Think of preventive health care as being provided on four levels:
- Primary - detection (screening for disease)
- Secondary - earliest possible diagnosis to minimise risk of death and disability
- Tertiary - rehabilitation - maximising support in the environment to keep people well
- Quaternary - palliation - comfort and security when disease progress cannot be arrested.
Screening - Primary
The general ethical principle of screening is that disease should be sought only if there is effective intervention available or possible. Hence screening for Huntingtons disease in childhood is currently not appropriate as no early intervention can be offered that will arrest the progress of the cerebral cell loss.
Generalised screening for uncommon illness is also not considered ethical on both cost effectiveness grounds, and in the induction of distress from the false positive pick ups.
In primary care, screening occurs in two ways:
- Opportunistic screening where a test, or measure is performed where people present for another problem - the best example would be blood pressure checks.
- Formal recall systems involve phone or mail, or email contact with a group of patients selected on the basis of risk.
Many practitioners do not believe they need to have a recall system as they have been implemented by government where necessary. E.g. Immunisation is promoted through denial of some family benefits to children not immunised, and women are recalled for their PAP smears at appropriate intervals.
The immunisation scheme is quite effective, but people do slip through the net and you will need to know which of your patients has been denied effective prevention if they turn up with a risus sardonicus, or whooping cough. Also people are misled into denying their children effective and appropriate immunisation by ignorant and hysterical publicity generated by people pushing a belief system and not scientific fact - you will need to address this issue with some people. The PAP smear system only recalls women who have already had a smear and who have elected to be on the system.
So what do you screen for? The RACGP red book fortunately provides an evidence based set of screening interventions which have been shown to be effective in reducing morbidity. This can be obtained from the RACGP website so it is simply a matter of establishing polices for screening at your practice. You may also wish to implement screening for problems which are current but not yet supported by clinical evidence - an example of this might be recall of children for Meningococcal type C immunisation.
Detection - Secondary
This is really an opportunistic activity. In the ideal practice every patient would have opportunistic anthropometry performed on every visit - it is managed in hospital emergency departments. If your practice is financially able the practice nurse should review all incoming patients, measure and record their height, weight, blood pressure, UA, and BSL annually (subject to age variations). Other opportunistic measures can be conducted by the medical practitioners as needed.
Monitoring - Secondary
Again the red book provides guidance on this. The major disease group of concern to Australia is diabetes and you are all well aware now of is required in the semi-annual, annual and biannual reviews of diabetic management. Others you may not consider are hypertension, glaucoma, hyperlipidaemia, drug abuse, depression, phobias, generalised anxiety disorder, vascular insufficiency, congestive cardiac failure, Parkinsons disease and the like where intervention to improve functioning and retard the progress of the disease is effective.
Rehabilitation - Tertiary
The aged care review is the prime example of this and most of you will have some means of identifying and screening your aged at risk people. The critical factors in this are the activities of daily living rather than disease states. But you do not need to limit this type of review to the aged. Anyone with disability deserves regular review to ensure that they are not becoming socially isolated even if the government does not see fit to remunerate you for this. Most clinical computer systems have inbuilt aged care screening with flagging of the patient by age, and you may need to test your system to see if the same package can be used for younger people with established disability.Palliation - Quaternary
This is a primary care function which has been devolved to specialist and para medical teams in urban areas because of the perceived neglect of the area by primary care practitioners. In rural areas it is mainly a GP role. I am not aware of any screening instrument that examines the quality of life for someone where death is soon and predictable but I will keep searching and publish details in a future Pulse IT article when I find one suitable. Areas that need to be assessed are:
- Pain control
- Bowel function
- Skin care
- Carer stress
- Others (pruritus, dyspepsia, cough, dyspnoea, fragility.)
Identifying Risk Groups
This is well set out in the red book and I will not repeat the recommendations here. This is where your data quality is essential. With some computer systems it is not possible to store socio-demographic risk factors beyond age sex and ATSI status. You may wish to consider storing other data like family risk (disease specific), marital status, unemployment, existing disability, victim of abuse, etc. Medical director has a limited number of data fields available for this function and you can use them provided you are careful to eliminate typographical errors.
It is necessary to seek the permission of the patient to store this data, some people are proud of their aboriginal heritage, others have been victimised and do not wish to be a victim again, and people may not wish to face a genetic risk.
The method you use to contact people also needs consideration. Any mail should be marked personal and confidential and the content should be phrased in such a way as to not cause anxiety or stimulate paranoia.
Telephone calls are good, but avoid leaving messages as you cannot guarantee who will hear the message. Email should not contain any private information unless you are prepared to encrypt everything individually. Remember that a public key system must be individualised - if you supply all your patients with the same key you are keeping security only for that cohort of patients and not between individuals in the group. Screening should only be performed where there is a well established effective (and proven) intervention available. The risk in the group needs to be sufficiently high to justify the expense of screening. Hence screening all women for BRAC1 is not cost justifiable even if prophylactic mastectomy can be offered, as the prevalence in the community is so low.
If your clinical system offers the capacity for selecting patients on demographic criteria it is relatively simple to generate a list of people. The system will also allow you to export to a mail merge or spreadsheet program. If you are to use the phone as the primary contact then produce a spreadsheet for your staff that lists the persons name, address, phone number, and some blank columns labelled first, second and third in which the staff can record the date and time they have phoned the person. Some people prefer this as a printed list - others are happy to use the spreadsheet function on the computer - negotiate this with your reception staff.
Mail merge is good where there are more than 50 people to contact. You can construct a mail merged personalised letter quite easily in most office packages. I have also scanned my signature and use this at the bottom of the letter rather than have someone sign each one for me. Some offices also have letter folding machines.
Window face envelopes are the easiest, but you can also use laser printed mail labels if you are careful to match the letter with the name on the envelope. Ensure there is a return address - any letters that are returned should be regarded as a signal that the patient is not longer active and they should be marked as such in your patient database. If the address is simply incorrect the inactivation can be reversed with correction when they visit next time but it avoids you wasting time and effort recalling them in the future.
If your system does not provide this function it is slightly more difficult. Export to a spreadsheet the entire active patient data set with any tags that indicate risk. In the spreadsheet eliminate any columns that will not be needed (Medicare number etc) but keep names, address, phone number and risk tags. To select your risk group simply sort the dataset on the risk criteria. More advanced users may wish to use a database rather than a spreadsheet.
After the records have been sorted, scroll to the block of names that fulfill the criteria, select and copy to a new spreadsheet - this can be used as indicated above. Some of the better clinical computer systems provide an inbuilt recall system based on criteria that you set.
The advantage with such systems is that they tag that patients have been recalled for some reason, this generates a warning message when they visit allowing the practice to follow up. If this is not provided the reception staff will need to tag the patients individually when the letters are sent, or phone calls made.
The clinical management software has improved vastly from when I conducted the recalls outlined on the previous page, but it demonstrates how with a bit of thought the capacity exists in all clinical software systems to generate recall programs. The idea is to provide a cost justified health improvement for the community in which you work. This may be through a more efficient way of delivering a service, or providing and publicising a new service.
Posted in Australian eHealth