lifetime mental disorder was 45.5%, with a 12-month prevalence of 14.4% for anxiety disorders and 6.2% for affective disorders.567 Patients, especially women, who experience underlying family violence, may present with depression and anxiety.568 Health inequity The national health survey identified that ‘the proportion of people who reported having mental problems increased as levels of socioeconomic disadvantage increased. In 2007–08, 16% of people living in the most disadvantaged areas had a mental or behavioural problem, compared with 11% of people living in the least disadvantaged areas’.569 The likelihood of depression among low SES persons is almost double that of high SES persons (most marked for persistent depression).570 Anxiety and affective disorders are more common in unemployed people and they are less likely to seek help from their GP.571, 572 In patients with chronic disease, lower educational level and unemployment are predictive of depression.573 Differences in the way depression is understood and presented may create barriers to accessing effective depression care for patients from non-English speaking and culturally diverse backgrounds.574 Practices in disadvantaged areas have a higher prevalence of depression to identify and manage in their patients.575 Being aware of this is important in the opportunistic screening for depression. Other general strategies to increase screening in this group are outlined above and are discussed in the RACGP green book. Suicide and attempted suicide are consistently associated with markers of SES disadvantage,576–579 including low SES, limited educational achievement and homelessness,580–582 and are also more prevalent in Aboriginal and Torres Strait Islander peoples.583 Refer to the National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander people, second edition. Postpartum depression is more common in women from culturally and linguistically diverse backgrounds and they are less likely to receive help for this.584 10.1 Depression Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79+ While there is evidence that depression screening instruments have reasonable sensitivity and specificity, the evidence for improved health outcomes and cost-effectiveness of screening for depression in primary care remains unclear. There is evidence for routine screening for depression in the general adult population in the context of staff-assisted support to the GP in providing depression care, case management and coordination (e.g. via practice nurses) (B).585 There is insufficient evidence to recommend routine screening in adults or adolescents where this level of feedback and management is not available (C).585 There is insufficient evidence to recommend screening in children.586 Clinicians should maintain a high level of awareness for depressive symptoms in patients at high risk for depression. 74 Guidelines for preventive activities in general practice 8th edition Table 10.1.1 Depression: identifying risk Who is at risk? What should be done? How often? References Average risk Be alert to possible depression, but do not routinely screen unless staffassisted depression care supports are in place (C). Opportunistically 585 The benefits of screening have not been established, particularly where access to effective treatment and followup is not available. At every encounter 586, 588 • Adult population aged 18 years and older Adolescents • Aged 12–18 years, particularly with: –– parental depression –– comorbid mental health or chronic medical conditions –– experienced a major negative life event Be alert for signs of depression in this age group (B). Consider use of HEADSS assessment tool (see Section 3: Preventive activities in children and young people) Increased risk • Family history of depression • Other psychiatric disorders, including substance misuse • Chronic medical conditions • Unemployment • Low SES Recurrent screening may be more useful in people deemed to be at higher risk of depression (B) 112, 587 Opportunistically 585 Maintain a high level of clinical awareness of those at high risk of depression. • Older adults with significant life events (e.g. illness, cognitive decline, bereavement or institutional placement) • All family members who have experienced family violence • Experience of child abuse Table 10.1.2 Test to detect depression Test Technique References Question regarding mood and anhedonia Asking two simple questions may be as effective as longer instruments: 589 ‘Over the past 2 weeks, have you felt down, depressed or hopeless?’ 590 and ‘Over the past 2 weeks, have you felt little interest or pleasure in doing things?’ Asking a patient if help is needed in addition to these two screening questions improves the specificity of a GP diagnosis of depression (IV) In adolescents, consider use of HEADSS assessment tool (see Section 3: Preventive activities in children and young people). In women in the perinatal period, the Edinburgh Postnatal Depression Scale (also known as the EPDS) can be used to detect women requiring further assessment of possible major depression (B in the postnatal period) at www.blackdoginstitute.org.au/docs/ CliniciansdownloadableEdinburgh.pdf or www.beyondblue.org.au/index.aspx?link_ id=103.885 See also Section 10.3: Identification of intimate partner violence, as depression is a common reason for presentation in those experiencing violence. 591 112, 587 75 Guidelines for preventive activities in general practice 8th edition 10.2 Suicide Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Lack of evidence for routine screening with a screening instrument, but be alert for higher-risk individuals and the possibility of suicide in those at higher risk There is a lack of evidence for the routine screening of patients using a screening instrument (C). GPs should be alert for higher-risk individuals and the possibility of suicide in those patients who are at higher risk. There is evidence that detecting and treating depression has a role in suicide prevention.592, 593 For example, incidence of suicide has decreased in older men and women in association with exposure to antidepressants.594, 595 Table 10.2.1 Suicide: identifying risk Who is at risk? What should be done? How often? References Average risk No routine screening for suicide (III,C) Evaluate risk for suicide (III,C) n/a 596–598 When risk factors present and with all people aged 14–24 years 52, 592, 595, 596 • General population Increased risk Attempted suicide is a higher risk in the following. • Mental illness, especially mood disorders, alcohol and drug abuse • Previous suicide attempts or deliberate self-harm • Male • Young people and older people • Those with a recent loss or other adverse event • Patients with a family history of attempted or completed suicide • Aboriginal and Torres Strait Islander peoples • Widowed • Living alone or in prison • Chronic and terminal medical illness. Table 10.2.2 Tests to detect suicide risk Test Technique References Evaluate the risk of suicide in the presence of risk factors Assessment of risk involves enquiring into the extent of the person’s suicidal thinking and intent, including: 112 • suicidal thinking – If suicidal thinking is present, how frequent and persistent is it? • plan – If the person has a plan, how detailed and realistic is it? • lethality – What method has the person chosen, and how lethal is it? • means – Does the person have the means to carry out the method? • past history – Has the person ever planned or attempted suicide? • suicide of family member or peer – Has someone close to the person attempted or completed suicide? Consideration should also be given to: • risk and protective factors • mental state – hopelessness, despair, psychosis, agitation, shame, anger, guilt, impulsivity • substance use – current misuse of alcohol or other drugs • strengths and supports – availability, willingness and capacity of supports. Patients with suicidal ideation should be questioned regarding preparatory actions (e.g. obtaining a weapon, making a plan, putting affairs in order, giving away prized possessions, preparing a suicide note). 