Σεμινάριο εισαγωγής στην ΠΦΥ- Εκπαιδευτικό πρόγραμμα ειδικευόμενων Γενικών Οικογενειακών Ιατρών σε συνεργασία με το Τμήμα Πολιτικών Δημόσιας Υγείας του Πανεπιστημίου Δυτικής Αττικής

1. Συχνότερα χρόνια
νοσήματα,
καταστάσεις υγείας,
συχνότερα
συμπτώματα
στην κοινότητα
Ευάγγελος Α. Φραγκούλης, MD, MSc
Γενικός Οικογενειακός Ιατρός
Αν. Αρχίατρος ΕΔΟΕΑΠ
Council Member European Primary Care Cardiovascular Society

2. •development of primary care guidelines
•allocation of resources
•design of training programs and curricula

3. 4 Key Features of Primary Care
1. It is person- rather than disease-focused.
This focus entails sustained relationships between patients and providers in primary care practices over time,
often referred to as continuity.
2. It provides a point of first contact for whatever people might consider a health or health
care problem.
In properly organized health care systems, primary care ensures access to needed services.
3. It is comprehensive.
By definition, it can encompass any problem. Many problems in primary care are ambiguous and defy precise
diagnosis. Nonetheless, primary care meets a large majority of patient needs without referral.
4. It coordinates care.
Primary care adopts mechanisms that facilitate the transfer of information about health needs and health care
over time.
Starfield and Horder, 2007

4. THE EUROPEAN DEFINITION OF GENERAL PRACTICE / FAMILY MEDICINE
THE WONCA TREE
https://www.woncaeurope.org/page/definition-of-general-practice-family-medicine

5. The characteristics of the discipline of General Practice/Family Medicine

6. Finley CR, Chan DS, Garrison S, et. al. What are the most common conditions in primary care? Can Fam Physician. 2018;64:832-840
RANK CLINICIAN REPORTED* PATIENT REPORTED
CONDITION RANK SCORE (MAX
SCORE OF 20)
CONDITION RANK SCORE (MAX
SCORE OF 20)
1 Upper respiratory
tract infection,(unsp)
16.7 Cough 19.0
2 Hypertension 16.1 Back pain or spinal
pain
16.8
3 Routine health
maintenance
8.7 Abdominal, (unsp) 16.6
4 Arthritis (not back) 8.6 Pharyngitis 14.4
5 Diabetes 8.4 Dermatitis 13.4
6 Depression or
anxiety
7.7 Fever 12.6
7 Pneumonia 7.2 Headache 12.4
8 Acute otitis media 6.8 Leg symptoms 9.4
9 Back pain or spinal
pain
6.7 Respiratory,
unspecified
8.8
10 Dermatitis 6.4 Fatigue 8.4
11 Cough 5.6 Depression or anxiety 8.0

7. Finley CR, Chan DS, Garrison S, et. al. What are the most common conditions in primary care? Can Fam Physician. 2018;64:832-840
RANK DEVELOPED COUNTRIES* DEVELOPING COUNTRIES
CONDITION RANK SCORE (MAX
SCORE OF 20)
CONDITION RANK SCORE (MAX
SCORE OF 20)
1 Hypertension 17.4 Upper respiratory tract
infection, (unsp)
18.5
2 Upper respiratory tract
infection, (unsp)
15.2 Hypertension 14.5
3 Depression or anxiety 12.0 Pneumonia 11.5
4 Back pain 12.0 Tuberculosis 10.0
5 Routine health
maintenance
11.6 Parasites 9.0
6 Arthritis (not back) 10.0 Anemia 8.3
7 Dermatitis 8.6 Diabetes 8.3
8 Acute otitis media 8.6 Arthritis (not back) 6.5
9 Diabetes 8.6 Bronchitis or
bronchiolitis
6.3
10 Cough 7.0 Epilepsy 6.0
11 Medication 5.8 Urinary tract infection 5.5
12 Urinary tract infection 5.4 Tonsillitis 5.5

8. Chronic condition
“any condition that requires
ongoing adjustments by the affected person
and interactions with the health care
system”

