Dec 15, 1993 - Helen E. Smith, BM,BS, MSc, MFPHM; Carol P. Herbert, MD, FCFP ... Dr. Herbert is Royal Canadian Legion professor and head, Department ...
ORIGINAL RESEARCH * NOUVEAUTES EN RECHERCHE
Preventive practice among primary care physicians in British Columbia: relation to recommendations of the Canadian Task Force on the Periodic Health Examination Helen E. Smith, BM, BS, MSc, MFPHM; Carol P. Herbert, MD, FCFP Objectives: To compare the current practice of preventive medicine in British Columbia with the recommendations of the Canadian Task Force on the Periodic Health Examination. Four common, preventable forms of cancer (cervical, breast, lung and colorectal) were used as sentinel conditions. Design: Random sample mailed survey. Setting: Private primary care practices in British Columbia. Participants: A sample of 300 primary care physicians in 1991; of 285 eligible physicians 185 (65%) responded. Outcome measure: Compliance with preventive practices recommended by the task force. Results: Preventive practice complied with the task force's recommendations for breast examinations, mammography, cervical smears and initial counselling against smoking; over 90% of the physicians performed these manoeuvres in all or most cases. However, less than half performed two recommended manoeuvres for all or most patients who smoke: advice to follow a diet high in P-carotene (reported by 10%) and scheduling of follow-up visits to reinforce antismoking counselling (by 46%). Most of the physicians stated that they perform preventive manoeuvres in the context of an annual general physical examination rather than integrating them into routine patient care. Conclusions: The task force's carefully constructed recommendations are incompletely followed. Overall, there appears to be a high level of compliance with traditional and recommended manoeuvres but also widespread persistence in performing traditional manoeuvres no longer recommended and failure to adopt new recommendations.
Objectif: Comparer la pratique actuelle de la medecine preventive en Colombie-Britannique avec les recommandations du Groupe d'etude canadien sur l'examen medical periodique. Quatre types de cancer repandus (du col uterin, du sein, des poumons et colorectal) et justiciables de mesures preventives ont servi de ph6nomenes sentinelles. Conception: Sondage aleatoire par la poste. Contexte: Cabinets prives de m6decins de premier recours en Colombie-Britannique. Participants: Echantillon de 300 medecins de premier recours en 1991; 185 medecins (65 %) ont repondu sur les 285 admissibles. Mesure des resultats: Conformite aux recommandations du groupe d'etude en matiere de prevention. Resultats: La pratique preventive respectait les recommandations du groupe d'etude relativement 'a l'examen des seins, a la mammographie, aux frottis cervicaux et aux premiers conseils anti-tabac; plus de 90 % des medecins ont effectue ces actes dans tous les cas ou presque. Cependant, moins de la moitie a effectue deux des actes recommandes chez tous ou Dr. Smith is a Visiting Research Fellow, Department of Health Care anzd Epidemiology, University of British Coluibia, Vancouver, BC, and Dr. Herbert is Royal Canadian Legion professor and head, Department of Family Practice, University ofBritish Columbia, Vancouver, BC.