76 Guidelines for preventive activities in general practice 8th edition Test Technique References Screening for psychological distress with young people The HEADSS tool has questions that can assist in assessing suicide risk, for example: 587 • Sometimes when people feel really down they feel like hurting, or even killing themselves. Have you ever felt that way? • Have you ever deliberately harmed or injured yourself (cutting, burning or putting yourself in unsafe situations, e.g. unsafe sex)? • Do you feel sad or down more than usual? How long have you felt that way? • Have you lost interest in things you usually like? • On a scale of 1 to 10, with 1 being the worst you feel and 10 being really great and positive, how would you rate your mood today? 10.3 Identification of intimate partner violence Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 Consider asking all pregnant adult and adolescent women about partner violence during antenatal care.599 There is insufficient evidence for screening the general population; however, there should be a low threshold for asking about abuse, particularly when the GP suspects underlying psychosocial problems.599 Training GPs to identify violence has resulted in increased identification and referral to services.600 There is some evidence for the effectiveness of interventions in clinical practice to reduce partner violence. Table 10.3.1 Intimate partner violence: identifying risk Who is at risk? What should be done? How often? References Increased risk Ask about partner violence Opportunistically 599 • Pregnant adult and adolescent women • Women with: –– symptoms of mental ill-health –– chronic unexplained physical symptoms –– unexplained injuries –– frequent attendance • Men who: –– ask for help with anger –– have marital problems –– are ‘wife mandated’ to change their behaviour –– have alcohol or other substance abuse problems –– were abused or witnessed intimate partner violence as a child Ask about relationship and any abusive or controlling behaviours Guidelines for preventive activities in general practice 8th edition 77 Table 10.3.2 Tests to detect intimate partner violence Test Technique References Ask about partner violence Victimised women stress the importance of a trusting patient–doctor relationship, confidentiality, respectful and non-judgemental attitudes to achieving disclosure as well as acceptance of non-disclosure and a supportive response. It is crucial for safety reasons that any questions are asked privately, when the patient is alone – not when another family member, adult or child over the age of 2 years is present. It is a clinician’s responsibility to ask and support women regardless of their response. Asking about abuse may ‘plant a seed’ for later action. 601 The collaborative group believed that GPs should ask women who are ‘symptomatic’ (e.g. symptoms of mental ill-health, chronic unexplained, physical symptoms, unexplained injuries, frequent attendance) Questions and statements to make if you suspect domestic violence • Has your partner ever physically threatened or hurt you? • Is there a lot of tension in your relationship? How do you resolve arguments? • Sometimes partners react strongly in arguments and use physical force. Is this happening to you? • Are you afraid of your partner? • Violence is very common in the home. I ask a lot of my patients about abuse because nobody should have to live in fear of their partners. 599 78 Guidelines for preventive activities in general practice 8th edition 11. Oral hygiene Age <2 2–3 4–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 ≥ 65 Good oral hygiene helps to prevent dental caries and gingivitis and improves oral health. There is evidence that use of fluoride in water, or topically, reduces caries in children.602 Table 11.1 Oral hygiene: identifying risk Who is at risk? What should be done? How often? References Increased risk Examination of the mouth (IV,C) At least every 12 months 52 (More frequent dental checkups as determined by dentist) 491 • Aboriginal and Torres Strait Islander peoples • Rural and remote populations • Migrant groups (especially refugees) • Lower socioeconomic groups with difficulty accessing dental care • People with reduced saliva flow (e.g. head and neck radiation therapy, Sjögren syndrome, multiple drug therapy including psychotropic medications) Education regarding prevention (I,B) Recommendation of professional or home application of topical fluoride pastes, gels or mouth rinses (I,A) 603 Table 11.2 Oral hygiene: preventive interventions Intervention Technique References Education • Advise about the hazards of snacks and drinks that contain high levels of carbohydrate and acid, especially between meals. 52, 491, 602 • Advise against the use of baby bottles with any fluid apart from water at night. • Advise patients to brush teeth twice daily with fluoride toothpaste. A pea-sized amount of lowfluoride toothpaste should be used before age 6 years. Encourage to spit not rinse. 604, 605 • Encourage home use of high-fluoride toothpastes, gels or mouth rinses for those at high risk. • Advise the use of sugar-free chewing gum for saliva stimulation. 606 • Advise the use of mouthguards for contact sports. 607 • Recommend regular dental check-ups. Oral examination Fluoridation Additional advice can be obtained from the findings of a national consensus workshop conducted in 2011. • Inspect mouth for dental caries, stained, worn or broken teeth and inflamed or swollen gums. 608 • Xerostomia may present as dry and reddened gums and increased caries rate particularly on root surfaces. • ‘Lift the lip’ of children for early identification of oral problems (see also Section 3: Preventive activities in children and young people). • Water fluoridation is beneficial at reducing dental caries. 94, 95 602 • Approximately 76% of Australians now drink fluoridated water. Details regarding fluoride levels in Australian water supplies and recommended dosages of fluoride are provided at www.nhmrc.gov.au/_files_nhmrc/publications/attachments/eh41_1.pdf Implementation Health inequity Oral disease is more prevalent among low socioeconomic groups. Significant financial barriers to accessing dental care remain in Australia. People on low incomes are more likely to delay dental visits and less likely to receive appropriate dental care. Private dental insurance is associated with higher rates of dental care, but insurance is less common in low income groups or those in regional or remote location. People who hold healthcare cards are less likely to receive preventive dental care and more likely to receive extractions when visiting the dentist.609, 610 Guidelines for preventive activities in general practice 8th edition 79 12. Glaucoma Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 The glaucomas are a group of relatively common optic neuropathies, in which there is pathological loss of retinal ganglion cells, progressive loss of sight and associated alteration in the retinal nerve fibre layer and optic nerve head. Evidence supports screening people at higher risk for glaucoma (A). GPs have an important role in identifying those at increased risk for glaucoma and referring them for testing. There is no consensus on the recommended frequency of screening for at-risk groups.611, 612 Table 12.1 Glaucoma: identifying risk Who is at risk? What should be done? How often? References Increased risk Refer for ocular examination 5–10 years earlier than the age of onset of glaucoma in the affected relative (A). No consensus on frequency 611, 612 • Family history of glaucoma (first-degree relatives) • Caucasian and Asian patients aged ≥50 years • African descent aged ≥40 years Higher risk • Patients aged >50 years with: –– diabetes –– myopia –– long-term steroid use –– migraine and peripheral vasospasm Refer for examination of the optic nerve head (ophthalmoscopy), measurement of intraocular pressure (tonometry) and assessment of visual fields (perimetry).