Παρουσίαση στα πλαίσια του 10ου Πανελλήνιου Συνεδρίου του Ελληνικού Κολλεγίου Γενικών Ιατρών

1. Προσυμπτωματικός
Έλεγχος
Υγείας
Ευάγγελος Α. Φραγκούλης, MD, MSc
Γενικός Οικογενειακός Ιατρός
Αν. Αρχίατρος ΕΔΟΕΑΠ
Council Member European Primary Care Cardiovascular Society

2. Delivering
Preventive Care
Earlier
in Lower Cost Settings
is the key for the success of
Value Based Care.
Providers must focus on improving
individual and population health,
reducing the number of avoidable
emergency room visits, hospitalizations
and readmissions and significantly
improving the patients outcomes at an
earlier point across their patient
population.

3. Prevention is better than cure
• Prevention is the key to avoid ill
health and achieve a high level of
mental and physical well-being
effectively and efficiently
• A shift in focus from sickness and
cure to prevention and the social
determinants of health is needed
State of Health in the EU. ec.europa.eu/health/state

4. Preventive Care
• people without specific complaints
• undergo interventions to identify and modify risk factors to avoid the
onset of disease or
• to find disease early in its course so that early treatment prevents
illness.

6. Risks associated with the highest number of deaths worldwide
for both sexes combined, all ages, in 2019
0 2 4 6 8 10 12
Number of deaths (millions)
Alcohol use Child and maternal malnutrition Kidney dysfunction High LDL
High body-mass index High fasting plasma glucose Air pollution Dietary risks
Tobacco High systolic blood pressure
http://www.healthdata.org/gbd/2019

7. Παράγοντες κινδύνου για χρόνια νοσήματα
Preventing Chronic diseases. A vital investment. WHO 2005

9. Chronic Diseases can be prevented and controlled
Preventing Chronic diseases. A vital investment. WHO 2005

10. Η παρέμβαση πρέπει να ξεκινά από την ενδομήτρια ζωή

12. Breaking the vicious cycle of ill health and poverty

13. Χρόνια Νοσήματα & Φτώχεια
• Φαύλος κύκλος
• Οι φτωχοί είναι περισσότερο ευάλωτοι
• Αυξημένο κίνδυνο έκθεσης σε παράγοντες
κινδύνου
• Ελαττωμένη πρόσβαση σε υπηρεσίες υγείας
Preventing Chronic diseases. A vital investment. WHO 2005

14. “If a patient asks a medical practitioner for help, the doctor does the
best he can. He is not responsible for defects in medical
knowledge.
If, however, the practitioner initiates screening procedures, he
is in a very different situation.
He should have conclusive evidence that screening can alter
the natural history of disease in a significant proportion of
those screened.”
Archie Cochrane and Walter Holland, 1971

20. Annual Wellness Visit (AWV)
• Visit to develop or update a Personalized
Prevention Plan (PPP) and
perform a Health Risk Assessment (HRA)
• ✔ Covered once every 12 months
• ✔ Patient pays nothing

22. Perform
Health
Risk
Assessment
(HRA)

23. Establish patient’s medical and family history

24. Establish list of current providers and suppliers

25. Measure

26. Detect any cognitive impairment patients may have

28. Review patient’s potential depression risk factors,
including current or past experiences with depression
or other mood disorders

31. Geriatric Depression Scale - Greek version
K.N. Fountoulakis, M Tsolaki, A. Iacovides, J. Yesavage, R O'Hara, A Kazis and Ch Ierodiakonou.:
The Validation of the Short Form of Geriatric Depression Scale (GDS) in Greece
published in "Aging:Clinical and Experimental Research, 1999;11:367-372"

32. Review patient’s functional ability and level of safety

33. Establish an appropriate written screening schedule for
patients, such as a checklist for next 5–10 years

34. Establish list of patient risk factors and conditions
where primary, secondary, or tertiary interventions are
recommended or underway

35. Provide patient’s personalized health advice and
appropriate referrals to health education or preventive counseling
services or programs

36. Process map of the AWV workflow

37. • CMS now recognizes the important work done by primary care physicians
that is different from the traditional “sick visit” model.
• Emphasized the health care provider's (HCP) role in helping patients
understand the importance of prevention
• By focusing the AWV on preventive screening, safety issues (eg, falls),
and social needs (eg, food insecurity, transportation), patients' qualities
of life can be enhanced.
• Setting up a system within your practice that involves contributions from
all members of the care team will maximize both patient benefit and
practice reimbursement for this important work.

