Opportunistic Screening Carried out in the Family Medicine Settings

To the Editor: Banu Ulusel’s comment on the article “Missed Opportunities for Coronary Heart Disease Diagnose: Primary Care Experience” by Turkay et al (1) brings forward various issues related to the functioning of family medicine both in Turkey and in general. Turkay et al investigated the incidence of non-diagnosed coronary diseases in the population of 15 695 persons aged over 30, attending a health care center with 9 general practitioners (GP), 8 nurses, 14 midwives, and 4 other health care workers.

Although the title suggests that the study deals with the experience of physicians in a primary health care setting, no GPs from that health care center took an active part in the research. Regarding this point, I agree with Banu Ulusel’s comments.

However, I think that the article entitled “Missed Opportunities for Coronary Heart Disease Diagnose: Primary Care Experience” encourages a better and more efficient utilization of opportunistic screening in the family medicine settings. In the Discussion section, the authors listed some of the reasons why the employment of the opportunistic screening in the Turkish family medicine practice can still be regarded insufficient, while Banu Ulusel’s provided a few more facts.

Since the opportunistic screening represents a part of the family medicine (practice), Dr Ulusel’s comment motivated me to present some of the elements important for its application and utilization. In addition, I also present data on preventive activities undertaken by GPs employed in the Croatian Family Medicine Service.

Definition and successfulness of the opportunistic screening

For the majority of the population, GPs represent first-line care providers who, owing to their long-term experience with the treated population get familiar with its health care needs. Most of the persons registered at GP’s office seek medical advice at least once in three years, while 70% does so every year. In addition, long-time work with the same population provides the GP an opportunity to gain insight into the results of preventive activities and their beneficial effects on the population. Opportunistic screening represents a term describing the possibility and liability of the GP to use his or her numerous contacts with the patients for exercising prevention. Insofar, opportunistic screening has been proven successful for elevated blood pressure, breast palpation, and Papanicolaou test (2).

The major disadvantage of such screening is that it covers only those patients visiting the GP’s office on their own initiative, putting those who do not do so in danger of being inadvertently left out of the preventive program. However, if a well-designed computer system is used, regular registration of preventive activities can be ensured, as well as information on the patients who have not been screened so far and should be invited in person (3).

How has prevention been exercised in Croatian family medicine service?

Within the health care system in Croatia, the GP plays a role of a gatekeeper, which puts him or her in a privileged position when it comes to preventive activities. Each GP provides health care for a defined population, working in a team with a practice and a public health nurse. According to the data collected by the Croatian Institute of Public Health, Family Medicine Service employed 2347 family medicine practicing teams in 2005, who provided health care for as many as 3 905 606 persons, ie, 87% of the Croatian population (4).

The investigations conducted in a number of countries have demonstrated that preventive activities are only rarely incorporated into the GP’s working pattern (5,6).

The same also goes for the working patterns of Croatian GPs (7) (Table 1).

Table 1.

The number of recorded preventive and overall health checks targeted at persons aged over 18, carried out in the Croatian Family Medicine Service in 2000 and 2005

Indicator	Year
	2000	2005
The number of persons in the care	3 740 801	3 905 606
The number of preventive and overall health checks in persons aged over 18	75 306	76 037
The average number of annual preventive and overall health checks, per insured person	0.02	0.02
The average number of annual visits to the general practitioner’s office, per insured person	5.9	6.3

According to the data for 2000 and 2005, within the frame of the Family Medicine Service only one in every 50 insured persons was subjected to a preventive or overall annual health check. At the same time, throughout 2005, the GPs employed in this service recorded as many as 24 723 313 visits due to various symptoms, complaints, or other reasons. Such a large number of contacts with their patients provided them with the opportunity to undertake not only curative, but also preventive activities, such as opportunistic screening.

