Screening and monitoring

Screening is the systematic individual evaluation of health status or risk of developing a particular health status. Conversely, monitoring involves routine evaluation of changes to health or health risks. Effective screening and monitoring share the need for standard assessment procedures, and protocols  to ensure proper management of patients.

Screening processes seek to identify individuals who are likely to have a health behaviour or condition that might benefit from intervention. They are not diagnostic, and positive screenings are usually given further examination before confirmation of diagnosis is possible. However smoking is an exception,  as patient responses are used to assess smoking status and it's not socially acceptable or cost-effective to engage in further invasive diagnostic tests.

Screening requires being able to identify which patients may need help, to approach appropriate patients in both a proactive and reactive manner, and to accurately assess the patient need for further diagnosis and further care. Monitoring involves not just assessment of a condition or behaviour,  but like screening also requires coordination of care and a systematic approach so that problems are acted upon.

Do pharmacists need to screen and monitor for hypertension and smoking cessation?
Answer: Yes

As with many chronic disease risk factors, underdiagnosis and undertreatment of hypertension and smoking cessation is a highly prevalent problem. Community pharmacists are uniquely placed with ready access to individuals with such risk factors, and can play a key role in facilitating and delivering  better management (Mc Namara et al., 2009; Mc Namara et al., 2010; National Stroke Foundation, 2009).

HypertensionIn Australia, just two thirds of women and half of males with hypertension are aware they are hypertensive (Janus et al., 2008; Briganti et al, 2003). Given that one in three adults have hypertension, this implies a significant proportion of adults have undiagnosed hypertension.  More intensive screening is necessary to identify these individuals. Among diagnosed individuals - although about 75% should be treated with medicines - just half are treated, and in these treated individuals blood pressure is controlled in only about 40-45% (Janus et al., 2008; Briganti et al, 2003).  This highlights the need for ongoing patient monitoring following diagnosis, and pharmacists can undertake this monitoring.

Smoking
There is evidence both in Australian hospitals (George et al., in press) and in primary care (Chapman et al., 2009) to demonstrate that most opportunities for health professionals to identify and discuss tobacco use are not used. Just one-third of smokers reported receiving  smoking cessation advice from their GP in the previous year, increasing from 30% of youngest to 60% of oldest smokers, despite most (87%) current smokers visiting a GP (Chapman et al., 2009). Pharmacists can fill this gap. It is noteworthy that smoking prevalence is highest at a younger age but this  group is less likely to get advice.

Which individuals should be screened and monitored?

ADVICE: If prioritising is required, identify patient groups with higher prevalence or with existing conditions where the benefits of intervention would be greater.

All patients of unknown smoking and blood pressure status are worth screening as high-prevalence conditions  such as smoking and hypertension have easy, non-invasive assessment. When there's not enough time to screen everybody - regularly the case in pharmacies - you may need to selectively target interventions towards patients most likely to benefit. Guidelines for hypertension and smoking cessation identify  high prevalence and high-risk patients groups. Also, patients may self-identify if you have posters and pamphlets advertising the support you can provide.

Hypertension
The following groups (not definitive) are demonstrated to be at greater risk of uncontrolled or undiagnosed blood pressure. They may be worth placing special emphasis on for screening and monitoring activities:

  • Older patients (over 65 years) may be less informed about their blood pressure, and also less intensively treated.
  • Overweight and obese patients as uncontrolled hypertension has also been linked to obesity and physical inactivity (as risk factors for hypertension, this makes sense).
  • Males are more likely than females to have undiagnosed hypertension, less likely to have blood pressure controlled if diagnosed, and are more likely to lack blood pressure awareness.
  • Ethnic groups at higher risk of heart disease: e.g. Aboriginal and Torres Strait Islander, Maori, Pacific Islander, Indian subcontinent.
  • Clinical groups at high risk of heart disease: e.g. those with kidney disease, diabetes, existing cardiovascular disease, obesity, smoking and those using hypertension-inducing medicines.

Smoking cessationThe following groups (not definitive) are known to have a higher prevalence of smoking:

  • Those with a lower educational status.
  • Younger people
  • Pregnant women (23% smoke but often deny this).
  • Aboriginal and Torres Strait Islanders (over 55% of men and 30% of women smoke) and several different culturally and linguistically diverse groups (e.g. studies show prevalence rates of 53% in Vietnamese men, 42%-55% in Arabic adults. Source: Zwar et al, 2004).
  • 50%-80% of people with mental illness smoke according to some surveys ( Zwar et al, 2004).

Sometimes there are other indications that a patient or customer smokes. E.g. Co-morbidities such as chronic obstructive pulmonary disease and slow wound healing, discoloured teeth or nails.

How should screening and monitoring be conducted?
Answer: Use best practices for measurement, management and referral.

Screening and monitoring are designed to identify patients who have certain uncontrolled health issues and need further assistance. Therefore it is important to be familiar with appropriate counselling points and know how to facilitate further assessment and management. Failure to ensure follow-up will  limit the benefits of screening and monitoring. Assessment during screening and monitoring should consider best measurement practices to minimise ‘false positives' (incorrectly giving somebody a diagnosis), and ‘false negatives' (failing to diagnose individuals with the condition).

Documenting results in patient files and providing written educational material is known to improve the effectiveness of health professional interventions. In interpreting results for patients, consider the potential for false positive results, the likelihood of positive screening arising by chance.  You also need to think about how co-morbidities (e.g. diabetes) and behaviours (e.g. smoking) to explain more accurately how uncontrolled blood pressure (or other screened condition) will affect health outcomes. Online educational tools from Australia and New Zealand provide useful health risk calculators which factor in the impact of tobacco use and hypertension.

Hypertension
Measuring blood pressure accurately can be a tricky process and you should certainly not make a diagnosis on the basis of a single reading. Refer to the section on measuring blood pressure for detailed instructions. Written guidance on blood pressure measurement and  overall cardiovascular risk is also available from national guidelines for hypertension management. Unexplained high readings deserve thorough investigation. The National Stroke Foundation ‘Know Your Numbers' program provides extensive guidance on how pharmacies should set up blood pressure stations and information that should be provided to patients.

Smoking cessation
As mentioned above, the best way to identify smokers is through direct questioning. While it is unlikely to result in many ‘false positives', it won't identify all smokers. The type of language used can be very important. Asking "Are you a smoker?" or "Do  you smoke?" may not identify social smokers or individuals who might have avoided cigarettes for a couple of dcays but still experience strong cravings. Asking instead "Have you ever smoked?" (GGT, 2006) is a more objective question. If answered in the positive, it can then be followed by other appropriate  questions such as "When did you last smoke?" (GGT, 2006) and inquiries about the quantity smoked, to get a better idea of their true smoking practices. Depending on where you work, tobacco may be chewed or otherwise ingested, so asking about ‘tobacco use' may be better than ‘smoking' in some  instances.
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