Transcript Lysbilde 1

Strategies in
preventive Health Care
Gisle Roksund
President of The Norwegian College of General Practice
Wonca Europe Council, Istanbul september 4. 2008
Why policydocument?
• We want a sustainable and responsible national
strategy for preventive health care
• We see ethical challenges with the modern,
proactive, individually focused preventive health
care
Gisle Roksund
September 4. 2008
Side 2
Of course unconditional positive:
• Lots of traditional, causespesific preventive
medical actions like vaccination, limitation of
infectious diseases, etc.
Gisle Roksund
September 4. 2008
Side 3
But:
• We see lots of ethical and practical problems
with modern, proactive medicine, where the
purpose is to interact in multifactorial conditions
based upon theoretical calculations of risk for
future illness and disease
Gisle Roksund
September 4. 2008
Side 4
And we are not alone..
• B Starfield, J Hyde, J Gérvas and I Heath:
The concept of prevention: a good idea gone
astray?
J.epidemiol.Community Health 2008;62;580-583
http://jech.bmj.com/cgi/content/full/62/7/580
• ”The concept of prevention has lost all practical meaning”
• ”The boundaries between prevention and cure are becoming
increasingly indistinct”
Gisle Roksund
September 4. 2008
Side 5
Three levels
• National
• Local and regional
• Individually
Gisle Roksund
September 4. 2008
Side 6
National level
• Political work, demands from authorities, national
strategies, campaignes etc
• One of the most important efforts:
Ensure that children are raised near responsible
adults
Gisle Roksund
September 4. 2008
Side 7
Priorities and responsibility
• Structural measures at the social level should be
prioritized over individual screening and
intervention when possible
Responsibel: authorities
• Demands political willingness and courage
• Medical organisations: information and attitudes
Gisle Roksund
September 4. 2008
Side 8
Local and regional level
• The responsibility of local and regional authorities
Public health
• The responsibility of the GPs
Be familiar with the local and regional efforts regarding
preventive health care, thus the patients can be informed
and motivated for participation
• GPs are encouraged to participate in local public health
work
Gisle Roksund
September 4. 2008
Side 9
Individual level
• Prevention of sickness and disease must be based on
the mobilisation of resources and vitality
• Informing, advising and counselling are the most
important measures
• The GPs are important with golden moments, local
knowledge and good dialogues
• It is important that the GPs communicate general health
factors to the patients in a suitable manner
Gisle Roksund
September 4. 2008
Side 10
Spesific prevention of illness and
disease
• So-called limit values for risk intervention do not express
medical facts, but reflect research based consensus in
combination with subjective value choices
• Value choices are often greatly influenced by narrow
professional circles with strong and committed opinion
leaders
• Commercial interests have for a long time set the agenda
for which diseases doctors are encouraged to prevent
• The pharmaceutical industry and many organ specialist
groups have a strong focus on individual interventions
and use of medicine
Gisle Roksund
September 4. 2008
Side 11
Progressive lowering of thresholds
for ”predisease”
•
•
•
•
•
•
Hypertension
Serum cholesterol
Blood glucose
Asthma
Heart failure
Myocardial infarction
Gisle Roksund
September 4. 2008
Side 12
An example…
Gisle Roksund
September 4. 2008
Side 13
Guidelines applied on the HUNT 2 population
% of individuals
100
90
Cholesterol ≥ 5 mmol/l and
not already included
below
80
70
60
Totally: 76% of persons ≥ 20 years
have unfavorable profile
50
BP ≥ 140/90 and/or on
antihypertensive treatment
40
30
20
10
0
20
25
30
35
40
45
50
55
Gisle Roksund
60
65
70
75 Age
Getz et al. SJPHC 2004
September 4. 2008
Side 14
CVD diseases and number of risk factors
%
100
0
90
1 risk factor
80
70
2 risk factors
60
50
40
≥ 3 risk factors
30
20
CVD, diabetes and
treated hypertension
10
0
20
25
30
35
40
45
50
55
60
65
70
75
Age
Gisle Roksund
September 4. 2008
Side 15
And this in a country where people
live longer than almost any other
places…
Gisle Roksund
September 4. 2008
Side 16
The sum of advices is a known
problem…
Gisle Roksund
September 4. 2008
Side 17
An overview over healthproblems
our authorities and specialists want
us to do....
Homo
Precystein
hypertention?
(Hormonal
replacement)
Earlys
ultrasound
Mikro –CRP?
Fibrinogen
Stenosis in
Diabetescarotis arterials
Physical
activity
Vision,
glaucoma,
Sexual dysfunction
redused hearing
Vaccinations/
STD
Influenza
Chlamydia
prevention
Pneumoni
Abdominal aorta aneurysme
Kilde:J. Sigurdsson/L.Getz
Gisle Roksund
September 4. 2008
Rapid tests
Genetic
tests?
Side 18
Of cource..
• We do NOT want to quit all this work
BUT:
Gisle Roksund
September 4. 2008
Side 19
We are talking about the utopic
visions of the riskmedicine
• Huge expantion
• Ever more investigations to identify increased
risk for future illness and disease
• Medical technology is central
• Ever more of us are going to be individuals at
risk
• Ever lower threshold to be ”abnormal”
Gisle Roksund
September 4. 2008
Side 20
High risk strategy includes high
risk…
• The HUNT data shows us that up to 84% of adult
norwegians have two or more risk factors that, if
we are going to follow the guidelines of the
european cardiologists litterally, will need
individual, clinical follow-up (Halfdan Petursson)
Gisle Roksund
September 4. 2008
Side 21
Consequences
• Increased medicalisation
Expanded exposure to drugs lead to important
harm
• Not better if other members of the
interdisciplinary team (nurses) take over
(Even more loyal to algoritmes than doctors..)
Gisle Roksund
September 4. 2008
Side 22
The engagement of the
pharmaseutical industry (1)
• 65 of the 77 most cited clinical (RTC) studies
between 1994 og 2003 were sponsed by the
industry. The ratio has been increasing
• 18 of the 32 most cited studies published after
1999 were totally financed by the industry
Patsopoulus NA, Analatos AA, Ioannidis JPA. Origin and funding of the most
frequently cited papers in medicine: database analysis. BMJ 2006; 332: 1061-4.
Gisle Roksund
September 4. 2008
Side 23
The engagement of the
pharmaseutical industry (2)
• It is well documented that the degree of
commersial financing of a research project,
predictes the results: the higher ratio, the more
probable is the result in favor of the sponsor
Ridker PM, Torres J. Reported outcomes in major cardiovascular clinical trials funded
by for-profit and not-for-profit organizations: 200-2005. JAMA 2006; 295: 2270-4.
Gisle Roksund
September 4. 2008
Side 24
Need for better theoretical
foundation
• Preventive medicine needs a comprehensive
and consistant theoretical basis to be sustainable
and responsible
• Biomedical, humanistic and healthpolitical
arguments should be included in this highly
necessary reorientation and theorybuilding
• Research in general practice is mandatory
Gisle Roksund
September 4. 2008
Side 25
A new strategy
• We want a sustainable and responsible national
strategy for preventive health care
• Stronger focus upon
• Population rather than individuals
Health rather than spesific diseases
Distribution and inequity in health within populations
Gisle Roksund
September 4. 2008
Side 26
More of the same:
The law of reduced benefit
Benefit
Inputs to medical care
Gisle Roksund
September 4. 2008
Side 27
Proposal
• Appoint an ad hoc committee to, in collaboration
with Europrev, work out a policy document for
strategies in preventive health care for WE
Gisle Roksund
September 4. 2008
Side 28