Screening in general practice/ family medicine in Europe

[Gatekeeper]

Τα παρακάτω προέρχονται απο την εσωτερική αλληλογραφία της UEMO.

FRANCE
Biology Screening
More than 60% of biology acts are prescribed by general practitioners.
One consultation out of seven ends with a prescription of biological examinations for the purpose of diagnosis or therapeutic management. If this prescription is not oriented by clinical examination, but carried out in a systematic way (the famous checks or check ups requested by some patients), it increases the probability of obtaining results outside normal values.
The normal values defined from a sample of population, healthy Caucasian individuals, are distributed according to a Gaussian curve.
The 95% confidence interval excludes 2.5% of higher scores and 2.5% of substandard results. In addition there is a variability depending on the reference population, sex, intra individual, related to the technique of sampling, measurement and equipment used by each laboratory.
A number of results will therefore be found in outside normal values without being pathological. In a healthy subject for a single biological parameter, the probability of obtaining an abnormal result is 5%; for 10 examinations of biological parameters carried out in a healthy subject the probability of obtaining an abnormal result is 40%
The misuse of biology, prescribed to reassure doctor and patient, increases the number of results outside the reference values considered at wrong as pathological and increases iatrogeny by conducting unnecessary additional examinations or by treatment of pathologies that are not. This misuse increases the discovery of abnormalities diagnosed with no therapeutic consequence and therefore anxiety in the patient who is waiting for his results.
The probability of discovering a non-pathological result by means of a systematic biological assessment but outside normal values is higher than that of discovering a disease at the infra-clinical stage.
The doctor must therefore set up a real quaternary prevention: "Primum non nocere" and prescribe only exams useful for his patient and in the context of the meeting.
What is really what I am prescribing?
Is this relevant?
Is it in respect with the recommendations?
How to manage abnormalities found in a fortuitous way?
Am I doing service to my patient?
Am I aware of the direct and indirect cost to society?

Three national organized screening programs are implemented in France :
•   Breast cancer : The organized breast cancer screening program aims to detect possible cancerous lesions to treat them as soon as possible. It is aimed at women aged 50 to 74 with no other risk factor than their age. The participation rate is 50%, to which 15% of individual screening is added, which represents a rate of 65% of the female population benefiting from it (the European objectives are 70%). The women concerned receive a letter encouraging them to meet the radiologist. a double reading of X-rays is performed. The GP receives the results.
•   Colorectal cancer : Screening for this cancer is facilitated by the fecal occult blood immunoassay. This test is distributed through the attending physician to those aged 50 to 74 who are involved in the organized screening program.The immunoassay has increased sensitivity, allowing better detection of cancers and adenomas. The role of GP is crucial to inform and sensitize the target population on the major interest of this screening. The participation rate is only 33% of the population
•   Cervix. : Regular screening of the entire target population is considered to reduce the incidence by 90%. Cervical uterine cervix screening is recommended every three years for all women 25 to 65 years of age.This screening will start in 2018 as part of an organized national program. This approach is complementary to a prevention strategy via vaccination against HPV, to offer to girls from the age of 11 years. Cervical uterine sampling can be performed by the Gp, a Gynecologist or a midwife. The GP receives the results and is responsible for organizing the follow-up. The participation rate is 60%

Health professionals including GPs are encouraged to detect skin cancers. Fact sheets on the early detection of skin cancer are distributed
GPs and dentists are encouraged to screen the oral cavity. But nothing is organized.
Early detection of prostate cancer is not recommended

Health check of the Primary Health Insurance
It is possible to claim the health check of the Primary Health Insurance Fund every 5 years.
The exam is personalized according to age, family history, lifestyle and risk factors. On average, the consultation lasts 2H30.
The exam is totally free, no advance fees to make.
Reception of the person: a medical questionnaire must be completed
Interview about lifestyle: it allows you to better target risk factors and implement preventive actions
Biological examinations: it consists of bio-medical analyzes (blood test and urine analysis) to detect possible diseases (diabetes, hypercholesterolemia ...)
Dental examination: it is generally proposed to people who have not performed a checkup for more than 6 months
Complete medical examination: it is carried out by a doctor in order to know the procedure to follow (complementary exams ...).
For women, a gynecological examination may be proposed
Paramedical examination: it is performed by a nurse who measures(weight, height, blood pressure). If necessary, visual, auditory, breath and electrocardiogram examination can be performed.
In addition to the previous email sent by Patrick I just mention an initiative made by Agricultural mutual social insurance (it is the national insurance for farmers and employees working in agricultural industry. Mutualité Sociale Agricole- MSA)
It is a targeted screening, to some turning points of life:
Chilhood, teenager, young adult , around fifty, and at retirement  different questionnaires for each period and gender are sent to the
members,( for instance for teenager it insist about drug addiction, gender identity etc.) when the questionnaire is filled the member go to the nurse for blood sample and  data recording (weight, waist, blood pressure, etc.) and after or directly to their registred GP .
We discuss each point of the questionnaire, examine the member and conclude . We are directly paid by the MSA.
What is interesting is that it is a population centered approach linked with the risks factors directly associated with the age or gender, and the GP as the full initiative to the follow up.
You will find in attached a leaflet (in French) I add in CC colleagues public health specialists working in MSA, perhaps they will add relevants comments or data.

