Health Promotion in Primary Care

Health Promotion in Health Promotion in Primary CarePrimary Care

Health Promotion in Health Promotion in Primary CarePrimary Care

Dr Lola SavageDr Lola Savage1515thth February 2012 February 2012

AIM• To increase awareness of health

promotion in General practice

• Case presentation

• NHS health Check

• Questions-Single best Answer

GP Curriculum

• Healthy people: promoting health and preventing disease

Definition

• WHO: Health promotion is a process of enabling people to increase control over and to improve their health

Prevention• Health Professionals-we aim to prevent diseases in

our patients

• Prevention can be classified into the following:

• Primary prevention• Secondary prevention• Tertiary prevention

• Which of the above categories do we spend most of our time doing?

Primary prevention

• What health promotion activities do we currently advocate in primary care?

Primary Prevention

• New Patients

• Well woman and well man clinics

• Immunisations

• Travel advice

• Screening programmes- cervical/mammogram/STI

New patients health check

• Urinalysis• BMI• Blood pressure• Smoking status• Exercise• Alcohol screen-Audit C• Family hx • Ethnicity• Health ed- diet/ exercise-recorded

• Well woman/men check:• Smear status

• How do we as GP registrars incorporate primary prevention into our practice?

How can we incorporate health promotion into our

consultations

• Medication review-review summary records- alcohol intake/BMI/cholesterol/renal function

• Pill check-promote LARC

• Adhere to prompts for QOF- e.g smoking/ blood pressure reading

• Pregnant patients-folic acid/blood pressure/alcohol/smoking/diet/vit D/refer to community midwife

• ? Promote NHS health checks

Case Presentation

• 53 man who presented with a 12 week history of Left foot pain following a car going over his foot in a motorcycle event. X-ray left foot-NAD

• PMH- Essential Hypertension

• DHx-Amlodipine 5mg od (last issued may 2010)

• SHx- Runs his own company. Doesn’t smoke

• What should I do next?

Case Presentation

• Took brief hx of the pain/ex his left foot and decided to refer him for physiotherapy

• Establish a rapport with him and explored his ideas about his medical hx and non compliance with medications

• Clinic blood pressure readings: 174/85, 162/93

Case Presentation• Arrange for him to do home readings for a week and to

review again• Average home readings-156/90

• Reviewed risk- bloods- cholesterol/renal function/glucose• Q-risk- 9.5%• Nice guidelines- ACEI- ramipril

• Reviewed in 1/12- bp 130/86

• Follow up- pt applied for health insurance- declined-previous hx of non-compliance to meds

NHS health check• Background• Heart disease/ Stroke /Diabetes and kidney disease are the biggest

cause of death in the UK

• 4 million of people in the UK affected

• 170,000 people die each year in England from these conditions

• Health inequalities in deprived areas and in certain ethnic groups

• 2008-DoH published ‘Putting Prevention First’ –sets out a systematic and integrated approach to assess individuals between 40-74

• This National Screening Programme is known as Health Checks- due to be rolled out by PCTs in 2012/2013

NHS health check

• Invites patients ages 40-74 who are not known to have DM/CVD/TIA/ MI/HT once every 5 years

• Fixed factors-Age/ Gender/Ethnicity

NHS health checks• Aims

• To identify patients at risk of developing MI/CVA/TIA/Diabetes/HT

• To sustain increase in life expectancy

• To reduce premature death associated with obesity/sedentary life

• Reduce health inequalities

• Reduce the cost of long term ill health on the NHS

What does it look like?

Data requirements: BMI Ethnicity Blood Pressure

Data requirements: Blood Pressure

QRISK 2

<10% Exit for routine recall in 5 years

>10% but <20% Explain risk to individual and provide lifestyle advice on lifestyle modification and risk reduction.