* 611, 612 –– abnormal BP –– history of eye trauma * This may be by ophthalmologist or optometrist. Table 12.2 Glaucoma: preventive interventions Intervention Technique References Patient education Educate patients about glaucoma and alert them to associated risk factors, with advice to attend regular full comprehensive eye examinations. 611, 612 Tonometry Schiotz tonometry has poor sensitivity and specificity for early detection of glaucoma. Tonometry alone is an inadequate screening tool, as it overestimates the prevalence of glaucoma. Perimetry (visual fields) Not advisable in general practice as only automated perimetry is sensitive for detecting loss of visual field due to glaucoma. Assessment of eye structure (ophthalmoscopy) Indirect ophthalmoscopy performed with a slit lamp is the examination of choice. 611, 612 80 Guidelines for preventive activities in general practice 8th edition 13. Urinary incontinence Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 ≥80 No evidence for screening general population There is no evidence for screening in the general population. Case finding in those at higher risk (B). Within the general population, up to 19% of children, 13% of men and 37% of women may be affected by some form of urinary incontinence.613 While urinary incontinence is most common in women and increases with age, bedwetting (enuresis) is common in children and 5.5% of children also report daytime wetting.614 In men, lower urinary tract symptoms, including urinary incontinence, is associated with surgical or radiation treatment for prostate cancer.615 Primary care professionals are in a position to take a more proactive approach to incontinence treatment by screening for urinary symptoms in at-risk groups during routine appointments. There remains considerable health decrement due to urinary incontinence in those not receiving help in a population readily accessible to primary care services.616 Table 13.1 Urinary incontinence: identifying risk Who is at risk? What should be done? How often? Average risk There is no evidence to support screening (IV) n/a Higher risk Case finding (IV,B) Every 12 months • Perinatal and postnatal women Ask about the occurrence of urinary incontinence • Younger women who have had children • Women who are overweight • Men following treatment for prostate cancer • People with respiratory conditions, diabetes, stroke, heart conditions, recent surgery or neurological disorders • Frail elderly people or long-term care residents In residential aged care facilities, residents are automatically assessed References 613 Guidelines for preventive activities in general practice 8th edition 81 Table 13.2 Urinary incontinence: preventive interventions Intervention Technique References Case finding Ask probing questions such as ‘Other people with … (state conditions of higher risk here) … have had problems with bladder control. Have you had any problems with leaking urine?’ 617 Simple patient survey assessment tools have been shown to be valid and reliable (A). 618 The three incontinence questions questionnaire (Appendix 6) is a simple, quick and noninvasive test with acceptable accuracy for classifying urge and stress incontinence and may be appropriate for use in primary care settings (A). Patients with urinary incontinence should be assessed to determine the diagnostic category as well as underlying aetiology. This can usually be determined on the basis of history, physical examination and urinary dipstick and culture if indicated. A post-void residual may be required in the assessment of possible retention/overflow. Assessment There are four common types of incontinence: • Stress incontinence is the leaking of urine, which may occur during exercise, coughing, sneezing, laughing, walking, lifting or playing sport. This is more common in women, although it also occurs in men, especially after prostate surgery. Pregnancy, childbirth and menopause are the main contributors. • Urge incontinence is a sudden and strong need to urinate. It is often associated with frequency and nocturia, and is often due to having an over-active or unstable bladder, neurological conditions, constipation, enlarged prostate or history of poor bladder habits. • Mixed incontinence is a combination of both stress and urge incontinence and is most common in older women. • Overflow incontinence is a result of bladder outflow obstruction or injury. Symptoms may be confused with stress incontinence. Because treatments differ, urge incontinence should be distinguished from stress incontinence (A). The patient’s diagnostic category can be reliably determined using the three incontinence questions questionnaire (Appendix 6). The Continence Foundation of Australia Helpline (telephone 1800 33 00 66) is available 5 days a week and is staffed by qualified continence advisers. Referral information is available regarding physiotherapy, nurse continence advisors and residual urine testing. 619 82 Guidelines for preventive activities in general practice 8th edition 14. Osteoporosis Age 0–9 10–14 15–19 20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69 70–79 Women Men Review of fracture risk factors for women aged over 45 years and men aged over 50 years is recommended (C). Those with increased risk should have bone density assessed (A). Osteoporosis is a disease characterised by low bone mass and micro-architectural deterioration of bone tissue, leading to bone fragility and increased fracture risk.620 It is diagnosed on the presence of a fragility fracture (fracture from the equivalent of a fall from standing height or less, or a fracture that under normal circumstances would not be expected in a healthy young man or woman). For epidemiological and clinical purposes, osteoporosis is defined by BMD as a T-score of ≤–2.5. However, age, lifestyle factors, family history and some medications and diseases all contribute to bone loss and increased risk of fragility fractures. Thus, the goal of prevention and treatment is to reduce a person’s overall fracture risk (not just bone density maintenance). Methods to estimate absolute fracture risk for osteoporotic fractures are available at: • www.shef.ac.uk/FRAX • garvan.org.au/promotions/bone-fracture-risk/calculator/ As bone densitometry is part of these estimates, BMD should be considered as part of the overall fracture risk assessment (D). Risk estimation is imperfect, but the calculator’s predictive performance is similar to absolute cardiovascular risk calculators.621 Risk factors (e.g. falls, glucocorticoid use, etc.) not included in one or other risk algorithm require clinical judgement to modify the risk estimate. To