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Screening for COPD IN PHC WORKSHOP Vasiliki Garmiri Athanasios Symeonidis TOBACCO USE STATISTICS Tobacco use is a major cause of lung cancer, CVD, and COPD. – PowerPoint PPT presentation

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Title: Prezentacja programu PowerPoint


1

Screening for COPD IN PHC WORKSHOP Vasiliki
Garmiri Athanasios Symeonidis
2
THE WHO DEFINITION OF HEALTH
  • Health is a state of complete physical, mental
    and social well-being and not merely the absence
    of disease or infirmity.

3
What is screening?
  • Screening is the presumptive identification of
    unrecognized diseases or defects by the
    application of tests, examinations or other
    procedures which can be applied rapidly.
  • Screening tests sort out apparently well persons
    who probably have a disease from those who
    probably do not.

The CCI Conference on Preventive Aspects of
Chronic Disease, 1951
4
  • A screening test is not intended to be
    diagnostic.
  • Persons with positive or suspicious findings must
    be referred to their physicians for diagnosis and
    necessary treatment.

The CCI Conference on Preventive Aspects of
Chronic Disease, 1951
5
Why SCREENING?
  • Because a plethora of medical conditions have no
    apparent symptoms.
  • Because it is important to know the incidence,
    prevalence and natural course of disease.

6
Principles of early disease detection
prerequisites
  • An important health problem
  • A recognizable early symptomatic/latent stage
  • Available facilities for diagnosis
  • Accepted treatment for persons with the condition
    AND an agreed policy on whom to treat as patients
    ()
  • Suitable screening test/examination (valid,
    reliable, easy, quick, with an acceptable yield)

7
Principles of early disease detection
prerequisites
  1. An acceptable test
  2. The economically balanced cost of screening and
    case finding
  3. A clear understanding of the natural history of
    the condition
  4. Casefinding should be a continuing process

8
What are the aims of Screening?
  • CASE FINDING (and treatment)
  • SURVEYS (POPULATION/ EPIDEMIOLOGICAL)
    (prevalence, incidence, the natural history of
    the disease)
  • EARLY DISEASE DETECTION (secondary prevention)

9
Screening Methodology
  • Physical examination by a medical practitioner
  • Lab tests
  • Medical history
  • Questionnaires

10
The primary health care approach
  • Equity
  • Universal coverage with basic services
  • Multisectoral approach
  • Community involvement
  • Health promotion

11
Why PRIMARY CARE?
  • Access to the majority of the population
  • Regarded as a credible source of lifestyle
    advice, it improves population levels of
    lifestyle risk factors
  • Health promotion disease prevention is a key
    component of the role of GPs
  • The unique doctor-patient relationship

12
Why PRIMARY HEALTH CARE?
  • The point of first contact it provides
    continuing care and a holistic approach.
  • GPs can guide their patients according to their
    findings.
  • GPs are familiar with the lifestyle modification
    approach.

13
Why PRIMARY HEALTH CARE?
  • It is oriented towards the needs of the patient
    AND the community.
  • The Primary Health Care doctor engages in
    organized activities outside the office
    (alone/PHC team).

14
THE OTTAWA CHARTER FOR HEALTH PROMOTION,
WHO,1986. THE ROLE OF GPs IN HEALTH PROMOTION
  • Advocating for health
  • Enabling people to achieve their fullest health
    potential
  • Mediating with government and nongovernment
    agencies, industry and the media

15
THE OTTAWA CHARTER FOR HEALTH PROMOTION, WHO,
1986. FIVE PRINCIPLES/STRATEGIES
  1. Build healthy public policy
  2. Create supportive environments
  3. Strengthen community actions
  4. Develop personal skills
  5. Reorient health services

16
SCREENING FOR COPD IN PRIMARY HEALTH CARE
17
COPD Statistics
  • It is difficult to assess the burden of COPD (the
    large gap between the prevalence described as
    airflow limitation and clinically significant
    disease).
  • The most appropriate criteria for different
    settings are still a matter of discussion.
  • Still, morbidity and mortality are significant.
  • GOLD REPORT,2009

18
Estimates of prevalence
  • A doctors self-report concerning COPD diagnosis
  • Spirometry with/without a bronchodilator
  • Questionnaires about respiratory symptoms

19
Why COPD?
  • Screening for COPD is quick, easy, not
    interventional and it can be done in PHC.
  • Early diagnosis and treatment can change the
    natural course of disease.
  • Smoking cessation intervention is an important
    preventive and health promotion measure in PHC.