Reprint requests to: Dr. Helen E. Smith, 13 Pewsey Pl., Southampton SOI 2RX, England DECEMBER 15, 1993
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presque tous les patients qui fument: conseiller une diete riche en B-carotene (signalee par 10 %) et revoir les patients pour renforcer les conseils anti-tabac (par 46 %). La plupart des medecins ont declare qu'ils effectuent des actes de prevention a l'occasion de l'examen g6neral annuel au lieu de les integrer aux soins courants. Conclusions: Les recommandations soigneusement formul6es par le groupe d'etude ne sont que partiellement observees. En g6neral, le taux de respect des actes recommandes et traditionnels semble 6leve, mais les medecins semblent aussi persister, dans une grande proportion, a effectuer des actes traditionnels qui ne sont plus recommandes ou 'a ne pas donner suite aux nouvelles recommandations. T he Canadian Task Force on the Periodic Health Examination was formed in 1976, at the request of the Deputy Ministers of Health, to determine which preventive manoeuvres were of proven benefit and could enhance the health of Canadians. The task force used predetermined criteria to conduct a rigorous assessment of the scientific literature and formulate its recommendations.' Its first report was published in 1979: the task force recommended that the annual check-up be abandoned and replaced with age- and sex-specific packages of preventive manoeuvres.' Instead of general history-taking, a full physical examination and extensive investigations for an apparently healthy person, a limited set of preventive procedures was proposed that could be more easily integrated into any doctor-patient contact. Since 1979 the task force has produced many updates to the original report. Summaries of its deliberations and the final recommendations have been disseminated to primary care physicians through CMAJ. However, recommendations may not be sufficient to achieve changes in clinical practice, even if they emanate from an authoritative committee.' Shortly after publication of the task force's first report two studies of the preventive practices of primary care physicians in Quebec and New Brunswick reported poor levels of compliance with the recommendations.4 Unpublished local surveys in Vancouver and Calgary have shown similar resistance. There have been no recent studies of the preventive practices of Canadian primary care physicians, and no province-wide study has been conducted in British Columbia to determine compliance with recommendations from the task force. We performed this study (a) to determine the current pattern of preventive practice in primary care in British Columbia and (b) to compare actual practice with the recommendations of the task force.
Methods A random sample of 10% of the primary care physicians in British Columbia was prepared from the medical register of the BC College of Physicians and Surgeons. To confine the sample to active practitioners, those billing less than $50 000 per year were excluded. A structured questionnaire was mailed to the remaining 300 general practitioners and family physicians in the summer of 1991: The self-reported questionnaire had two sections: 1796
CAN MED ASSOC J 1993. 149d ( 11)
the first asked about preventive practice with respect to four common types of cancer (cervical, breast, lung and colorectal), and the second section examined the demographic characteristics and training of the physicians, their practice profiles and geographic settings. To maintain anonymity a postcard was mailed with the questionnaire on which physicians indicated their name and whether they were or were not completing the questionnaire. The postcard was returned to the investigators separately.8 After 4 weeks a reminder was sent to physicians who had not returned the postcard. Responses were encoded onto magnetic media and the data analysed on a microcomputer with the SPSS/PC+ statistical package (version 2.0, SPSS Inc., Chicago, 1988). The x2 test was used to assess the relation between compliance with the task force's recommendations and membership in the Canadian College of Family Physicians, training in a family medicine residency program, affiliation with an academic department, practice size and practice setting.
Results Fifteen of the 300 physicians sampled were not eligible to participate in the survey because they had either moved out of the province, ceased to practise or were practising in a different specialty. The response rate from eligible practitioners was 65% (186/285).
Cervical cancer The task force recommends that Papanicolaou smears be taken at least every 3 years for all sexually active women up to the age of 35 and every 5 years thereafter. For high-risk groups it recommends that smears be taken at least annually.) In all, 62% of the physicians reported that they obtain a cervical smear at least once every 5 years for asymptomatic women aged 35 and over. A further 35% perform this preventive manoeuvre for most women in this age group (Table 1). The remaining 3% perform the test on some of their patients. All but one of the physicians felt that it was an effective manoeuvre. Lack of patient compliance was the reason cited most frequently for not screening all eligible women (by 59% [42/711). In unsolicited comments several physicians remarked that they obtain cervical smears much more frequently than every 5 years, and 15 wrote that they favour annual LE 15 DECEMBRE 199'3
conditon, adonly13% wuld phsicaly examne th
testing for ease of recall. Smears are taken during a gen- condition, and only 13% would physically examine the eral check-up (reported by 95% of the physicians) or at a breasts at such a visit. visit scheduled specifically for this purpose (by 58%) Lung cancer (Table 2).
