things we knew, things we did… things we have learnt, things we should do prevention:...

Things we knew, things we did… Things we have learnt, things we should do

Prevention: consultations for the 50 years

old patient in general medicine

Docteur Guy RECORBETDocteur Guy RECORBETMarseilleMarseille

[email protected]@wanadoo.fr

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Summary

DefinitionsAround the WorldPrevention ConsultationPrevention Guidelines

• Eating Behavior• Screening• Addictive behavior• Suicide risks• High-risk sexual behavior

Questionnaire

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DEFINITIONS

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According to the WHO, health prevention includes all steps taken to avoid the onset, development of an illness or the occurrence of an accident.

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1.2 Primary prevention

The goal of a primary prevention is to avoid the onset of an illness by acting upon the causes.

This means acting on the risk factors of an illness before they occur, or preventing transmission or an infection (e.g. vaccinations).

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1.3 Secondary prevention

Secondary prevention aims to detect an illness or damage that precedes a stage where one can intervene.

The goal is to detect illnesses and to prevent the onset of clinical or biological symptoms (e.g. screening for breast cancer).

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1.4 Tertiary prevention

The objective of tertiary prevention is to reduce recidivism, incapacities and to support social re-integration

The goal is to limit the complications and sequelae of an illness.

It is generally carried out during or after treatment and attempts to limit the severity of the consequences of the disease (e.g. prevention of recurrent myocardial infarctions).

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1.5 In fact, non-specifics

In practice, the classification of a prevention action may vary according to different criteria, the population affected by this action, its aim, as well as the associated pathology.

Therefore, helping someone to quit smoking is a primary prevention when it affects teenagers or young adults. It is a secondary prevention in people who don’t have any symptoms, but who are presenting precancerous alterations of sputum cells. Finally, it is a tertiary prevention in patients suffering from angina pectoris.

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1.6 Individual and Group Prevention

Individual prevention is aimed at a specific individual.

Group prevention is aimed at an entire population or a target group within a population.

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1.7 Individual and Group Prevention

These two notions are often interrelated. Hence, a physician can take part in a group prevention by providing information on mammograms within a breast cancer screening campaign, whereas he is participating in an individual prevention if he prescribes a mammogram outside of an organized framework.

Finally, health education is aimed at the comprehension and control of an illness and its treatment by the patient, but it also broadly includes behavior and lifestyle.

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Around the World

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2.1 Prevention around the World

United Kingdom, Finland, Quebec...• The General Practitioner has a central role in prevention

policies.

• Absence of Prevention Consultation• Other forms of remuneration, principle of delegating tasks

and competences.• Experienced PCs in Quebec and Belgium (CVRF++)

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In France

A specific prevention consultation does not exist, except in an experimental framework or in pilot studies.

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In DenmarkOne "general consultation to promote good health" per

year.Remuneration identical to a consultationContested by general practitionersLittle impact on prevention policy

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In GermanyIncreased public awareness of physicians by IMF and

CMECreation of a new occupational titleHighlighting the preventative aspect of medicine

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In NorwayRemuneration of physicians by capitation with

bonuses for preventative actions(e.g.: smoking consultation)

In SwedenAbandonment of capitationSignificant role of other professionals

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In ItalyEssential role for GPs in local health agenciesRemuneration by capitation with compensation for

prevention programs

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Prevention Consultation

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3.1 Why a prevention consultation?

Prevention in GM = 1/3 of the reasons for consultation *CVR, cancer and vaccinations ++

But, random and not well structured

Included case by case in health-care activities

Preventative care and curative care are not clearly individualized (difficulties with identification)

Underevaluation of acts linked to prevention in GM

* FSGM

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3.2 Goals of a prevention consultation

Create a favorable moment specifically dedicated to prevention

Early detection of risks and illnesses

Structured and hierarchical implementation of interventions (related to prevention) based on professional recommendations

Develop a synergy between individual and group prevention

Initiate a process of health education (accountability of patients)

Participate in the assessment of practices and results

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3.3 Implementation principles for a prevention consultation

Methodology for analysis and management of individual risks according to Professor Ménard*:

Be informed about the most common diseases in the age group considered (incidence up to ten years)

Prioritize the most common diseases that may arise in the next decade and indentify the principal determinants of these illnesses

* Ménard Report 2005

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3.4 Implementation principles for a prevention consultation

3) Select screening methods (sensitiviy, specificity) that have a predictive reference value appropriate for the targeted group