20
COPD screening
  • Community-based spirometric screening still of
    unclear benefit (the GOLD report, 2009)
  • High-risk group Males gt 40, smokers and
    ex-smokers

21
CAN I DISCRIMINATE THROUGH SYMPTOMS?
  • In a multivariate analysis, age, BMI, smoking
    status and pack-years, symptoms (cough, phlegm,
    dyspnoea, wheeze) and prior diagnosis consistent
    with asthma or COPD all showed a significant
    ability to discriminate between persons with and
    without obstruction in the general population.
  • van Schayck CP, Halbert RJ, Nordyke RJ et al.
    Comparison of existing symptom-based
    questionnaires for identifying COPD in the
    general practice setting. Respirology 2005 10
    323-333

22
What do I need to access in PHC?
  • Tobacco use
  • Pulmonary function
  • Patient questionnaires
  • Number of exacerbations
  • Exercise (?)

23
Who should be screened with spirometry?
  • Smokers gt 35()
  • Patients with symptoms suggestive of COPD
  • Patients testing positive on a risk evaluation
    questionnaire (COPD/IPCRG COPD)
  • Patients 30 at high-risk (e.g. a family
    history of COPD, occupational or environmental
    risk, a smoker since childhood)

Spirometry in primary care case-identification,
diagnosis and management of COPD. David Price,
Alan Crockett, Mats Arne, Bernard Garbe, Rupert
Jones, Alan Kaplan, Arnulf Langhammer, Siân
Williams, Barbara Yawn.
24
Who should be referred for diagnostic spirometry?
  • FEV1 lt 80 predicted
  • or
  • FEV1/FVC lt 0.8 (80)
  • or
  • FEV1/FEV6 lt 0.8 (80)

Spirometry in primary care case-identification,
diagnosis and management of COPD. David Price,
Alan Crockett, Mats Arne, Bernard Garbe, Rupert
Jones, Alan Kaplan, Arnulf Langhammer, Siân
Williams, Barbara Yawn.
25
COPD Risk factors
  • Genes
  • Exposure to particles
  • Tobacco smoke
  • Occupational dusts, organic and inorganic
  • Indoor air pollution from heating and cooking
    with biomass in poorly vented dwellings
  • Outdoor air pollution

26
COPD Risk factors
  • Lung growth and development
  • Oxidative stress
  • Gender
  • Age
  • Respiratory infections
  • A previous case of tuberculosis
  • Socioeconomic status
  • Nutrition
  • Comorbidities (Asthma)

27
REMEMBER!
  • Everyone should be asked about present or past
    tobacco use.
  • Health promotion should be directed toward
    everyone.

28
PART III
  • TIME TO WORK IN GROUPS OF THREE!

29
CASE
  • Patient, 50 years old, thin
  • Wants a lab. check-up as a result of pressure
    from his/her spouse, otherwise he/she wouldnt
    bother, theres nothing wrong with me
  • Occasionally measures bp always around 120/80
    mmHg

30
CASE
  • Paying attention to international guidelines, you
    ask about tobacco use.
  • The patient is a smoker.

31
DOCTORS
  • You have five minutes to talk to the patient and
    make a smoking cessation intervention.

32
PATIENTS
  • After you have heard your doctor you have three
    minutes to tell him
  • How you felt
  • Whatever you would like to point out
  • (e.g. What you would like to hear, how you would
    have preferred to be approached, how you might be
    motivated, etc.)

33
OBSERVERS TO THE GROUP
  • Each observer will have one min. to focus briefly
    (a few words) on the following
  • What was particularly good about the
    consultation.
  • The main aspect that would need improvement or
    was not mentioned.
  • The most interesting thing the patient said.

34
TOBACCO USE STATISTICS
  • Tobacco use is a major cause of lung cancer, CVD,
    and COPD.
  • Tobacco use causes 1 200 000 deaths each year in
    WHO's European region (14 of all deaths).
  • Unless more is done to help the 200 million
    European adult smokers stop smoking, the result
    will grow to 2 million European deaths from
    smoking a year by 2020.
  • http//tobaccocontrol.bmj.com/content/11/1/44.full

35
The European Commission published a survey on the
smoking of 26 500 Europeans which took place in
28 countries (EU 27 and Norway) in December 2008.
2008 EUROBAROMETER SURVEY ON TOBACCO SUMMARY
REPORT
  • 3/10 EU citizens 15y say they smoke 26 smoke
    daily, 5 occasionally, 22 of citizens say they
    have quit smoking.
  • Almost half of EU citizens claim that they have
    never smoked.
  • The proportion of smokers is the highest in
    Greece (42), followed by Bulgaria (39), Latvia
    (37), Romania, Hungary, Lithuania, the Czech
    Republic and Slovakia (all 36).

36
The European tobacco control report 2007
  • A fall in death rates from lung cancer among men
    across the Region.
  • Rates among women are still increasing.
  • Among young people, around 25 of 15-year-olds
    smoke every week and there has been no
    significant change in this level in recent years.
  • The prevalence of smoking among 15-year-old girls
    in many western European countries exceeds that
    among 15-year-old boys, while the reverse is true
    in eastern Europe.