Breast cancer The task force recommends that annual physical breast examination and mammography be performed in all women over the age of 50;9 instructing women in breast self-examination techniques is not currently recommended. Most of the physicians reported performing physical examinations: 48% stated that they examine all female patients aged 50 years and over annually, and a further 45% examine most women in this age group. Annual screening by mammography is recommended for all women in this age group by 33% of the physicians and for most women by 48% (Table 1). The most frequent reason given for not complying with the recommendation for annual mammography was lack of patient compliance. Unavailability of the test, radiation risk and cost were also cited as factors. Most physicians stated that they teach breast self-examination to all of their female patients (reported by 43%) or to most (by 44%). All three of these screening manoeuvres for breast cancer were performed most often in the context of an annual general physical examination. Half of the physicians reported that they would perform them as part of a consultation for a related condition (Table 2); 24% would advise mammography at a visit for an unrelated
The task force strongly recommends that counselling about the risk of smoking be included in the periodic health examination of a patient who smokes.9 Of the physicians 96% claimed to counsel all or most of their patients against smoking. Most (94%) would offer adjuvant therapies in addition to counselling. A wide range of smoking cessation strategies were recommended: the most common ones were nicotine gum (recommended by 95%), hypnosis (by 26%), support groups (by 24%), acupuncture (by 21%) and formal smoking cessation programs (by 16%). The task force recommends the scheduling of follow-up visits to enhance the effect of antismoking counselling. However, only 8% of the physicians stated that they arrange follow-up visits for all counselled patients; 38% arrange them for most and 35% for some. Several of the physicians commented that the fee-for-service system acted as a disincentive, since there was no facility within the fee schedule to bill for such counselling. In its 1990 update the task force reported that there was fair evidence that smokers and ex-smokers would benefit from eating foods high in P-carotene and that this advice should be included in the periodic health examination.'` In our survey very few of the physicians reported that they provide this advice; 64% did not give
.cfpyimended by
the CTFPHE*
Manoeuvre
All
Most
Some
Few
None
Cervim.c-cancer
PapanM0laou
smear.
Breast cancer Annual physical exafliination of women >50 yr
Self-examination
Yes,
1.
0
62
35
48 43
45
5
2
0
NR
44
11
-2
0
Yes
33
48-
17
2
0
Yes
71
25
1
0
Yes
8
38
35
14
5
Yes
2
8
925
18 37
64
No
0
1'
8
28
18 63
NR
12
29
24
6
Yes
Mammography for women
>5`yr Lung ca1ter Antismoking counselling Follow.*up visit to reinforce counsellingAdvice 4o follow diet high in1-carotene Chest rdiography Sputum clytokgy
No
3-
Colorec~-cancer
Fecal occult blood testing in patients 45 yr
29
*CTFPHE = Canadian Task Force on the.Periodic Heafh Examnination, NR = neutral recommendation.
-tThe figures may not add up to 100 bat DECEMBER 15, 1993
f rounding.
CAN MED ASSOC J 1993; 149 (12)
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this advice to any patient, 20% were unaware that f3carotene had been implicated in the prevention of lung cancer, and 46% denied that there was any evidence to justify this advice. Chest radiography and sputum cytology have been shown to be ineffective methods for screening lung cancer, and the task force has recommended that these manoeuvres be excluded from the periodic health examination.2 "' However, 20% of the physicians stated that they use annual chest radiography for the early detection of lung cancer in all or most asymptomatic smokers (Table 1). Only 37% reported that they still use sputum cytology as a screening test, and even these physicians restrict its use to a small portion of their eligible patients (Table 1). Most (63%), including many of those still performing sputum cytology, were aware of the lack of its effectiveness.
patient noncompliance were the two most common reasons for not performing the test (given by 49% and 26% respectively). The physicians who continued to perform fecal occult blood testing did so most frequently as part of a general check-up (Table 2).