4) Have immediate access to validated regulations of care and treatment of risks and their causes

5) Have immediate access to references from administrative, social or health structures, or health care professionals eventually necessary for an efficient care and treatment

6) Make this approach attractive for everyone


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3.5 Hierarchy of risks

Age, Sex, Region, Profession

Causes of mortalityat 10 years

Causes of mortalityat 10 years

Height, Weight

Behavioral risksBehavioral risks• SmokingSmoking• Alcohol consumptionAlcohol consumption• EatingEating• Physical exercisePhysical exercise

Biological risksBiological risks• CardiovascularCardiovascular• CancersCancers• DepressionDepression

Environmental risksEnvironmental risks• Infections (vaccinations)Infections (vaccinations)• Work, activitiesWork, activities

Familial risksFamilial risks• Family historyFamily history

Other sources?Other sources?Lifetime risk?Lifetime risk?

J. Ménard, J. Ménard, SPIM, Juin 2006SPIM, Juin 2006

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3.6 Why a prevention consultation for patients in their fifties?

Premature mortality in France among the highest in Europe (Unexpected death before the age of 65)*: • 1/5th of total mortality (110,000 deaths annually)• 1/3 of deaths in men, 16.5% of deaths in women

Time difference (years) between exposure to a health risk and the apparition of the illness

At the age of 50: 60% of the causes of premature mortality can be prevented

Cancers (40%) and cardiovascular disease (11.9%), besides traumas, accidents and poisonings


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Prevention Guidelines

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4.1 Causes of premature mortality based on sex (Inserm 1997)

Bronchopulmonary tumorsIschemic heart diseaseURDT cancerCerebrovascular diseasesAlcoholic cirrhosisColorectal cancerSuicideHeart failureCOPDProstate cancer

Breast cancerCerebrovascular diseaseIschemic heart diseaseColorectal cancerBronchopulmonary tumorsAlcoholic cirrhosisOvarian cancerSuicideUterine cancerHeart failure

Men Women

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4.2 Prevention Guidelines

Eating BehaviorPhysical ActivitiesOrganized screeningAddictive BehaviorSuicide RiskHigh-Risk Sexual Behavior

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4.2.1 Eating Behavior

• Too many calories overall Obesity• Excess of hidden fat (french fries, deli meat, cheese)• Excess of simple sugars (pastries, candy, sugary drinks)• Excess of salt• Certain deficiencies: iron, Mg, starch, fibers

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4.2.2 Eating Behavior Health Consequences

Accidents: no breakfast, alcohol, postprandial drowsinessCardiovascular diseases such as atherosclerosis or HT

(avoidable risk factor)Metabolic diseases: diabetes, obesityCertain cancers

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4.2.3 Eating Behavior SUVIMAX STUDY

(Antioxydant Vitamin and Mineral supplements)

13,000 volunteers during 8 yearsBeta carotene, Vitamin E, Selenium and Zinc

supplementsReduced mortality (-31%) and with all causes of

death combined (-37%)Eat 5 fruits and vegetables per day

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4.3.1 ALCOHOL AND RISKY BEHAVIOR

The WHO classification and the standard 10g "bistro" amountNormal consumption

• Less than 30 g/d or 210 g/week for men• Less than 20 g/d or 140 g/week for women

The at-risk drinkers: above these amounts but without physical, psychological or social repercussions

Excessive drinkers (= harmful use): non-specific signs of alcoholismDependencyAcute consumption

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4.3.2 REPORT (1)

Excessive drinkers: 5 to 6 million FrenchDependant on alcohol: 2 million45% of traffic accidents due to alcohol30% of fatalities75% of night-time mortalities!

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4.3.2 REPORT (2)

20% of work accidents 20% of hospitalized patients and patients who consult

a doctor have problems with alcohol20% of domestic accidents1 out of 4 suicides are alcohol-related40,000 to 50,000 deaths per year: 10% of all causes

of mortality combined

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4.3.4 ALCOHOL AND INDIVIDUAL PREVENTION

Screen the at-risk and excessive drinkersKeep track of the number of glasses of alcohol consumed

dailyRecognize the nonspecific symptoms and be aware of their

causesRapid screening tools: "CAGE" questionnaire (or "DETA", in

French)Clinical and biological signs

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4.3.5 STANDARDIZED CAGE - DETA QUESTIONNAIRE

Have you already felt the need to Reduce the amount of alcohol you drink?