<6mmol/l ≥ 7mmol/l and symptomatic

BMI ≥ 30 or ≥ 27.5 in Indian, Pakistani, Bangladeshi, Other Asian or Chinese OR Blood Pressure ≥140/90mmHg or SBP ≥140 or DBP ≥90mmHg

Blood Pressure ≥140/90mmHg or SBP ≥140 or DBP ≥90mmHg

If YES Carry out serum creatinine test and recall for assessment by GP practice team

If eGFR <60ml/min/1.73m2 Manage and assess for CKD including urine albumin:creatinine ratio (ACR). Follow up inline with NICE guidance 73

If YES Recall for

fasting blood glucose test

If NO Exit for routine recall in 5 yrs

Oral Glucose Tolerance Test

FBG results

Provide brief intervention

Exit for routine recall in 5 yrs

≥ 6 to 7 mmol/l OR ≥ 7mmol/l and asymptomatic

Diabetic – follow LES for diabetes

If NO Exit for routine recall in 5 yrs

If eGFR >60ml/min/1.73m2 provide lifestyle advice

Exit for routine recall

in 5 yrs

Data requirements: Family History of CHD Gender (M/F) Smoking Status (Current/ Non (inc. ex))

Age (yrs)

Medical History (Rheumatoid arthritis or Atrial fiibrilation)

Ethnicity

Townsend score/ postcode Blood Pressure Cholesterol BMI

Cardiovascular Risk Assessment Diabetes Risk Assessment

Chronic Kidney Disease Risk Assessment

If NO Exit for routine recall in

5yrs

Blood Pressure ≥140/90mmHg or SBP ≥140 or DBP ≥90mmHg

Data requirements: Blood Pressure

Hypertension Risk Assessment

If YES Discuss links between BP and lifestyle. To identify hypertension recall for at least two further appointments, checking BP twice on each occasion.

>20% Provide lifestyle advice on reducing risk. Statins are recommended for primary prevention in individuals with 10 year risk >20%.

If OGTT confirms diabetes – follow LES for diabetes

If OGTT does not confirm diabetes – give advice on symptoms and lifestyle. Recall annually for follow up OGTT If Hypertension diagnosed

place on GP hypertension register and follow up appropriately

If not hypertensive repeat lifestyle advice and exit for routine recall in 5 yrs

Physical Activity Assessment – Everyone attending for a vascular check should have their current levels of physical activity assessed using the GP Physical Activity Questionnaire (GPPAQ). This classifies individuals into active, moderately active, moderately inactive and inactive. Any individual identified as less than active should receive a brief intervention advising them to aim for 30 minutes physical activity on at least 5 days of the week.

NHS Health Checks – Summary Flow Chart

• Questions-Single best Answer

1 Which of the following statements does not apply to the Cardiovascular Disease Screening Programme?

a) Cardiovascular disease screening will identify risk factors that will contribute to vascular disease b) Early intervention can reduce the onset of vascular disease c) Cardiovascular Disease screening will support patients who have had a heart

attack. d) Cardiovascular Disease screening can prevent and in some circumstances reverse

the onset of vascular disease

2 For what age group is the National Cardiovascular Disease screening programme recommended?

a) 20yrs- 40yrs b) 30yrs- 64yrs c) 35yrs- 65yrs d) 40yrs- 74yrs

3 Which of the following blood pressure measurements would you refer your client to their GP?

a) 130/75 b) 130/85 c) 140/85 d) Above 140/90

4 Which of the following risk factors can be modified or potentially reversed in the Cardiovascular Disease Screening process?

a) Age b) High Blood pressure c) Ethnicity d) Family History Cardiovascular disease

5 Which of the following conditions will not affect a patient’s Cardiovascular Disease risk calculation?

a) Smoking b) Elevated BP c) Diabetes d) Alcohol

6 Why would a 45 year old male who smokes, has a blood pressure of 160/90, Total Cholesterol/ HDL ratio of 6.0 and a BMI of 27.7 have a low CVD QRISK Risk Score of 8%?

a) They drink above the recommended 21 units of alcohol per week b) They have Asthma c) Because he is 45yrs old d) Because he has Diabetes

7 Lifestyle advice/or referral as part of the NHS Health Check is important because…. a) Fresh air is good for everyone b) It offers patients the opportunity to make lifestyle changes that will improve their

health c) It looks good for the practice d) The government thinks it’s a good idea.

8 When should a patient be sent for a fasting blood glucose test for assessment of Diabetes through NHS Health Checks?

a) BMI is in the obese range >30 b) Blood pressure is at or above 140/90, or where the SBP or DBP exceeds 140 or 90 respectively. c) The patient has a BMI >27.5 and is either Indian, Pakistani, Bangladeshi, Other

Asian or Chinese d) All the above

Summary

• Increase awareness of health promotion in primary practice

• Case presentation

• NHS health checks

Any questions?

Thank you

References• www.doh.gov.uk. Putting

prevention first. Vascular checks: risk assessment and management

• Oxford handbook of GP