9. Differentiating acute and chronic conditions

14. https://vizhub.healthdata.org/gbd-compare/

15. https://vizhub.healthdata.org/gbd-compare/

16. Disability Adjusted Life Years
Source:
Public Health England (2015)
Mortality does not
give a complete
picture of the burden
of disease borne by
individuals in different
populations.
The overall burden
of disease is
assessed using the
disability-adjusted life
year (DALY), a time-
based measure that
combines years of
life lost due to
premature mortality
and years of life lost
due to time lived in
states of less than
full health,

17. 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

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

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

20. Η παρέμβαση πρέπει να ξεκινά από την ενδομήτρια ζωή

21. The ageing
population
Developed countries
>60 years
• 12% (1950)
• 23% (2013)
• 32% (2050)

22. Multi-morbidity
Presence of 2 or more long-term health conditions,
which can include:
• defined physical and mental health conditions such as diabetes or
schizophrenia
• ongoing conditions such as learning disability
• symptom complexes such as frailty or chronic pain
• sensory impairment such as sight or hearing loss
• alcohol and substance misuse.

23. Number of chronic disorders by age-group
Lancet 2012

24. Multimorbidity matters
it is associated with
• reduced quality of life
• higher mortality
• polypharmacy and higher rates of adverse
drug events
• high use of unplanned health care

25. Cluster medicine
• The shift includes moving from thinking about multimorbidity as
a random assortment of individual conditions to recognising it
as a series of largely predictable clusters of disease in the
same person.
• Some of these clusters will occur by chance alone because
individuals are affected by a variety of commonly occurring diseases.
• Many, however, will be non-random because of common genetic,
behavioural, or environmental pathways to disease. Identifying
these clusters is a priority and will help us to be more systematic in our
approach to multimorbidity.
• The cluster around diabetes is a good example, with the common serious
disease affecting the heart, nervous system, skin, peripheral vasculature, and
eyes. Diabetologists already provide care for the cluster of multiorgan diseases
around diabetes, and some specialties, such as geriatrics or general practice,
have multimorbidity at their heart
BMJ 2020;368:l6964

27. Prevalence of multimorbidity by age and socioeconomic status
Lancet 2012

28. Physical and mental health comorbidity and the association with socioeconomic status
Lancet 2012

30. 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

31. Frailty
• a long-term health condition characterised by
• loss of physical, emotional and cognitive resilience as
a result of the accumulation of multiple health deficits.
• progressive, typically erodes functional, cognitive
and/or emotional reserves and
• increases vulnerability to sudden loss of
independence and adverse health outcomes following
a comparatively minor stressor event such as an acute
infection or injury.

32. Frailty
• severe frailty: 3% >65y
• moderate frailty: 12% >65y
• mild frailty: 35% >65y
While severe frailty can be comparatively easy to recognise and diagnose,
lesser degrees of frailty may be more difficult to differentiate from normal
ageing.

34. There is evidence that for some of
this group, adverse outcomes
could be avoided through
proactive case finding, timely
comprehensive assessment, care
planning and targeted proactive
use of services outside of hospital
Mytton et al, 2012
With early identification of frailty
and clear consideration of ways to
optimise care and support for
adults with multimorbidity, there
are interventions that can be
used to manage its progression
effectively at key stages
https://www.england.nhs.uk/publication/toolkit-for-general-practice-in-supporting-older-people-living-with-frailty/

36. Multimorbidity
• Long-term disorders are the main challenge facing health-care
systems worldwide, but health systems are largely configured for
individual diseases rather than multimorbidity
• individual diseases dominate health-care delivery, medical research, and medical education
• Use of many services to manage individual diseases can become
duplicative and inefficient, and is burdensome and unsafe for
for patients because of poor coordination and integration.

37. 2021 GLOBAL STRATEGY FOR
PREVENTION, DIAGNOSIS AND
MANAGEMENT OF COPD
https://goldcopd.org/2021-gold-reports/

38. 2021 GINA
Global Strategy
for Asthma
Management
and Prevention
https://ginasthma.org/gina-reports/