Have your Friends and family commented on how much alcohol you drink?

Do you have the impression that you drink Too much?Have you ever needed to drink Alcohol in the morning in order to feel

like yourself?

Two or more positive answers indicate a possible alcohol problem

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4.4.1 SMOKING INDIVIDUAL AND GROUP PREVENTION

Consumption: "Anti-smoking" law37% of men and 31% of women smoke; 20% and 7%

of these men and women, respectively, smoke more than 20 cigarettes per day

Significance of smoking among youths: equality between the two sexes

In 1 year, reduction of comsumption by 18% (price increases)

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4.4.2 EFFECTS OF SMOKING ON HEALTH (1)

4 million deaths world-wide in 1998 (WHO) in one generation: 10 million deathsOne half of smokers die from a disease directly linked

to smoking

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More than half of the deaths are of an oncological nature (of which 21,000 are localized in the lungs)

The risk of lung cancer is multiplied by 2 when the amount of smoking is multiplied by 2

If the length of time is multiplied by 2, the risk is multiplied by 20

Upper respiratory and digestive tract cancers are multiplied by 150 if the patient smokes more than 30 cigarettes per day and drinks more than 120 g of alcohol per day

Bladder cancers: risk multiplied by 2

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One quarter of deaths: of a cardiovascular nature, the risk of ischemic heart disease is multiplied by 20 (infarctus and sudden death)

Smoking is a risk factor for CVA, arteritis, HT1/5 of these deaths are due to a respiratory system

disease: COPD, emphysema…3,000 annual deaths are attributed to passive smoking

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4.4.5 PASSIVE SMOKING

Lung cancer +26%Sinus cancer multiplied by 2 to 6 (not seen in the smoker

themselves)Heart diseases +25%Independent risk of CVA in spouses/partners (multiplied by

2 in a study)Passive smoking could be a source of decompensation in

patients with chronic respiratory diseases (COPD, asthma, etc.)

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4.4.6 EFFECTS OF SMOKING IN PREGNANT WOMEN

28% of pregnant women smoke3 times more spontaneous miscarriages2 times more ruptured membranes (stops during the course of the

1st trimester RR 1.6)Retardation of interuterine growth: multiplied by 2EP: RR at 1.5 if less than 10 cigarettes per day, RR at 3 if 20

cigarettes per day and at 5 if more than 30Risk of abruptio placentae and placenta previa increases

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4.4.7 AND FOR WOMEN?

Female deaths will be multiplied by 10 in 2025 if no steps are taken

1950: 20% of women and 60% of men were smoking2000: 31% of women and 37% of men... In 1995: 58.3% of women aged 18 to 24 were smoking

compared to 52% of menMortality due to lung cancer is higher than that of breast

cancer in three countries: CANADA, USA and DENMARK

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4.4.8 INDIVIDUAL SMOKING PREVENTION

The general practitioner is on the first lineShort-term intervention at each consultation: ask

about consumption and about stoppingArguments based on age groupsStopping: the methodsThe influence of physician behavior

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4.4.9 Assess the pharmacological dependence: FAGERSTROM TEST

How soon after waking up do you smoke your 1st cigarette?

• Within 5’ 3• Between 6' and 30' 2• Between 31' and 60' 1• At least 1h 0

Do you find it difficult not to smoke in places where it's forbidden?

• Yes 1• No 0

Which cigarette would be most difficult to skip?

• The first 1• Any other 0

How many cigarettes do you smoke each day?

• 10 or less 0• 11-20 1• 21-30 2• More than 30 3

Do you smoke more in the morning than in the afternoon?

• Yes 1• No 0

Do you smoke if you're sick or have to stay in bed?

• Yes 1• No 0

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4.4.10 NICOTINE DEPENDENCE

0-2 not dependent3-4 low dependence5-6 moderate dependence7-10 high, or very high, dependence

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4.5.1 Drugs and Medicine

Barbituates, Benzodiazepines, combined with alcoholAmphetamines, EcstasyCannabisCocaineHallucinogensOpiates

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4.5.2 Drugs and Medicine - Health Consequences

Psychiatric disordersAccidentsViral infections: HBV, HCV (80% of drug addicts are

infected) and HIV (30%)

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4.5.3 Drugs and Medicine - Health Consequences

The high-risk subject (predisposed personality, exposed environment- either within or outside of the family)

Occasional user of "soft" drugs, transition to drug addictSecondary prevention or risk reduction policy:

"substitution”, prevention of viral transmissions (syringes, "clean needles", risky sexual behavior)

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4.5.4 Drugs and Medicine Health Consequences

Community outreach activities (work) Legislative measuresTherapeutic injunctionLiberalization of the sale of syringes and their distributionPunishment of traffickers, campaigns against laundering drug

moneyWelcome center for drug addicts, liasion by a doctor, access to

care...