date, there are no RCTs directly evaluating screening effectiveness, harms and intervals, whether screening is performed by bone density screening by dual-energy X-ray absorptiometry (DXA) or by estimating absolute fracture risk. The place of absolute fracture risk assessment in the prevention and management of osteoporosis requires further clarification as its effectiveness is yet to be tested. ≥80 Guidelines for preventive activities in general practice 8th edition 83 Table 14.1 Osteoporosis: identifying risk Who is at risk? What should be done? How often? References Average risk Assessment for risk factors (II,C) Every 12 months (Practice Point) 620, 621 • Postmenopausal women (aged 45 years or older) • Men aged 50 years or older Preventive advice (II,C) Increased risk Bone mineral densitometry and management of risk factors (II,A) At presentation and no more than every 2 years. Repeat when it is likely to change management (II,C) 622, 623 • Age >60 years for men and >50 years for women plus any of: –– family history of fragility fracture –– smoking –– high alcohol intake (>2–4 standard drinks per day for men, less for women) Investigate for causes of secondary osteoporosis if indicated by history, examination findings or BMD result (Practice Point) –– vitamin D deficiency <60 nmol (screening for vitamin D not indicated just for risk assessment) –– low body weight (BMI <20) –– recurrent falls –– low levels of physical activity –– immobility (to the extent that person cannot leave their home or cannot do any housework) Where there is a specific bone mineral wasting condition or medication, consider more frequent repeat of DXA if likely to change treatment (Practice Point) • Medical conditions and medications that may cause secondary osteoporosis: –– endocrine (e.g. hypogonadism, Cushing syndrome, hyperparathyroidism, hyperthyroidism) –– inflammatory conditions (e.g. rheumatoid arthritis) –– malabsorption (e.g. coeliac) –– CKD, chronic liver disease –– drugs, especially corticosteroids (e.g. 7.5 mg x 3 months) used for immunosuppression including as part of chronic anti-rejection therapy in organ or bone marrow transplant, antiepileptic, aromatase inhibitors, anti-androgen, excessive thyroxine, possibly selective serotonin reuptake inhibitors (also known as SSRIs) High risk of further fracture • Patients aged over 45 years who sustain a low trauma fracture • Postmenopausal women, and men with a suspected vertebral fracture (loss of height >3 cm, kyphosis, back pain) BMD and management of risk factors (II,A) Investigate for causes of secondary osteoporosis if indicated by history, examination findings or BMD result (Practice Point) Recommend that such individuals are initiated on effective anti-osteoporosis therapy unless there are specific contraindications DXA at presentation and no more than every 2 years (II,B) Repeat only when it is likely to change management (Practice Point) Where there is a specific bone mineral wasting condition or medication, consider more frequent repeat of DXA (Practice Point) 620 84 Guidelines for preventive activities in general practice 8th edition Table 14.2 Osteoporosis: preventive interventions Intervention Technique Assessment of risk factors Take a thorough history, paying particular attention to the risk factors above plus: References • vertebral deformity (if within 5–10 years, this is equivalent risk as any other fragility fracture) • loss of height (>3 cm) and/or thoracic kyphosis (consider lateral spine X-ray for vertebral deformity) • premature menopause • anorexia nervosa or amenorrhea for greater than 12 months before age 45 years Preventive actions • Ensure adequate daily calcium intake: dietary calcium ((A) for prevention of bone loss, (C) for fracture) 1200 mg/day. Exercise caution with supplements.* • Encourage healthy lifestyle (e.g. smoking cessation and limiting alcohol and caffeine intake) (D). • Education and psychosocial support for risk factor modification (Practice Point) • Falls reduction strategies: for fracture risk reduction (Practice Point) • Encourage exercise: for prevention of bone loss (A) and fracture risk reduction (Practice Point). • Advise on safe sun exposure levels as a source of vitamin D (II,C).† • Discuss absolute risk of fracture (Practice Point) Bone mineral densitometry (BMD) BMD should be measured by DXA scanning performed on two sites, preferably anteroposterior spine and hip. Without bone-losing medical conditions (e.g. steroid use), it is unlikely to change significantly in less than 2 years (II,B) and DXA should generally be repeated only when patient is at risk of reaching treatment thresholds (average decrease in T-score is usually approx 0.1/year if no specific bone-losing medical conditions) (Practice Point). Rate of bone loss tends to be slower in early older age (60+) than in later old age (80+), and slower in men than women. 624 * Controversial level II evidence of increased risk of cardiovascular events with calcium supplements in postmenopausal women, not seen in dietary studies.625–627 † Population screening for vitamin D deficiency is not recommended, but targeted testing of people who are at risk of osteoporosis and who are at high risk of vitamin D deficiency should be considered. Vitamin D supplements could be considered in deficient individuals if increasing sun exposure is contraindicated or not feasible or if deficiency is more than mild (i.e. <25 nmol/L) and so is less likely to be corrected by safe sun exposure628 (Practice Point). Other tests for bone density A number of other X-ray and ultrasound tests have been shown to predict fractures, although not as well as DXA. Moreover, intervention trials have been based on cases identified through DXA assessment, so their results cannot readily be applied to individuals identified by other means.620, 621 Implementation Several Australian studies have shown an evidence–practice gap, where the majority of people with a fragility fracture tend to have their fracture treated, but not the underlying osteoporosis.629, 630 Those with a previous fragility fracture have a very high risk of further fracture, and have greatest benefit from specific anti-osteoporosis treatment. Fracture risk reductions with optimal therapy are substantial and treatment according to current guidelines is recommended unless absolutely contraindicated. Optimal treatment includes ensuring adequate calcium intake and correcting vitamin D deficiency. There are inequities in the use of BMD measurement with relative underutilisation in people from rural and remote locations and men.631 Guidelines for preventive activities in general practice 8th edition 85 15. Screening tests of unproven benefit The following are not recommended as screening tests in low-risk general practice populations. These tests may have value as diagnostic tests or as tests to monitor disease progression. Table 15.1 Screening tests not recommended in low-risk general practice populations Screening test Condition Reason not to use References for further reading Genetic profiling Genetic disorders Limited evidence on the balance of benefits and harms, ethical issues and uncertain utility 632, 633 Cardiac CT CHD No RCT evidence. RCTs of therapy show no effect on coronary artery progression. May be of benefit in those at intermediate risk of CHD 634–636 Serum homocysteine CHD Value as a risk factor for CHD is uncertain and published RCTs show no evidence of benefit by lowering levels 636–638 Exercise ECG CHD Low yield and high false positive rate given low prevalence in asymptomatic population 636, 639 High sensitivity C-reactive protein (CRP) CVD Some evidence of benefit (i.e. reduction in CRP linked with reduction in major CVD events in one study, but not currently recommended as a screening test for CVD) 636, 639–643 Ankle:brachial index (ABI) Peripheral vascular disease Longitudinal studies showing increased risk of clinical CVD if low ABI, but there is variable reliability and low sensitivity of assessment and no published RCT evidence showing benefit of screening 640, 644, 645 MRI Breast cancer Ongoing surveillance strategies for women at high risk of breast cancer may include imaging with MRI. A Medicare rebate is available for MRI scans for asymptomatic women under 50 years at high risk of breast cancer 506, 507, 646–648 CA125/transvaginal ultrasound Ovarian cancer There is no evidence to support the use of any test – including pelvic examination, CA125, or other biomarkers, ultrasound (including transvaginal ultrasound), or combination of tests – for routine population-based screening for ovarian cancer. 