37
THE FIVE As Brief strategies to help patients
willing to quit smoking
  • ASK
  • ASSESS
  • ADVISE
  • ASSIST
  • ARRANGE

38
THE FIVE Rs Providing motivational
interventions to patients unwilling to quit
  • RELEVANCE
  • RISKS
  • REWARDS
  • ROADBLOCKS
  • REPETITION

39
A few key points to cover in a few minutes
  • Set a stop day and stop completely on that day.
  • Review past experiences and learn from them.
  • Make a personalized action plan.
  • Identify likely problems plan on how to cope
    with them.
  • Ask family and friends for support.

40
DONT FORGET TO
  • Prevent relapse!!!
  • Open-ended questions
  • Active discussion
  • Help patients identify coping mechanisms to
    address threats

41
DONT FORGET
  • The young
  • Ex-smokers
  • Secondhand smokers

42
Top 5 secondary losses when someone quits smoking
  • Friends
  • Feelings of loneliness
  • Low self-esteem
  • Boredom
  • Indulgence

43
Recommendations for smoking cessation specialists
Intensive Support
  • Treatment as back-up to brief opportunistic
    interventions.
  • Individually/in groups
  • Coping skills training social support
  • Around five one-hour sessions over approx. one
    month follow up
  • NRT/bupropion/varenicline as appropriate

44
PHARMACOTHERAPY
  • Bupropion and varenikline
  • NRT products the patch, gum, nasal sprays,
    inhalators, tablets, lozenges
  • Smokers of 10 or more cigarettes a day who are
    ready to stop should be encouraged to use NRT or
    bupropion/varenikline as a cessation aid.

45
References
  • Wilson JMG, Jungner G. Principles and practice of
    screening for disease. WHO, Public Health Papers
    No. 34. Geneva WHO, 1968
  • Braveman PA, Tarimo E. Screening in primary
    health care. Setting priorities with limited
    resourses. Geneva WHO, 1994
  • Price DB, Tinkelman DG, Halbert RJ et al.
    Symptom-based questionnaire for identifying COPD
    in smokers. Respiration 2006 73 285-295
  • Tinkelman DG, Price DB, Nordyke RJ et al.
    Symptom-based questionnaire for differentiating
    COPD and asthma. Respiration 2006 73 296-305
  • Calverley PMA, Nordyke RJ, Halbert RJ et al.
    Development of a population-based screening
    questionnaire for COPD. J COPD 2005 2 225-232
  • van Schayck CP, Halbert RJ, Nordyke RJ et al.
    Comparison of existing symptom-based
    questionnaires for identifying COPD in the
    general practice setting. Respirology 200510
    323-333
  • David Price, Alan Crockett, Mats Arne, Bernard
    Garbe, Rupert Jones, Alan Kaplan, Arnulf
    Langhammer, Siân Williams, Barbara Yawn.
    DISCUSSION PAPER. Spirometry in primary care
    case-identification, diagnosis and management of
    COPD. Primary Care Respiratory Journal 2009
    18(3) 216-223

46
  • http//www.copdguidelines.ca/guidelines-lignes_e.p
    hp
  • http//www.theipcrg.org/resources/ipcrg_copd_opini
    on_5.pdf
  • http//www.thepcrj.org/journ/view_article.php?arti
    cle_id654
  • WWW.THEIPCRG.ORG
  • WWW.CCQ.NL
  • www.ginastma.org
  • www.copdgold.org
  • https//fhs.umr.com/oss/export/sites/default/Fiser
    vHealthServices/SharedFiles/FH0060_Adult.pdf
  • http//www.euro.who.int/document/e88698.pdf
  • http//www.apa.org/pubs/videos/4310588-scale.aspx
  • http//www.ncbi.nlm.nih.gov/pmc/articles/PMC251908
    3/

47
DICTIONARY OF USED TERMS AND DEFINITIONS
  • Screening is the presumptive identification of
    unrecognized diseases or defects by the
    application of tests, examinations or other
    procedures which can be applied rapidly.
    Screening tests sort out apparently well persons
    who probably have a disease from those who
    probably do not. A screening test is not intended
    to be diagnostic. Persons with positive or
    suspicious findings must be referred to their
    physicians for diagnosis and necessary treatment.
  • Mass screening is the large scale screening of
    whole population groups.
  • Selective screening is screening in selected
    high-risk groups in a certain population. It can
    be large-scale.

48
Multiple (or multiphasic) screening is the
application of two or more screening tests in
combination to large groups of people.   Surveilla
nce is a long-term process (close and continuous
observation) similar to the application of
screening examinations repeatedly at selected
regular intervals of time. It is often used as a
synonym of the word screening.   Case-finding is
a form of screening aimed at detecting disease
and bringing patients to treatment.   Population
or epidemiological surveys are surveys that
primarily aim at elucidating the prevalence,
incidence and natural history of the variable/s
under study rather than bringing patients to
treatment (although case-finding is a by-product
of surveys). Early disease detection is the
detection of disease at a primary stage by any
means.
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