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4.6.1 Individual and Group Suicide Prevention

12,000 deaths per year

73% of men and 27% of women

3,000 among persons older than 65 (we don't talk about them often…)

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4.6.2 Evaluation Factors for Suicide Mortality Risk

Social factors – epidemiologicalAge: elderly subjects are most vulnerable, but it is one

cause of mortality among other causesSex: much higher risk in men than in womenIsolation: celibate men or period following a separationProfessional problems: precariousness and subjects who

lost a job a long time ago

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4.6.3 Evaluation Factors for Suicide Mortality Risk: Psychiatric Factors

Depression: unipolar or bipolar, with major anxiety or during the introduction of a disinhibitory drug. Mortality rate: 15%

Factors favoring the short-term: severe anxiety, loss of concentration and alcohol abuse

Factors favoring the long-term: previous suicide attempts, thoughts of suicide and despair

SchizophreniaPersonality disorders: increased risk in cases of alcoholism or

drug addiction, and during a psychiatric hospitalization

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4.6.4 Suicidal Behavior

20 to 50% of suicidals try again1% will succeed in the year following an attemptHigh prevalence of psychiatric disorders among

suicidals: 90%, of which 50% were depressed and 30% were alcoholics

The screening scales are deceiving (serenity before the act)

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4.6.5 Prevention of Suicide

Recognition of risk of suicide with an implementation of a psychotherapeutic and chemotherapeutic approach

Recognition of depression in older subjects (look for cognitive disorders)

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4.6.6 Screen for the Risk of Suicide

Take note of a history of suicide risk in adolescence: include this question during normal consultations.

It is useful to know about past attempts because the risk of death is strongly correlated to the existence of attempts.

Experience shows that talking about it does not provoke one to act upon it

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4.7.1 High-Risk Sexual Behavior

Prevent sexually transmitted infections by changing behavior.

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The Organization of a Prevention Consultation

Interrogate• Starting with a validated questionnaire

Examine• Be systematic

Educate• Starting with identified risks

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Putting the brakes on a Prevention Consultation

Patient resistance (40.1%) Not enough time (29.7%), Not enough training (7.1%), Lack of remuneration (6.7%)An impression of inefficacy (2.9%)Not valuable (1%).

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Prevention for patients in their Fifties

Questionnaire

Dr. Guy RECORBETMARSEILLE

[email protected]

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1- Identification

SexAgeHeightWeightBPHeart Rate

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2- Family History

(Grandparents, Parents, Brothers, Sisters...)?

Early Cardiovascular Diseases (Stroke, Embolism, Hypertension, Infarctus ...) men < 55 years, women < 65 years?

Colon, lung, prostate, ovarian, breast, uterine cancer? Diabetes?Hypercholesterolemia?

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3 – General Order

Do you smoke? If yes, do you want to quit?Do you regularly drink alcoholic beverages (beer, wine,

whiskey...)Have you already been treated for heart or artery

disease?Have you already been treated for cancer?Are your sugar levels too high (Diabetes)?Is your cholesterol level too high ( Hyperlipidemia)?Have you already had suicidal thoughts?

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4 – Linked to Sex

If you are a woman

Last pap smear?Last mammogram?

If you are a manLast PSA (Prostate)?

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5 – In all Cases

Last Hemoccult (testing stool for blood)? Last blood work-up?Last vaccination against tetanus?Last flu vaccination?

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6 – Last known analysis

Cholesterol?

Glycemia (sugar)?

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7 - Treatment

For cholesterol?For diabetes?For stress?For the heart?

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Do you want to go deeper into other issues with your doctor?

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Conclusion

PC fits within a strengthened prevention policy

Objective: fight against high premature mortality

Conditions • Must not be an isolated or exceptional act• Must be integrated within a global process of promoting health

(customized prevention plan and therapeutic education)• Must be organized and structured (hierarchization and analysis of

principal individual risks) • Training and interest of professionals• Must be evaluated (avoid the juxtaposition of instruments)

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Thank you for your Attention

things we knew, things we did… things we have learnt, things we should do prevention:...

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