649, 650 Vascular Cancer CA125 is limited by poor sensitivity in early-stage disease and low specificity. The specificity of transvaginal ultrasound is low. The low prevalence of ovarian cancer means that even screening tests that have very high sensitivity and specificity have a low positive predictive value for disease detection Virtual colonoscopy/ CT colonography CRC Good sensitivity for lesions larger than 10 mm, but no evidence of reduction of CRC incidence or mortality. Not currently recommended 523, 651–655 Whole body CT or MRI Cancer Whole body imaging has not been shown to improve quality of life and/or decrease mortality. It is associated with additional radiation exposure and a high number of false positive results. There are no RCTs of whole body imaging to detect cancer or CVD 656–661 86 Guidelines for preventive activities in general practice 8th edition Screening test Condition Reason not to use References Chronic obstructive pulmonary disease (COPD) Assessment is unreliable and screening for COPD using spirometry has no net benefit. 662–665 Thyroid dysfunction Despite the relatively high incidence of subclinical hypothyroidism in older women (up to 17%), there is a lack of convincing data from controlled trials that early treatment reduces lipid levels, symptoms or the risk for CVD in patients with mild thyroid dysfunction detected by screening. 666–669 Vitamin D deficiency High prevalence, variability in assessment and lack of rigorous evidence of benefit of screening 670–674 Asymptomatic bacteriuria (elderly) Identifying and treating non-pregnant adults with asymptomatic bacteriuria does not improve outcomes and may increase antibiotic resistance 675 Lung disease Spirometry Endocrine Thyroid function tests Chronic disease prevention Vitamin D Infection MSU culture Table 15.2 Screening tests of indeterminate value Screening test Condition Reason not to use References Pregnancy Moderate prevalence and associated morbidity, but no RCT evidence of benefit. There is debate about what is an adequate level of vitamin D. High-risk groups for vitamin D deficiency may benefit from screening and supplementation. 676–679 Ultrasound Abdominal aneurysm USPSTF recommend screening, but low yield as declining incidence and ethical issues of screening only one subgroup (male smokers), and cost-effectiveness not clear 680–682 B-type natriuretic peptide (BNP) Congestive cardiac failure The evidence for screening for heart failure using BNP is mixed despite its sensitivity and prognostic significance. It may be useful in excluding the condition in suspected heart failure 683–686 Chest CT Lung cancer Good sensitivity but poor specificity; one RCT underway in smokers has preliminary results showing a 20% reduction in mortality in the CT arm. Low-dose CT screening may benefit individuals at an increased risk for lung cancer, but uncertainty exists about the potential harms of screening and the generalisability of results. Approximately 20% of individuals in each round of screening had positive results requiring some degree of follow-up, while approximately 1% had lung cancer. 687–689 Positron emission tomography – computed tomography (or PET CT scan) Lung cancer Good sensitivity and specificity, but no RCT results 688 Visual impairment No benefits of screening, even though impaired visual acuity is common and effective treatments are available 165, 690 Women Vitamin D Vascular Cancer Elderly Visual acuity Guidelines for preventive activities in general practice 8th edition References 1. Britt H, Miller GC, Charles J, Henderson J, Bayram C, Pan Y, et al. General practice activity in Australia 2009–10. General practice series no. 27. Cat. no. GEP 27. Canberra: AIHW. 2010 2. World Health Organization. Preventing chronic diseases. A vital investment. Geneva: WHO, 2005 [accessed 2012 June]. Available at www.who.int/chp/chronic_disease_report/full_report.pdf 3. Council of Australian Governments. 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World J Gastroenterol 2010;16(32):3987–94 655. Lieberman DA. Clinical practice. Screening for colorectal cancer. N Engl J Med 2009;361(12):1179–87 656. Weltermann B, Hermann M, Gesenhues S. Diagnostic screening for cancer and coronary heart disease with radiological and nuclear imaging techniques: early diagnosis at any price? Dtsch Med Wochenschr 2010;135(16):813–8 657. Canadian Health Services Research Foundation. Myth: whole-body screening is an effective way to detect hidden cancers. J Health Serv Res Policy 2010;15(2):118–9 658. Ladd SC. Whole-body MRI as a screening tool? Eur J Radiol 2009;70(3):452–62 659. Fayngersh V, Passero M. Estimating radiation risk from computed tomography scanning. Lung 2009;187(3):143–48 660. Schoder H, Gonen M. Screening for cancer with PET and PET/CT: potential and limitations. J Nucl Med 2007;48 (Suppl 1):S4–18 661. Anderiesz C, Elwood JM, McAvoy BR. Whole-body computed tomography screening: looking for trouble? Med J Aust 2004;181(6):295–6 662. O’Reilly J, Rudolf M. What’s nice about the new NICE guideline? Thorax 2011;66(2):93–6 663. COPD guidelines committee. The COPD-X Plan: Australian and New Zealand Guidelines for the management of chronic obstructive pulmonary disease. Canberra: Australian Lung Foundation and the Thoracic Society of Australia and New Zealand, 2011 664. US Preventive Services Task Force. Screening for chronic obstructive pulmonary disease using spirometry: recommendation statement. Am Fam Physician 2009;80(8):853 665. O’Donnell DE, Hernandez P, Kaplan A. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease – 2008 update – highlights for primary care. Can Respir J 2008;15(Suppl A):A1–8 666. Gopinath B, Wang JJ, Kifley A. Five-year incidence and progression of thyroid dysfunction in an older population. Intern Med J 2010;40(9):642–9 114 Guidelines for preventive activities in general practice 8th edition 667. Ochs N, Auer R, Bauer DC. Meta-analysis: subclinical thyroid dysfunction and the risk for coronary heart disease and mortality. Ann Intern Med 2008;148(11):832–45 668. Empson M, Flood V, Ma G. Prevalence of thyroid disease in an older Australian population. Intern Med J 2007;37(7):448–55 669. Helfand M. Screening for subclinical thyroid dysfunction in nonpregnant adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2004;140(2):128–41 670. Bjelakovic G, Gluud LL, Nikolova D, Whitfield K, Wetterslev J, Simonetti RG, et al. Vitamin D supplementation for prevention of mortality in adults. Cochrane Database Syst Rev 2011;7:CD007470 671. Chung M, Balk EM, Ip S, Lee J, Terasawa T, Raman G, et al. Systematic review to support the development of nutrient reference intake values: challenges and solutions. Am J Clin Nutr 2010;92(2):273–6 672. Hanley DA, Cranney A, Jones G, Whiting SJ, Leslie WD. Vitamin D in adult health and disease: a review and guideline statement from Osteoporosis Canada (summary). CMAJ 2010;182(12):1315–9 673. Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2011;96(7):1911–30 674. Wang L, Manson JE, Song Y, Sesso HD. Systematic review: Vitamin D and calcium supplementation in prevention of cardiovascular events. Ann Intern Med 2010;152(5):315–23 675. Lin K, Fajardo K. Screening for asymptomatic bacteriuria in adults: evidence for the U.S. Preventive Services Task Force reaffirmation recommendation statement. Ann Intern Med 2008;149(1):W20–4 676. Ebeling PR. Routine screening for vitamin D deficiency in early pregnancy: past its due date? Med J Aust 2011;194(7):332–3 677. Dror DK, Allen LH. Vitamin D inadequacy in pregnancy: biology, outcomes, and interventions. Nutr Rev 2010;68(8):465–77 678. Lichtenstein AH. Nutrient supplements and cardiovascular disease: a heartbreaking story. J Lipid Res 2009;50 (Suppl):S429–33 679. Holmes VA, Barnes MS. Vitamin D deficiency and insufficiency in pregnant women: a longitudinal study. Br J Nutr 2009;102(6):876–81 680. Aggarwal S, Qamar A, Sharma V, Sharma A. Abdominal aortic aneurysm: a comprehensive review. Exp Clin Cardiol 2011;16(1):11–15 681. Ferket BS, Grootenboer N, Colkesen EB, Visser JJ, van Sambeek MR, Spronk S, et al. Systematic review of guidelines on abdominal aortic aneurysm screening. J Vasc Surg 2012;55(5)1296–304 682. US Preventive Services Task Force. Screening for abdominal aortic aneurysm: recommendation statement. Ann Intern Med 2005;142(3):198–202 683. Felker GM, Hasselblad V, Hernandez AF, O’Connor CM. Biomarker-guided therapy in chronic heart failure: a metaanalysis of randomized controlled trials. Am Heart J 2009;158(3):422–30 684. Krum H, Jelinek MV, Stewart S, Sindone A, Atherton JJ. 2011 update to National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand Guidelines for the prevention, detection and management of chronic heart failure in Australia, 2006. Med J Aust 2011;194(8):405–9 685. National Institute for Clinical Excellence. Chronic heart failure. National clinical guideline for diagnosis and management in primary and secondary care. London: NICE, 2010 686. Porapakkham P, Zimmet H, Billah B, Krum H. B-type natriuretic peptide-guided heart failure therapy: a meta-analysis. Arch Intern Med 2010;170(6):507–14 687. Mulshine JL, van Klaveren RJ. Lung cancer screening: what is the benefit and what do we do about it? Lung Cancer 2011;71(3):247–8 688. Baldwin DR. Imaging in lung cancer: recent advances in PET-CT and screening. Thorax 2011;66(4):275–7 689. Bach PB, Mirkin JN, Oliver TK, Azzoli CG, Berry DA, Brawley OW, et al. 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Ann Intern Med 2009;151(1):44–58 Guidelines for preventive activities in general practice 8th edition 115 Appendix 1: Dutch Lipid Clinic Network Criteria for making a diagnosis of Familial Hypercholesteroloemia (FH) in adults Score Family history First-degree relative with known premature coronary and/or vascular disease (men <55 years, women <60 years) 1 or First-degree relative with known LDL-cholesterol above the 95th percentile for age and sex First-degree relative with tendinous xanthomata and/or arcus cornealis 2 or Children aged less than 18 years with LDL-cholesterol above the 95th percentile for age and sex Clinical history Patient with premature coronary artery disease (ages as above) 2 Patient with premature cerebral or peripheral vascular disease (as above) 1 Physical examination Tendinous xanthomata 6 Arcus cornealis prior to age 45 years 4 LDL-cholesterol (mmol/L) LDL-C ≥8.5 8 LDL-C 6.5–8.4 5 LDL-C 5.0–6.4 3 LDL-C 4.0–4.9 1 DNA analysis: functional mutation in the LDLR, APOB or PCSK9 gene 8 STRATIFICATION Total score Definite FH ≥8 Probable FH 6–7 Possible FH 3–5 Unlikely FH <3 116 Guidelines for preventive activities in general practice 8th edition Modified UK Simon Broome criteria 1.DNA mutation 2.Tendon xanthomas in patient or first/second-degree relative 3.Family history MI <50 in second-degree or <60 in first-degree relative 4.Family history of cholesterol >7.5 in first- or second-degree relative 5.Cholesterol >7.5 (adult) or >6.7 (age <16 years) 6.LDL-C >4.9 (adult) or >4.0 (age <16 years) Definite: (5 or 6) + 1 Probable: (5 or 6) + 2 Possible familial hypercholesteroloemia: (5 or 6) + (3 or 4) Adapted from Watts GF, Sullivan DR, Poplawski N, van Bockxmeer F, Hamilton-Craig I, et al. Familial Hypercholesterolaemia Australasia Network Consensus Group (Australian Atherosclerosis Society). Familial hypercholesterolaemia: a model of care for Australasia. Atheroscler Suppl 2011;12(2):221–63 Guidelines for preventive activities in general practice 8th edition Appendix 2: ‘Red flag’ early intervention referral guide Reproduced with permission from Queensland Health. No further reproduction is allowed. http://www.health.qld.gov.au/rch/professionals/brochures/red_flag.pdf 117 118 Guidelines for preventive activities in general practice 8th edition Appendix 3: Audit-C (available for use in the public domain) AUDIT-C – Overview The AUDIT-C is a three-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence). The AUDIT-C is a modified version of the 10-question AUDIT instrument. Clinical utility The AUDIT-C is a brief alcohol screen that reliably identifies patients who are hazardous drinkers or have active alcohol use disorders. Scoring The AUDIT-C is scored on a scale of 0–12. Each AUDIT-C question has five answer choices. Points allocated are: a = 0 points, b = 1 point, c = 2 points, d = 3 points, e = 4 points • I n men a score of 4 or more is considered positive, optimal for identifying hazardous drinking or active alcohol use disorders. • In women a score of 3 or more is considered positive (same as above). owever, when the points are all from Questions 1 alone (questions 2 and 3 are zero), it can be assumed that the patient is H drinking below recommended limits and it is suggested that the provider review the patient’s alcohol intake over the past few months to confirm accuracy.1 Generally, the higher the score, the more likely it is that the patient’s drinking is affecting their safety. Psychometric properties For identifying patients with heavy/hazardous drinking and/or active DSM alcohol abuse or dependence. Men2 Women3 ≥3 Sens: 0.95/Spec. 0.60 Sens: 0.66/Spec. 0.94 ≥4 Sens: 0.86/Spec. 0.72 Sens: 0.48/Spec. 0.99 For identifying patients with active alcohol abuse or dependence: Men2 Women3 ≥3 Sens: 0.90/Spec. 0.45 Sens: 0.80/Spec. 0.87 ≥4 Sens: 0.79/Spec. 0.56 Sens: 0.67/Spec. 0.94 1. Bradley KA, Bush KR, Epler AJ, et al. Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): Validation in a female veterans affairs patient population. Arch Internal Med April 2003;163:821–829 2. Frequently asked questions guide to using AUDIT-C can be found via the website: www.oqp.med.va.gov/general/uploads/FAQ%20AUDIT-C 3. Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Arch Internal Med 1998(3):1789–95 www.thenationalcouncil.org/galleries/business-practice%20files/tool_auditc.pdf Guidelines for preventive activities in general practice 8th edition Audit-C Questionnaire Patient name ____________________________________________________ Date of visit ______________ 1. How often do you have a drink containing alcohol? ❍ a.Never ❍ b. Monthly or less ❍ c. 2–4 times a month ❍ d. 2–3 times a week ❍ e. 4 or more times a week 2. How many standard drinks containing alcohol do you have on a typical day? ❍ a. 1 or 2 ❍ b. 3 or 4 ❍ c. 4 or 6 ❍ d. 7 to 9 ❍ e. 10 or more 3. How often do you have six or more drinks on one occasion? ❍ a.Never ❍ b. Less than monthly ❍ c.Monthly ❍ d.Weekly ❍ e. Daily or almost daily 119 120 Guidelines for preventive activities in general practice 8th edition Appendix 4:The Australian Type 2 Diabetes Risk Assessment tool – AUSDRISK The Australian Type 2 Diabetes Risk Assessment Tool was originally developed by the International Diabetes Institute on behalf of the Commonwealth, State and Territory governments as part of the COAG reducing the risk of type 2 diabetes initiative. The Australian Type 2 Diabetes Risk Assessment Tool (AUSDRISK) 1. Your age group? 8. How often do you eat vegetables or fruit? Under 35 years 0 points Every day 0 points 35–44 years 2 points Not every day 1 point 45–54 years 4 points 55–64 years 6 points 65 years or over 8 points 9.On average, would you say you do at least 2.5 hours of physical activity per week (for example, 30 minutes a day on 5 or more days a week)? 2. Your gender? Female 0 points Male 3 points 3. Your ethnicity/country of birth: 3a. Are you of Aboriginal, Torres Strait Islander, Pacific Islander or Maori descent? Yes 0 points No 2 points 10.Your waist measurement taken below the ribs (usually at the level of the navel)? For those of Asian or Aboriginal or Torres Strait Islander descent: No 0 points Yes 2 points 3b. Where were you born? Asia (including the Indian 2 points sub-continent), Middle East, North Africa, Southern Europe Other 0 points 4.Have either of your parents, or any of your brothers or sisters been diagnosed with diabetes (type 1 or type 2)? No 0 points Yes 3 points 5.Have you ever been found to have high blood glucose (sugar) (for example, in a health examination, during an illness, during pregnancy)? No 0 points Yes 6 points 6.Are you currently taking medication for high blood pressure? Men Women Less than 90 cm Less than 80 cm 0 points 90–100 cm 80–90 cm 4 points More than 100 cm More than 90 cm 7 points For all others: Men Women Less than 102 cm Less than 88 cm 0 points 102–110 cm 88–100 cm 4 points More than 110 cm More than 100 cm 7 points Add up your score Your risk of developing type 2 diabetes within 5 years:* Less than 5: Low risk Approximately one person in every 100 will develop diabetes. 6–14: Intermediate risk For scores of 6–8, approximately one person in every 50 will develop diabetes. No 0 points For scores of 9–14, approximately one person in every 20 will develop diabetes. Yes 2 points 15 or more: High risk 7.Do you currently smoke cigarettes or any other tobacco products on a daily basis? For scores of 15–19, approximately one person in every seven will develop diabetes. No 0 points Yes 2 points For scores of 20 and above, approximately one person in every three will develop diabetes. If you scored 15 or more points, it is important that you discuss your score with your doctor. The Australian Type 2 Diabetes Risk Assessment Tool was originally developed by the International Diabetes Institute on behalf of the Australian, State and Territory Governments as part of the COAG reducing the risk of type 2 diabetes initiative *T he overall score may overestimate the risk of diabetes in those aged less than 25 years and underestimate the risk of diabetes in people of Aboriginal and Torres Strait Islander descent. Reproduced with permission from the Commonwealth Government. No further reproduction is permitted. www.diabetesaustralia.com.au/PageFiles/937/AUSDRISK%20Web%2014%20July%2010.pdf Reproduced with permission. No further reproduction is permitted. Many Australians, particularly those over 40, are at risk of developing type 2 diabetes through lifestyle factors such as physical activity and nutrition. Family history and genetics also play a role in type 2 diabetes. Risk factors People with diabetes have a higher risk of developing heart disease, stroke, high blood pressure, circulation problems, nerve damage and damage to the kidneys and eyes. Type 2 diabetes is a chronic (long-term) disease marked by high levels of sugar in the blood. It occurs when the body does not produce enough insulin (a hormone released by the pancreas) or respond well enough to insulin. Type 2 diabetes is the most common form of diabetes. There are approximately 1 million people with type 2 diabetes currently. This figure is expected to increase significantly in the coming years. What is type 2 diabetes? Discuss your score and your individual risk with your doctor. Improving your lifestyle may help reduce your risk of developing type 2 diabetes. If you scored 6–14 points in the AUSDRISK you may still be at increased risk of type 2 diabetes. You can have type 2 diabetes and not know it because there may be no obvious symptoms. By increasing your physical activity and improving your eating habits you can lower your risk. Eat plenty of vegetables and high fibre cereal products every day and use a small amount of fats and oils. Monounsaturated oils, such as olive or canola oil, are the best choice. If there is type 2 diabetes in your family, you should be careful not to put on weight. Reducing your waist measurement reduces your risk of type 2 diabetes. You cannot change risk factors like age and your genetic background. You can do something about being overweight, your waist measurement, how active you are, eating habits, or smoking. Your lifestyle choices can prevent, or at least,delay, the onset of type 2 diabetes. What can you do to lower your risk of developing type 2 diabetes? How do you score? The AUSDRISK Australian Type 2 Diabetes Risk Assessment Tool See your doctor about having a fasting blood glucose test. Act now to prevent type 2 diabetes. You may be eligible for enrolment in a lifestyle modification program, so discuss this with your doctor. If you scored 15 points or more in the AUSDRISK you may have undiagnosed type 2 diabetes or be at high risk of developing the disease in the next 5 years. Guidelines for preventive activities in general practice 8th edition 121 122 Guidelines for preventive activities in general practice 8th edition Appendix 5: Australian cardiovascular risk charts Figure 1. Australian cardiovascular risk charts People without diabetes Men Non-smoker Women Smoker Non-smoker 179 * Age 65–74 160 Systolic blood pressure (mm Hg) 140 120 179 * 179 * 160 160 140 140 120 179 * 179 * Age 55–64 160 140 160 140 120 120 179 * 179 * Age 45–54 160 140 160 140 120 120 179 * 179 * Age 35–44 160 140 160 140 120 120 4 5 6 7 8 4 5 6 7 8 4 Total cholesterol:HDL ratio* 5 6 7 8 4 5 6 7 Systolic blood pressure (mm Hg) Smoker Systolic blood pressure (mm Hg) Women Non-smoker People 8 Smoker 120 179 * 160 140 120 179 * 160 140 120 179 * Charts in this age bracket are for use in Aboriginal and Torres Strait Islander populations only. 160 140 120 4 Total cholesterol:HDL ratio* 5 6 7 8 4 5 6 7 8 Total cholesterol:HDL ratio* * In accordance with Australian guidelines, patients with systolic blood pressure ≥ 180 mm Hg, or a total cholesterol of > 7.5 mmol/L, should be considered at increased absolute risk of CVD. * In accordance with Australian guidelines, pa or a total cholesterol of > 7.5 mmol/L, shou Risk level for 5-year cardiovascular (CVD) risk Risk level for 5-year cardiovascular (CVD High risk High risk ≥ 30% Moderate risk 10–15% 25–29% Low risk 5–9% ≥ 30% < 5% 25–29% 20–24% 20–24% 16–19% 16–19% How to use the risk charts 1. Identify the table relating to the person’s diabetes status, sex, smoking history