38. Informed Decision Vs Shared Decision
 Πληροφορηµένη λήψη απόφασης: (Informed decision making)
◦ «συνολική διαδικασία µε την οποία ένα άτοµο συλλέγει σχετικές πληροφορίες για την υγεία
του από τον προσωπικό του επαγγελματία υγείας, αλλά και από άλλες πηγές µε ή χωρίς
ανεξάρτητη αποσαφήνιση της αξίας της πληροφορίας»
 Aµοιβαία λήψη απόφασης: (Shared decision making)
◦ «τη διαδικασία στην οποία οι ασθενείς εµπλέκονται ως ενεργοί συμμέτοχοι µαζί µε τον κλινικό
ιατρό, που τους εξηγεί τις αποδεκτές ιατρικές απόψεις και επιλέγουν το προτιμώμενο είδος
κλινικής φροντίδας»
Source: Sheridan S.L., Harris R.P., Woolf S.H. (2004). Shared decision making about screening and chemoprevention. A suggested approach from the U.S. Preventive Services Task Force.
Am J Prev Med. 26:56-66.

39. Informed decision

40. The benefits of breast cancer
screening on important
outcomes,
including
preventing death from breast
cancer,
reducing rates of advanced breast
cancer,
less aggressive surgery
(lumpectomy vs mastectomy),
less aggressive adjuvant therapy
and
improving quality of life.
The potential harms of breast
cancer screening, such as
overdiagnosis and
resulting overtreatment,
false-positive and false-negative test
results, and
adverse effects related to
breast cancer treatment

41. Benefit vs Harm
 In a meta-analysis of 11 randomized trials, the relative risk of breast cancer mortality for
women invited to screening compared with controls was 0·80 (95% CI 0·73—0·89), which is
a relative risk reduction of 20%.
 for every 10 000 UK women aged 50 years invited to screening for the next 20 years, 43
deaths from breast cancer would be prevented and 129 cases of breast cancer, invasive and
non-invasive, would be overdiagnosed
 ΟΝΕ breast cancer death prevented for about every THREE overdiagnosed cases
identified and treated.’
The Lancet 2012, 380; 9855:1778 - 1786

42. The Breast Cancer Screening Debate
• When to start screening
mammography?
• How often to have a mammogram?
• At what age woman should stop
getting mammograms?

46. Trends in Colorectal Cancer
Incidence Rates
• by Age and Year of Birth
• by Age and Year of Diagnosis
United States, 1975 to 2014
Data source: Surveillance, Epidemiology, and End Results
(SEER) program, SEER 9 registries, delayed adjusted rates,
1975-2014, National Cancer Institute.

47. Options for CRC screening
Stool-based tests
• Fecal immunochemical test every y
• High-sensitivity, guaiac-based fecal occult blood test every y
• Multitarget stool DNA test every 3 y
Structural examinations
• Colonoscopy every 10 y
• CT colonography every 5 y
• Flexible sigmoidoscopy every 5 y

48. • Men should have a chance to make an informed decision with their health
care provider about whether to be screened for prostate cancer.
• The decision should be made after getting information about
the uncertainties, risks, and potential benefits of prostate cancer
screening.
• Men should not be screened unless they have received this information.

50. Prostate Cancer Screening- When to start?
• Age 50 for men who are at average risk of prostate cancer and
are expected to live at least 10 more years.
• Age 45 for men at high risk of developing prostate cancer
(African Americans, first-degree relative (father or brother)
with prostate cancer at an early age (<65y).
• Age 40 for men at even higher risk (≥ 1 first-degree relative
who had prostate cancer at an early age).
Men who want to be screened should get PSA +/- DRE

51. Factors that might raise PSA levels
• An enlarged prostate: Conditions such as benign prostatic hyperplasia (BPH), a non-cancerous enlargement
of the prostate that affects many men as they grow older, can raise PSA levels.
• Older age: PSA levels normally go up slowly as you get older, even if you have no prostate abnormality.
• Prostatitis: This is an infection or inflammation of the prostate gland, which can raise PSA levels.
• Ejaculation: This can make the PSA go up for a short time.This is why some doctors suggest that men abstain
from ejaculation for a day or two before testing.
• Riding a bicycle: Some studies have suggested that cycling may raise PSA levels for a short time (possibly
because the seat puts pressure on the prostate), although not all studies have found this.
• Certain urologic procedures: Some procedures done in a doctor’s office that affect the prostate, such as a
prostate biopsy or cystoscopy, can raise PSA levels for a short time. Some studies have suggested that a digital
rectal exam (DRE) might raise PSA levels slightly, although other studies have not found this. Still, if both a PSA
test and a DRE are being done during a doctor visit, some doctors advise having the blood drawn for the PSA
before having the DRE, just in case.
• Certain medicines: Taking male hormones like testosterone (or other medicines that raise testosterone levels)
may cause a rise in PSA.
• 5-alpha reductase inhibitors: Certain drugs used to treat BPH or urinary symptoms, such as finasteride or
dutasteride, can lower PSA levels.

52. Frequency of screening
the time between future screenings depends on the results of the
PSA blood test:
• PSA < 2.5 ng/mL - may only need to be retested every 2 years.

55. The most important thing to remember is to get
screened regularly, no matter which test you
get!
Those
• >65y
• had regular screening in the past 10 years with normal results
• no history of CIN2 or more serious diagnosis within the past 25 years
SHOULD STOP cervical cancer screening.
• People who have had a total hysterectomy (removal of the uterus and cervix) should
stop screening (such as Pap tests and HPV tests), unless the hysterectomy was done
as a treatment for cervical cancer or serious pre-cancer.
• People who have had a hysterectomy without removal of the cervix (called a supra-
cervical hysterectomy) should continue cervical cancer screening according to the
guidelines above.
• People who have been vaccinated against HPV should still follow these guidelines
for their age groups.