Colorectal cancer
Discussion
In its original report the task force recommended that fecal occult blood testing be included in the annual health examination of patients 45 years or over.' However, in 1989 it changed its opinion and expressed a neutral recommendation (i.e., that there was insufficient evidence to recommend inclusion or exclusion of such
The preventive practice patterns in this sample of physicians largely complied with the task force's recommendations on breast examination, mammography, cervical smears and counselling against smoking. However, in several other areas the physicians had not adopted the recommendations and were still ordering tests that have been clearly demonstrated to be valueless in the periodic health examination. Other studies have detected this apparent reluctance to stop performing procedures for which the task force had been unable to demonstrate any benefit. For example, in 1982, 77% of clinicians in New
testing).' In our study 41% of the physicians reported that they routinely test for occult blood in stool samples from all or most of their asymptomatic patients aged 45 years and over (Table 1). Lack of confirmed effectiveness and
Factors influencing preventive practice Compliance with the task force's recommendations was examined in relation to membership in the College of Family Physicians, residency training in family medicine, affiliation with an academic department, practice type (group v. solo), practice setting (urban v. rural), time since graduation, medical school of graduation and the number of patients seen per week. None of these characteristics appeared to influence the performance of any of the preventive practice manoeuvres studied.
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13
51
58
94 91
13 9
50
$4
91
24
*
*
190
62
6:
76'
49
9 .1:1
3
57
..
11
1798
CAN MED ASSOC J 1993: 149
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LE 15 DECEMBRE 1993
Brunswick were still requesting routine chest radiography for early detection of lung cancer in smokers, and 49% performed cytologic screening of sputum samples for the same purpose, 3 years after the task force published its recommendations against these screening tests.5 In our study the magnitude of such noncompliance was less, but sputum cytology was still being used as a screening manoeuvre by 37% of the physicians, 12 years after the first task force report. Physicians failed to perform two recommended manoeuvres considered in our study: advice to follow a diet high in P-carotene and scheduling of follow-up visits to reinforce antismoking counselling. The two most frequently offered reasons for not scheduling follow-up visits were (a) that counselling is time-consuming and (b) that there is no provision in the provincial medical services fee schedule to bill for it. Appropriate remuneration for recommended preventive activities would seem to be one way of encouraging their availability and their integration into primary care practice. Advising smokers to eat foods high in P-carotene was the manoeuvre that showed the greatest disparity between the task force's recommendations and clinical practice. In its 1990 update the task force reported that there was fair evidence to recommend that smokers and ex-smokers be advised to eat such foods (e.g., carrots) once daily on average. However, almost two thirds of the clinicians did not give this advice to any of their patients who smoked, and most of the physicians were unaware that such dietary modification was of benefit. This recommendation was included in a review of interventions to prevent lung cancer published 1 year before our survey. '° For screening for colorectal cancer, there was a clear mismatch in our survey results between knowledge and behaviour. Recent changes in the task force's recommendation may go some way to explain the discrepancy between widespread knowledge of the lack of proven effectiveness and the number of physicians still performing the manoeuvre. In its 1979 report the task force recommended fecal occult blood testing in middle-aged people with no known risk factors and no gastrointestinal symptoms.2 In 1989 it reconsidered the literature and concluded that there was insufficient evidence to recommend such screening." At the same time, it found the evidence equally insufficient to warrant stopping the practice where it already existed; hence, physicians may feel justified in continuing to perform this test even though they know that its benefit is unproven. Failure to adopt the task force's recommendations may be due in part to how the recommendations are disseminated. The recommendations are not summarized in any single document but instead are dispersed through many issues of CMAJ. In 1983 the College of Family Physicians of Canada published the Health Maintenance Guide, a loose-leaf book containing the recommendations. In our survey, only 41% of the physicians still had DECEMBER 15, 1993