and age. ‘Smoker’ is defined as either current daily cigarette smoker or former smoker who has quit within the previous 12 months. The charts should be used for all adults aged 45–74 years (and all Aboriginal and Torres Strait Islander adults aged 35 years and older) without known history of CVD or already known to be at high risk. 2. Within the chart, choose the cell nearest to the person’s age, systolic blood pressure (SBP) and total cholesterol (TC):HDL ratio. For example, the lower left cell contains all non-smokers without diabetes who are 35–44 years and have a TC:HDL ratio of less than 4.5 and a SBP of less than 130 mm Hg. 3. The colour of the cell that the person falls into provides their 5-year absolute cardiovascular risk level (see legend above for risk category). For people who fall exactly on a threshold between cells, use the cell corresponding to higher risk. The risk calculator may underestimate cardiovascular risk in these groups: • Aboriginal and Torres Strait Islander adults • adults with diabetes aged 60 years or less • adults who are overweight or obese • socioeconomically deprived groups. • SBP (mean of two readings on two occasions). • Total cholesterol/high-density lipoprotein cholesterol (HDL-C) ratio (ensure correct ratio is used). Heart Foundation Guide to management of hypertension 2008 Reproduced with permission from the Heart Foundation. No further reproduction is permitted. www.heartfoundation.org.au/SiteCollectionDocuments/aust-cardiovascular-risk-charts.pdf 15 Moderate risk 10–15 % Guidelines for preventive activities in general practice 8th edition Figure 1. Australian cardiovascular risk charts (continued) People with diabetes Women Non-smoker Men Smoker Non-smoker Smoker 179 * 179 * Age 65–74 Systolic blood pressure (mm Hg) 140 160 140 120 120 179 * 179 * Age 55–64 160 140 160 140 120 120 179 * 179 * Age 45–54 160 140 160 140 120 120 179 * in this age are for use in al and Torres Islander tions only. Systolic blood pressure (mm Hg) 160 179 * Age 35–44 160 140 160 140 120 120 4 5 6 7 8 4 5 6 7 8 4 Total cholesterol:HDL ratio* 5 6 7 8 4 5 6 7 8 Total cholesterol:HDL ratio* * In accordance with Australian guidelines, patients with systolic blood pressure ≥ 180 mm Hg, or a total cholesterol of > 7.5 mmol/L, should be considered at increased absolute risk of CVD. Risk level for 5-year cardiovascular (CVD) risk High risk ≥ 30% 25–29% Moderate risk 10–15 % Low risk 5–9% < 5% 20–24% 16–19% Notes: The risk charts include values for SBP alone, as this is the most informative of conventionally measured blood pressure parameters for cardiovascular risk. CVD refers collectively to coronary heart disease (CHD), stroke and other vascular disease including peripheral arterial disease and renovascular disease. Charts are based on the NVDPA’s Guidelines for the assessment of absolute cardiovascular disease risk and adapted with permission from New Zealand Guidelines Group. New Zealand Cardiovascular Guidelines Handbook: A Summary Resource for Primary Care Practitioners. Second edition. Wellington, NZ: 2009. www.nzgg.org.nz. 16 Heart Foundation Guide to management of hypertension 2008 Reproduced with permission from the Heart Foundation. No further reproduction is permitted. Adults over the age of 60 with diabetes are equivalent to high risk (> 15%), regardless of their calculated risk level. Nevertheless, reductions in risk factors in this age group can still lower overall absolute risk. Charts in this age bracket are for use in Aboriginal and Torres Strait Islander populations only. 123 124 Guidelines for preventive activities in general practice 8th edition Appendix 6: The three incontinence questions 1. During the last 3 months, have you leaked urine (even a small amount)? Yes No >> questionnaire completed 2.During the last 3 months, did you leak urine (check all that apply): a. When you were performing some physical activity, such as coughing, sneezing, lifting or exercise? b.When you had the urge or the feeling that you needed to empty your bladder, but you could not get to the toilet fast enough? c Without physical activity and without a sense of urgency? 3.During the last 3 months, did you leak urine most often: (check only one) a. When you are performing some physical activities such as coughing, sneezing and lifting or exercise? b.When you had the urge or the feeling that you needed to empty your bladder but you could not get to the toilet fast enough? c. Without physical activity and without a sense of urgency? d. About equally as often with physical activities as with a sense of urgency? Response to question 3 Type of incontinence a. Most often with physical activity Stress only or stress predominant b. Most often with the urge to empty the bladder Urge only or urge predominant c. Without physical activity or sense of urgency Other cause only or other cause predominant d. About equally with physical activity and sense of urgency Mixed Reference: Brown J, Bradley C, Subak L, Richter H, Kraus S, Brubaker L. The sensitivity and specificity of a simple test to distinguish between urge and stress incontinence. Ann Intern Med 2006;144:715–23. Guidelines for preventive activities in general practice 8th edition Glossary Screening Screening: detection of unrecognised disease or condition in the general population by using reliable tests, examinations or other procedures that can be applied rapidly Opportunistic screening: detection of, or case finding of specific diseases that can be controlled better when detected early in their natural history, particularly in individuals or groups who may be predisposed to that disease, for example, those with particular risk factors High risk individuals: those individuals who have risk factors that are likely to predispose them to impending disease High index of suspicion: level of awareness of clusters of risk factors such as lifestyle, socioeconomic, personal medical history and family medical history, which may predispose individuals to disease. Evidence Good evidence: there is good quality evidence obtained from randomised clinical trials to support or reject a recommendation Fair evidence: evidence obtained from studies such as well designed pseudo-RCTs (alternate allocation or some other method), comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies, or interrupted time series with a control group or comparative studies with historical control, two or more single arm studies, or interrupted time series without a parallel control group Poor evidence: evidence obtained from case series, either post- or pre-test and post-test, or opinions of respected authorities based on clinical experience, descriptive studies or reports of expert committees No evidence: exhaustive searches have revealed there are no studies that address recommendations in general practice for the target disease or condition. Prevention Primary prevention: prevention of diseases or disorders in the general population by encouraging community-wide measures such as good nutritional status, physical fitness, immunisation and making the environment safe. Primary prevention maintains good health and reduces the likelihood of disease occurring Secondary prevention: detection of the early stages of disease before symptoms occur, and the prompt and effective intervention to prevent disease progression Tertiary prevention: prevention or minimisation of complications or disability associated with established disease. Preventive measures are part of the treatment or management of the target disease or condition. 125 Healthy Profession. Healthy Australia.
