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Screening for COPD IN PHC WORKSHOP Vasiliki
Garmiri Athanasios Symeonidis
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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.

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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
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• 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
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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.

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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)

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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

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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)

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Screening Methodology

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

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The primary health care approach

• Equity
• Universal coverage with basic services
• Multisectoral approach
• Community involvement
• Health promotion

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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

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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.

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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).

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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

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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

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SCREENING FOR COPD IN PRIMARY HEALTH CARE
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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

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Estimates of prevalence

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

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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.

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COPD screening

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

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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

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What do I need to access in PHC?

• Tobacco use
• Pulmonary function
• Patient questionnaires
• Number of exacerbations
• Exercise (?)

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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.
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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.
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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

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COPD Risk factors

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

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REMEMBER!

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

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PART III

• TIME TO WORK IN GROUPS OF THREE!

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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

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CASE

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

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DOCTORS

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

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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.)

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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.

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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

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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 TOBACCOSUMMARY
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).

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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.

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THE FIVE AsBrief strategies to help patients
willing to quit smoking

• ASK
• ASSESS
• ADVISE
• ASSIST
• ARRANGE

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THE FIVE RsProviding motivational
interventions to patients unwilling to quit

• RELEVANCE
• RISKS
• REWARDS
• ROADBLOCKS
• REPETITION

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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.

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DONT FORGET TO

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

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DONT FORGET

• The young
• Ex-smokers
• Secondhand smokers

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Top 5 secondary losses when someone quits smoking

• Friends
• Feelings of loneliness
• Low self-esteem
• Boredom
• Indulgence

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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

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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.

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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

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• 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/

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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.

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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.