GPs, besides other conditions, collect data on cardiovascular risk factors and perform screening for many of them. Opportunistic screening is most easily applied in the case of elevated blood pressure. Despite the fact that Croatian GPs provide health care for the registered populations, play the role of a gatekeeper, and have National Guidelines for the Prevention of Cardiovascular Diseases at their disposal, Croatian Institute of Public Health estimated that GPs managed to diagnose only 509 432 hypertension cases in 2005 (4). Based on epidemiological data on the prevalence of hypertension in Croatia, this number is lower than expected.

Prerequisites for successful application of opportunistic screening

I. Adequate education and training. It is provided by physicians and their coworkers with skills needed for the preventive work. Within the frame of the postgraduate (master’s) program in family medicine, which represents an integral part of the professional training, physicians become acquainted with evidence-based preventive programs and trained to develop and implement such programs and evaluate their practical impact. In her comment, Banu Ulusel made a well-grounded observation that a physician’s competence in the preventive work area is not to be built solely on the continuous education courses, but primarily on the fundamental education provided within the professional training program. Of course, this does not diminish the virtues of continuous education courses. The number of physicians in Croatia who completed the professional training in Family Medicine within the project entitled ″Harmonisation of Family Medicine Practice with the European Standards by Means of Introducing a Mandatory Vocational Training″ increased to 537 between 2003 and 2006. In the years to come, education and training of a considerable number of physicians will probably yield significant results in the family medicine preventive practice (8).

II. The pattern of financing preventive activities. This represents the second major and operatively relevant segment where preventive activities are concerned. The combined model of payment, which includes capitation-fee, fee-for-service, preventive programs, and other payment modalities, would allow for a more equitable rewarding of the work, a more precise follow-up of the health care services, and an enticement for improving the quality of work (9). Conformant to the contract made with the National Health Services, GPs in Great Britain, who obey and comply with the Good Medical Practice principles, are granted 20% of financial surplus in recognition of their line of work. Quality indicators harmonized and jointly proposed by expert bodies, regulatory bodies, and stakeholders include a considerable number of indicators focused on preventive activities (10).

III. Organizational frame of medical practice represents a major determinant of the pattern in accordance to which preventive activities are carried out. Preventive work calls for a population approach. It is completely understandable that preventive activities undertaken by more than one physician practicing at the same locality and providing health care for the local community members are better coordinated and directed toward more members than the groups targeted by a particular preventive program. Organizational framework of this kind calls for a joint work and close collaboration between the physicians and other health care workers, but allows the latter to achieve common and personal benefits, both on professional and financial level. As for now, organizational frame that prevails in the Republic of Croatia is that of independent and private practicing, so that each of our physicians makes a separate contract with the Croatian Institute of Health Insurance. In 2005, over 80% of GPs had such a status. After the problems arising from the existing system of privatized individual family medicine practices were identified, group practice has been recognized as an organizational and financial framework capable of contributing to the improvement of quality of the practice (11-13).

Conducting preventive programs in accordance with the harmonized guidelines. This should be regularly updated along the line of practice. The best-known evidence-based guidelines for preventive work are those prepared in Canada, as well as those prepared within the frame of the Countrywide Integrated Noncommunicable Diseases Intervention program (14,15). Despite the fact that in the Croatian national guidelines for certain preventive programs, for instance those targeted at cardiovascular or malignant diseases (16,17), have already been implemented, the role of a GP is still not fully recognized. These programs rely more on the activities undertaken in certain fields of clinical expertise, or on the activities undertaken by competent public health authorities.

Therefore, the guidelines for preventive work that would stand a chance in the everyday practice should include the greatest possible number of family medicine experts and recommendations for efficient organization of health care systems taken from previous research.

Conclusion

The use of indicators qualifying the level of professional conduct, including that targeted at the detection of cardiovascular risk factors, would provide GPs with both professional and financial stimulation for a programmed and efficient detection of various risk factors and chronic conditions. Payment modality and the follow-up of the conduct quality level represent the additional elements, which would allow more frequent utilization of opportunistic screening and increase its impact on population health care.