access to a copy in their office, and of course some of the information contained in the guide is now obsolete. There seems to be an urgent need to address the way in which the task force's updates can be disseminated to gain maximum impact. Although the content of preventive activity is quite close to the recommended practice, most of the preventive manoeuvres are being carried out either as part of a scheduled complete physical examination (general check-up) or at a visit scheduled specifically for a preventive manoeuvre. The task force strongly recommended that the general check-up be abandoned and that preventive manoeuvres be incorporated into all types of patient visits, including consultations for unrelated problems.2 At least for the screening tests considered in this survey, this opportunistic approach to prevention has apparently not been adopted. Exploration of the most effective method of adding preventative care to traditional therapeutic encounters is an important topic for future research.'2 In addition, other professional bodies have made recommendations in some areas of preventive practice that contradict the task force's advice. Such reports clearly weaken the strength of the task force's recommendations and will lead to confusion among generalists over the optimum preventive strategies. We had hypothesized that physicians who had trained in family practice residency programs might differ from other physicians in their health promotion and disease prevention activities. However, family practice residency training was not associated with greater compliance with the task force's recommendations. This conflicts with the findings of a chart-review study in Ontario, in which certificants in family practice scored higher for secondary preventive activities than noncertificants.'3 On the other hand, similar results from studies in the United States are consistent with our findings.'1'6 The reported level of preventive practice in our study may be an overestimation of the true level in British Columbia. In a validation study in Quebec, an overreporting factor of 10% was identified in selfreported estimates of colorectal cancer screening activity.4 Our data were self-reported, and we did not attempt to validate responses by comparing the physicians' answers with actual practice. In theory, provincial billing data for specific preventive practices (e.g., counselling, Papanicolaou smears) could have been used to compare "reported" preventive activity with "remunerated" prevention, but it was considered that a request for permission to examine such data might adversely affect the response rate. Moreover, most preventive manoeuvres are not billed as such, and thus it would be impossible to derive meaningful data from billing records. In summary, we found that many primary care physicians in British Columbia are playing a role in health promotion and providing appropriate preventive medicine. However, there is still room for improvement to bring worthwhile manoeuvres to all eligible people in CAN MED ASSOC J 1993; 149 (12)
1799
that province. Conversely, energy, time and money are being dissipated in performing procedures for which there is no proven benefit. Integration of preventive activities into daily clinical practice remains an unattained goal. Funds for preventive medicine are limited, and it is vital that they are used efficiently and appropriately. If the health of Canadians is to benefit fully from the task force's rigorous and innovative approach to appraising preventive activities, rhetoric must be translated into reality by addressing the important issue of implementation. We thank Dr. Anthony J. Frew for his advice and assistance in preparing the paper. The study was supported by a grant from the Department of Health, London, England.