57. The ACS recommends annual screening for lung cancer with LDCT in adults aged 55
to 74 years in relatively good health who:

58. Πότε πρέπει να υποβάλλονται οι ασθενείς σε
Μέτρηση Οστικής Πυκνότητας;

59. Clinician’s guide to prevention and treatment of osteoporosis
International Osteoporosis Foundation and National Osteoporosis Foundation 2015

60. Osteoporosis to Prevent Fractures: Screening
June 26, 2018

63. Risk estimation: key messages

64. Recommendations for cardiovascular disease risk estimation

65. Systematic Coronary Risk Estimation chart
for
European populations
at
low cardiovascular disease risk
Calibrated country-specific versions are available for many
European countries and can be found at
www.heartscore.org

66. Intervention strategies
as a function of total
cardiovascular risk and
untreated low-density
lipoprotein cholesterol levels
the higher the risk,
the more intense
the action should be!

67. Recommendations for lipid analyses for
cardiovascular disease risk estimation

68. Screening and diagnosis of hypertension
• All adults should have their BP recorded in their medical record and be aware of their BP
• further screening should be undertaken at regular intervals with the frequency dependent on
the BP level

69. | 69
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1):S15-S33

70. | 70
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1):S15-S33

71. | 71
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1):S15-S33

72. | 72
CLASSIFICATION AND DIAGNOSIS OF DIABETES
diabetes.org/socrisktest
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2021. Diabetes
Care 2021;44(Suppl. 1):S15-S33

73. Abdominal Aortic Aneurysm: Screening

74. Integrating
Evidence-Based
Clinical and
Community
Strategies to
Improve Health
Burden of
Disease,
Preventability, and
Research and
Translation Gaps
Am J Prev Med 2007;32:244-2

75. Greater care complexity
• Studies estimate that it would take 7.4 hours to deliver all recommended preventive
services and 10.6 hours per working day to deliver all evidence-based care for chronic
conditions to a primary care panel.
• “These excessive demands contribute to long waiting times and inadequate quality of
care for patients.”
• Concern about one’s ability to manage complex, chronically ill patients may contribute to
driving career choice away from primary care.
Kimberly et al, Am J Public Health. 2003 3
Østbye et al, Ann Fam Med. 2005
Bodenheimer T. N Engl J Med. 2006

77. Poor performance in cancer screening

80. Cancer Doesn't Stop for COVID-19 and Neither Should
You
JAMA Netw Open. 2020;3(8):e2017267

81. Cancer Doesn't Stop for COVID-19 and Neither Should
You
• Concerns that the pandemic would delay the diagnosis and
treatment of some cancers with potentially serious
consequences.
• Delays in screening could mean that the “missed” cancers
might be larger and more advanced when they were
ultimately detected.
• The impact of the pandemic on overall cancer deaths will not
be clear for many years

83. IT as a facilitator of enhanced integration between Primary Care and Public Health
Calman et al., 2012

84. Ψηφιακή ώθηση στο Εθνικό Πρόγραμμα Πρόληψης «Σπύρος Δοξιάδης»
• Δοκιμασμένα ψηφιακά εργαλεία – που αναδείχτηκαν
στο υπό εξέλιξη εμβολιαστικό πρόγραμμα «Ελευθερία»
• Οι γονείς θα λαμβάνουν προσωποποιημένα sms –
αντίστοιχα με αυτά που λαμβάνουν σήμερα μέσω της
πλατφόρμας emvolio.gov.gr – που θα τους υπενθυμίζουν
πότε πρέπει να κλείσουν το επόμενο ραντεβού με τον
παιδίατρο, ώστε να υποβληθούν τα παιδιά τους στον
τακτικό εμβολιασμό που προβλέπεται από το Εθνικό
Πρόγραμμα Εμβολιασμών
• Αντίστοιχο σύστημα υπενθύμισης και για τον κρίσιμο
αντιγριπικό εμβολιασμό που ξεκινά κάθε φθινόπωρο,
ενώ οι πολίτες θα λαμβάνουν επίσης υπενθύμιση για
κρίσιμες προληπτικές εξετάσεις, όπως αυτές που
αφορούν σε καρδιαγγειακά νοσήματα ή τα τεστ ΠΑΠ
κ.ο.κ.

85. Pay for Performance (P4P)
• financial incentives for reaching targets on predefined
performance measures
• providers are responsive to financial incentives
• commonest payment methods not designed to stimulate good
performance and separately creates incentives for undesired
behavior
• The main goal of P4P is to improve patient outcomes while
mitigating unintended consequences
• Contributing to better prevention and disease management/
including efficiency measures, could also mitigate cost growth

86. alexandre.lourenco@icloud.com
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87. alexandre.lourenco@icloud.com
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