INTRODUCTION AND OVERVIEW

Although the healthcare system still tends to undervalue and under-fund preventive medicine and health promotion, there has nevertheless been a growing recognition of the need to undertake preventive activities and screening within primary healthcare. General practitioners are well placed to be at the forefront of these activities because of their long-term and regular contact with patients and families, providing avenues for both opportunistic and structured approaches.

Preventive and screening activities require informed, disciplined and motivated patients as well as doctors. It also requires the support of reliable systems for recording data and sending reminders. Respective colleges in Australia through the RACGP,¹ and in the United Kingdom, United States and many other countries, along with the World Health Organization,² have actively reviewed evidence and made recommendations for best practice in screening and preventive activities. This chapter attempts to distill some of the key points raised by these recommendations.

PREVENTION

There are three main levels of prevention.

SCREENING

Screening, whether through physical examination (e.g. blood pressure, random blood glucose) or special tests (e.g. mammography, colonoscopy), is the mainstay of preventive activities within general practice. Which tests to order, how often to perform them and for whom—and whether to order them at all—are far from clear-cut. Guidelines often shift with each new study that comes out, making decisions difficult for clinicians and patients.

Research must determine whether there are significant gains to be made that outweigh the costs to the patient and community in terms of time, emotional and physical discomfort, side effects and monetary expense, before a test can be widely recommended and funded. These issues may also need to be addressed with an individual patient in order for them to have a positive attitude to screening activities. In other words, the case for screening needs to be made—it should not be assumed that a patient will wish to follow guidelines just because they are there.

The WHO recommends that for a screening activity to be widely taken up, it should be identifying important health conditions (i.e. common, disabling and/or life-threatening) where there is a window of opportunity between latency and clinical manifestation. The test should be simple, as uninvasive as possible, safe, accurate and supported by evidence. Treatment for the health condition should be available and have been demonstrated to have a beneficial outcome. The outcomes should be of benefit in terms of morbidity or mortality, the benefits should outweigh the side effects and it should be cost-effective.

There are many shades of grey in answering these questions and in deciding who, where and when people are screened. Ultimately, it is the patient who will make their own informed choice as to whether to accept the guidelines or their doctor’s advice, and so although guidelines are useful, they will need to be individualised for each patient. A very anxious patient, for example, may be a candidate for screening at an earlier age than someone less anxious. Furthermore, guidelines may vary between various groups in the community (e.g. taking into account the relevance of ethnic background or socioeconomic status) as to who may be at greater or lesser risk.

Specific recommendations on screening for various conditions in children and adults are given in the charts in Guidelines for Preventive Activities Over the Lifecycle, which can be downloaded and/or printed for use in the patient records (see the Resources list at the end of this chapter). The charts provide an excellent summary that can be used to help to keep track of which examinations and tests have been done and what the key findings were. Further details regarding each of these activities can also be explored on the RACGP Red Book (page numbers are given on the charts), which can also be downloaded and/or printed.

ISSUES IN PREVENTION AND SCREENING