References 1. Canadian Task Force on the Periodic Health Examination: Periodic Health Examination Monograph: Report of the Task Force to the Coniference of Deputy Miniisters of Health (cat H393/1980E). Health Services and Promotion Branch, Dept of National Health and Welfare, Ottawa, 1980 2. Idem: The periodic health examination. Can Med Assoc J 1979; 121: 1193-1254 3. Lomas J. Anderson GM, Domnick-Pierre K et al: Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians. NEngl JMed 1989: 321: 1306-1311 4. Battista RN: Adult cancer prevention in primary care: patterns of practice in Quebec. Am J Public Health 1983; 73: 1036-1039 5. Battista RN, Palmer CS, Marchand BM et al: Patterns of preventive practice in New Brunswick. Can Med Assoc J 1985; 132: 1013-1015 6. Ho A, Herbert C, Farrall J: Periodic Health Screening: What Members of the Department of Family Practice at Vancouver General Hospital Are Doing, Dept of Family Medicine, U of British Columbia, Vancouver, 1988 7. Elford RW: Patterns of Preventive Practice in Primary Care: a Pilot Survev of Southertn Alberta Family Physicians, Dept of Family Medicine, U of Calgary, Calgary, 1987 8. Dillman DA: Mail and Telephone Survevs - the Total Design Method, Wiley, New York, 1978 9. Canadian Task Force on Periodic Health Examination: Periodic health examination: 2. 1985 update. Can Med Assoc J 1986; 134: 724-727 10. Idem: Periodic health examination, 1990 update: 3. Interventions to prevent lung cancer other than smoking cesssation. Can Med Assoc J 1990; 143: 269-272 11. Idem: Periodic health examination: 2. 1989 Update. Can Med Assoc J 1989; 141: 209-216 12. Battista RN, Williams JI, Boucher J et al: Testing various methods of introducing health charts into medical records in family medicine units. Can Med Assoc J 199 1; 144: 1469-1474 13. Borgiel AEM, Williams JI, Anderson GM et al: Assessing the quality of care in family physicians' practices. Can Fam Physician 1985; 31: 853-862 14. Wechsler SH, Levine S, Idelson RK et al: The physician's role in health promotion. A survey of primary care practitioners. N Engl JMed 1983; 308: 97-100 15. Radecki SE, Mendenhall RC: Patient counselling by primary care physicians. Results of a nationwide survey. Patient Educ Couns 1986; 8:165-177 16. Attarian L, Fleming M, Barrow P et al: A comparison of health promotion practices of general practitioners and residency trained family physicians. J Community Health 1987: 12: 3 1-39 1800
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Conferences continuedfrom page 1779 Feb. 28-Mar. 2, 1994: Consensus Development Conference on the Effect of Corticosteroids for Fetal Maturation on Perinatal Outcomes (cosponsored by the National Institute of Child Health and Human Development and the US National Institutes of Health Office of Medical Applications of Research) Bethesda, Md. Debra Steward, Technical Resources, Inc., 3202 Tower Oaks Blvd., Rockville, MD 20852; tel (301) 770-0610, fax (301) 468-2245
Apr. 25-26, 1994: Canadian Pharmacoepidemiology Forum Toronto Abstract deadline: Feb. 1, 1994 Dr. C. Ineke Neutel, Health Protection Branch, Health Canada, 3rd flr. E, Sir F.G. Banting Research Centre, Tunney's Pasture, Ottawa, ON K l A OL2; tel (613) 954-6745, fax (613) 941-5061
May 20-21, 1994: 3rd Intemational Perinatal and Gynecological Ultrasound Symposium Ottawa Study credits available. Ms Nicole Belisle, Department of Obstetrics and Gynecology. Ottawa General Hospital, Rm. 8420, 501 Smyth Rd., Ottawa, ON KIH 8L6; tel (613) 737-8566, fax (613) 737-8470
June 3-4, 1994: Alcohol and Other Drugs in Pregnancy: Issues for Families and Communities - a Conference to Address Fetal Alcohol Syndrome and Neonatal Abstinence Syndrome (cosponsored by Sunny Hill Health Centre for Children) Vancouver Study credits available. Alcohol and Other Drugs in Pregnancy, Continuing Education in the Health Sciences, University of British Columbia, Rm. 105, 2194 Health Sciences Mall, Vancouver, BC V6T lZ3; tel (604) 822-2626, fax (604) 822-4835
June 12-15, 1994: Critical Care Symposium Banff, Alta. Study credits available. Continuing Medical Education, Faculty of Medicine, University of Alberta, 2J3 Walter Mackenzie Centre, Edmonton, AB T6G 2B7; tel (403) 492-6346, fax (403) 492-5487
Aug. 18-19, 1994: Pharmacologic Treatment of Obesity (satellite symposium of the 7th International Congress on Obesity) Saint-Adele, Que. Dr. George A. Bray, Pennington Biomedical Research Center, 6400 Perkins Rd., Baton Rouge, LA 70808; tel (504) 765-2513, fax (504) 765-2525 For prescribing information see page 1809
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