ROMANIA
Approximately 6000 family doctors (half of all family doctors in Romania) were involved in a screening program for cervical, breast and colorectal cancer, being trained by family-trained doctors for collecting cytological tests (smear tests). The program has been running since 2012, it continues theoretically now as well, but its financing had syncope, the interval of repeating the cytological test was fixed at 5 years, with other technical and administrative problems, which greatly decreased the efficiency of the program

PORTUGAL
 In Portugal it is the GPs who carry out breast cancer, colorectal and cervical cancer screening, but there are regional differences in terms of organized screening. So some regions have organized screening for some cancers, others don't, so in the regions that don't, GPs request opportunistic screening.

IRELAND
National Cervical Screening Programme done though GPs - 3 yearly from 25 yo  up to 44 yo - 5 yearly afterwards - HPV testing of all smears will come soon
National Colorectal screening done by National programme from 60 yo by way of FOB testing - does not involve GP
National Breast screening mammogram from 50 to 67 yo - does not involve GP
If FOB is + National screening service organises all
Screenin info available at Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

There is also a heel prick at birth fot 8 diseases Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

There is a Diabetic eye screening for registered Diabetics - gp just notified of findings - all care organised by screening service
All babies at birth have auditory testing
Mandatory HIV testing with other bloods is done for all maternity cases
There is free combined maternity care if registered through GP with 2 and 6 week check of baby  with GP  and 6 week check of mother togerther with combined Hospital / GP care - The 2 and 6 week checks could ber counted as screenin

We dont have A AAA or infectious disease screening servioce in GP land like UK


NORWAY
The attitude is to keep screening in line with the WHO concept. Avoid wild screening (difficult, especially PSA-testing). Some major diseases: recommended case finding by GP´s (diabetes, hypertension) 

Screening for cervical cancer is done in GP surgeries, in collaboration with a central office, sending out reminders. Smears every third year 25-31, and then HPV-test every fifth year to 70


Mammography is every second year from ages 50-70, GPs are not involved.


A new scheme for colorectal cancer screening is about to start up for 55 year Norwegian's, after thorough investigation in one county. FOB-test, and coloscopy in a combination, with a planned increase in use of coloscopy. Most likely, GP´s will not be directly involved, but we suspect an increased interest in testing, for other age groups.


A few years ago, we got a controversial program screening for diabetes in pregnancy, performed by the GP´s. Evaluation most likely will change the content of this.
Infectious diseases in pregnancy: a mandatory test for syphilis, and voluntary tests for HIV and rubella. And of course blood type and Rh.


Diabetic eye screening: supposed to be arranged from the GP´s, as a referral to eye specialists - who decide the intervals and methods.


Ultrasound in 18. week of pregnancy, newborn screening, hearing: hospitals


Screening and vaccination of children; a separate service, run by nurses, with some participation from GP´s, as a salaried, "mandatory" position.


In Norway, patients pay a fee to the GP´s, with some exceptions:
* Pregnant women, including post partum control
* Highly infectious diseases.

We get special pay for doing yearly checkups of mentally disabled, patients with psychoses and dementia (home dwelling). And for doing thorough evaluation of the medication, if the patient uses 4+ medicines.

 We don't have screening for:
Aortic aneurysm, sickle cell and thalassaemia 
No "health checks" for people without symptoms


UK
In the UK screening for colorectal cancer (Feacal Occult Blood) and breast cancer (mammography) is centrally organised and recalled with further invitations for colonoscopy or biopsy issued if required.
Screening for cervical cancer is done by smears in GP surgeries with further investigations at hospital if the smear is abnormal.
The intervals are 2 years for bowel cancer between the ages of 60-74 with a single test at 55 years
Mammography is every three years from ages 50-71
Cervical screening is every three years from 25-49 and every five years from 50-64.
There is, of course screening for other diseases
Aortic aneurysm, diabetic eye screening, fetal abnormality screening, infectious diseases in pregnancy, newborn screening, hearing, sickle cell and thalassaemia 
Explanation of population screening is available on the government website
Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