39. https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines

40. https://link.springer.com/article/10.1007/s00125-019-05039-w

41. Standards of Medical
Care in Diabetes—2021
https://care.diabetesjournals.org/content/44/Supplement_1

42. https://ipccs.org/

43. https://www.ipcrg.org/desktophelpers

44. http://www.greekphcguidelines.gr/

45. Case A.
A 78-year-old woman with
previous MI,
type 2 diabetes,
osteoarthritis and
depression.

46. Case: morbidities and risk factors
MI diagnosed 2 years previously with no angina or heart failure
Asymptomatic type 2 diabetes diagnosed at the time of her MI with
hyperglycaemia uncontrolled on diet alone, but with no microvascular
complications
Osteoarthritis of the knee for 5 years with regular pain and some
functional impairment
Depression of moderate severity diagnosed 2 months before managed
solely in primary care with psychosocial support and antidepressant
medication with reasonable response
Smokes 10 cigarettes per day, would like to stop; body mass index of 29
kg/m
2
Age and Ageing,Volume 42, Issue 1, January 2013

47. Case: minimal drug treatment recommendations
Citalopram
Omeprazole
Metformin
Aspirin
Lisinopril
Simvastatin
Bisoprolol
Paracetamol or topical ibuprofen gel
Smoking cessation medication (nicotine replacement, varenicline or buproprion)
Additional drugs routinely recommended for more severe disease, notably if poor control of
blood pressure (up to three additional drugs),
HbA1c control (up to three additional drugs) and/or
lipids (up to one additional drug);
poor pain control in osteoarthritis on simple analgesia (potentially multiple drug classes);
persistent depression despite initial treatment (switching of antidepressant medication rather than addition);

48. Case: self-care recommendations
Improve sleep hygiene
20–30 min daily of aerobic exercise
Local muscle strengthening exercise
Mediterranean diet/healthy diet and eat 2–4 portions of oily fish
Alcohol consumption within recommended limits
Weight loss
Self-monitoring of plasma glucose integrated with the educational
programme
Smoking cessation
Appropriate footwear for diabetes and osteoarthritis
Age and Ageing, Volume 42, Issue 1, January

49. Case: Follow-up recommendations
Active monitoring of mood by general practitioner
Low-intensity psychosocial intervention
Annual clinical review for diabetes (includes most recommended care post-MI)
Annual clinical review for osteoarthritis
Annual retinal screening by quality assured digital retinal photography
programme
3–6 monthly monitoring of HbA1c and 4–6 monthly monitoring of blood pressure
One-off pneumococcal and annual influenza immunisation
Offer referral to smoking intensive support service
Age and Ageing, Volume 42, Issue 1, January 20

51. An approach to care that takes account of multimorbidity
• how the person's health conditions and their treatments interact and how
this affects quality of life
• the person's individual needs, preferences for treatments, health priorities,
lifestyle and goals
• the benefits and risks of following recommendations from guidance on
single health conditions
• improving quality of life by reducing treatment burden, adverse events,
and unplanned care
• improving coordination of care across services.
Multimorbidity: clinical assessment and management NICE guideline [NG56]

52. BMJ 2016;354:i48
43

54. Lack of active follow-up
to ensure the best
outcomes
Lack of care coordination
and planned care
Rushed practitioners not
following established
practice guidelines
Patients inadequately
trained to manage their
illnesses

55. http://www.improvingchroniccare.org/
Management of multiple chronic conditions requires a transformation in health care

56. Paradox of Primary Care
• Poor quality of care by disease-specific process of
care measures
• Better quality at population level
• Similar whole-person functional health
• Better population health
• Lower resource use and cost

58. "using financial incentives to encourage patients to register with a general
practitioner (GP) or family doctor and
using a referral system to define a cost-effective path of care: from GP, to
outpatient specialist, to hospital, to emergency care, while encouraging
patients to have less recourse to unnecessary care and emergency services”
Suggested measures for Investing in Sustainable Health Systems two clear
recommendations for Member States:
• Reducing the unnecessary use of specialists and hospital care
• Improving primary healthcare services
“Investing in Health - Key Messages”, European Commission, DG Health and Consumers; February 2013
Σύστημα παραπομπής-
Cost effective path of care

59. Ελεύθερη πρόσβαση σε ιατρούς εξειδικεύσεων;

63. Ενδείξεις παραπομπής διαβητικών ασθενών από Οικογενειακό Ιατρό και
διεπιστημονική ομάδα ΠΦΥ προς την εξειδικευμένη φροντίδα
Joslin Diabetes Center and Joslin Clinic Guideline for Specialty consultation/referral (07/29/13)

64. • 3.5 hours a day, were required to provide care for the top 10
chronic diseases, provided the disease is stable and in good
control.
• We recalculated this estimate based on increased time requirements
for uncontrolled disease. Estimated time required increased x3.

65. 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