TURKEY
Cancer screening
*Screening for cervical cancer is done by smear/HPV TESTSin some GP offices by certificated nurses  with further investigations at hospital if the smear is abnormal and
 inHealthy Life Centers (Sağlıklı Hayat Merkezleri) in collaboration with a central office.. Smears every fifth year between 30-64
 
*Screening for breast cancer in Healthy Life Centers ,every 2 years between 40-69
 
* Screening for colon cancer by rapid diagnostic tests (fecal occult blood)  both inGP offices and in Healthy Life Centers ,every 2 years between 50-69
 
 
 
(Healthy Life Centers (Sağlıklı Hayat Merkezleri) are builded for investing in health not disease. Activation of 100 Healthy Life Centers started in September 2017 and nearly 200 in number at the movement.They are founded by the government.In these centers; within the scope of healthy nutrition, healthy eating habits suggestions are given under the guidance of dietitian, and psychological support and physical activity habits for obesity are gained with the support of psychologists and physiotherapists. Smoking cessation counseling is provided by a team of physicians, nurses, dieticians and psychologists, who are directly involved in counseling, support and follow-up services integrated with the Alo 171 line. Chronic disease management; in order to provide full support to family health centers and family physicians, teams consisting of psychologists, dietitians, physiotherapists and social workers are involved in personal and community trainings. Psychologist support is provided for alcohol and drug addicts. In order to increase and maintain physical activity, physiotherapists, physiotherapists in Healthy Life Centers are assigned..Cancer screening devices are collected there. Case Controllers provide the organization between our Healthy Life Centers and the people receiving service.)
 
Pre-wedding:
*Thalassaemia
*Syphilis,  HIV,HBV
*Graphy for tuberculosis
Bloods taken by GPs;graphy in tuberculosis dispensary
 
 
 
Birth:
*Heel blood (first at hospital;second at GP Office)( Phenylketonuria, Hypothyroidism, Biotinidase Deficiency, Cystic Fibrosis).
 
*Hearing(hospital)
*Eye screening(both at hospital and by GP)
* Developmental Hip Dysplasia examination by GP
*Testis/Genital examination by GP
*Mandotary followups:7 till 1 year of age;7 till 5 year 3 months of age;every year from 6 to 21 years of age
*Eye ,teeth examinations at schools
 
Pregnancy:
*TORCHES;blood type,CBC
*4 mandatory followup by GP offices
*OGTT;not mandotory
*Triple scan;not mandotary
*3 followups till 1 month after birth;by GP offices
*vitamin d and iron supplements

HOLLAND
In the Netherlands population-based screening is the responsibility of public health/the state.
There are three big national programs for the general population: for colorectal cancer, breast cancer and cervical cancer. The smears for cervical cancer are done by the GP (the invitations are sent through the national program). Also referrals to hospital in case these screenings have a bad outcome, is done by GP's for all three programs. We get notified of bad results through the national program a few days before the patient.
 
There are other national screening programs for
•   Newborns (blood, screening on 23 diseases, a.a. thalassaemia, and hearing)
•   Pregnant women (blood and ultrasound, a.a. hepatitis, and Down syndrome)
•   Refugees (X-rays and blood, a.a. tuberculosis)
 
Screening on STD's (done by public health doctors) is free for special groups, like people below 25, sexworkers, gays, people from a list of countries that have high levels of STD's and for people having sex with people from these countries.
 
You can read about the biggest programs on: Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος
Of course GP's can do screening on for instance cardiovascular diseases if necessary, but it is more on a case finding basis or if there is a big risk factor in the family. These are not programs.

Czech Rep.
in Czech Rep. 3 screening programs are in course, as in other countries it is CRCa, mammo and cervical screening.

Colorectal screening:
Starts at the age of 50 completely managed by GPs (rarely gyneco) who deliver test tubes for quantitative testing mostly examined in the GPs´surgeries by POCT methods. GPs who don´t have any POCT advice send the tests to the laboratory. Within the age 50 - 55 patients are screened annually, when reaching 55 the testing continues each 2 yrs or a patient may chose screening colonoscopy. Health insurances are sending reminders to persons, who had not been screened within  last 3 yrs.
CRCa screening was launched in 2000, when CZ was a leading country in the world + EU ( ! ) as for the incidence of this disease. The actual figures are much more positive - CZ is now between 15th - 18th place.

Mamma:
Starts at the age of 45, managed by either gynecologist or GP - both are sending to mammology once in 2 yrs - more frequently in case of  TABAR 4 finding

Cervix:
Fully managed exclusively by gynecologists since 25 yrs of age
Vaccination against HPV fully covered by health ensurances. for young girls

So this is the answer for CZ

ITALY

see attachment