Personalized Preventive Plan in General Medicine

Background: In recent years, prevention has become increasingly important in General Medicine (GM) and has become the focus of several debates worldwide. The evolution of the Tunisian society urges to seek a preventive approach then a Specific Preventive Consultation (SPC) became a necessity. Objective: We aimed at determining the output of a SPC within a consultation of GM. Method: A descriptive study was carried out for 9 months (from November 2016 to July 2017) in a primary care at Monastir governorate. A SPC was incorporated into the daily care consultations. An appropriate questionnaire, highlighting cardiovascular, carcinogenic and depressive risk factors, was sent to 313 consultants who agreed and adapted actions have been proposed to them. We have analyzed follow up results for screened participants according to personalized preventive plan (PPP). Results: For 313 participants, 48 (15%) have high cardio vascular risk (HCVR). Obesity, physical inactivity, smoking and alcohol consumption were notified respectively among 30.5%, 19%, 19% and 7% of our population. Familial ATCD of breast cancer was present in 2.2%, anxiety in 32% and depression in 23% of our patients. All screened participants provided with a personalized prevention plan (PPP). Therapeutic education was performed for 140 patients; awareness to a tobacco free environment for 155 and 71 mammography was prescribed for women at risk from which one returned with cancer. Conclusion: SPC has improved the knowledge and practices of patients. It also identified several risk factors and especially breast cancer at an early stage. We concluded that Personalized Preventive Plan can be performed in GM to improve and promote health.


Introduction
The profession of family physician is changing. The European definition of general practice improves health promotion and education through appropriate and effective intervention. Each country or region seeks to find a "compromise" of what should be an appropriate and effective response to the demands and expectations of care of an aging population with chronic diseases and the inflationary financial cost of specialized medicine.
In recent years, prevention has become an increasingly important part of general medicine (GM) and has become the focus of several debates on new health laws in several countries [1]. Thus, the introduction of a specific preventive consultation (SPC) will aim to establish the risk factors that will prevent certain pathologies; to reach as many patients as possible, to improve the health of patients and especially to value general medicine. The establishment and systematization of these specific consultations would make it possible to link care and prevention and would be an important source of feedback on the health status of the population.
This would allow for a better understanding and assessment of the health needs of our country. We aimed at describing the contribution of the SPC on screening risk factor of cardiovascular diseases, cancer and depression and on educating population.

Method Study area
Bembla is one of the 13 delegations of Monastir governorate. It covered 44,685 inhabitants representing 16% of Monastir population [2]. It is served by a local hospital and six primary health center which are provided by six family doctors, a pediatrician and a dentist.
In 2016, the number of consultants at these structures was 65086. We have performed our study in the GM center of the local hospital which assured 9763 consultations per year.

Study design
This is a cross-sectional descriptive study carried out during 9 months from November 2016 to July 2017 including 313 participants.

Study population
We have included subjects aged 18 to 65 years. During the study period 7231 patients have consulted from them 3253 have inclusion criteria. Information for SPC was performed by poster and during the interview.
An appointment was given according to patient agreement. The SPC was realized one day per week including 7 participants per day. Thus, 313 patients benefited from a SPC including a personalized preventive project (PPP).

Data collection
The data was collected using a questionnaire including the Sociodemographic information, clinical examination data (personal or family ATCDs, risk factors of cardiovascular diseases, cancer and depression, weight, height, waist circumference). Anxiety and depression were assessed using the HAD (Hospital Anxiety and Depression Scale) scale.
For the assessment of high cardiovascular risk (HCVR), the summative method was used [3]. A patient with HCVR is defined as any patient with multiple vascular risk factors which when added together increase the risk of ischemic cardiovascular complications [4].

Statistical analysis
Data analyze was performed using SPSS 21.0. Qualitative variables were expressed as numbers and percentages, quantitative variables by means and standard deviation.

Socio-demographic and psychological characteristics of the study population
A total of 313 patients have beneficed of SPC. The average age was 40 ± 12 years. Women accounted for 73.8% of consultants and patients without partners represented 27.4% of the participants, 58.7% felt they had an unstable social life.
Anxiety and depression were expressed respectively, by 32% and 23% of our consultants (

Cardiovascular risk factor
30% of the participants were obese, 5.7% were overweight and 19% were sedentary (practiced physical activity less than 30 min/week). Active smoking was notified in 54% of men. We have screened 39 cases of hypertension, 7 cases of type 2 diabetes, 6 cases of moderate fasting hyperglycemia and 58 cases of dyslipidemia.
High risk for cardiovascular disease was detected in 15% of our study population (Table 2).

Cancer risk factors
The average exposure to passive smoking was over 2 hours per day for 30% of patients.
The half of patients consumed more than 15 times a month meat and protein products. Salts and nitrites were consumed on a daily basis between 15 and 30 times/month by 23% of the consultants. Alcohol consumption was reported by only 7% of participants. Helical bacteria pylori infection was noted in 9.9% of participants.
Protective factors was notified among 81.2% (high fiber diet) and 17.8% (physical activity>2 hour 30 min/week) in our population.

Personalized Preventive Plan (PPP)
Several actions have been put in place following preventive consultations.
Then, 85% of smokers had minimal counseling and 15% were referred to smoking cessation clinic awareness to a tobacco free environment was offered for 155 participants (Tables 3 and 4).
Therapeutic education was performed for 140 patients. 71 mammography was prescribed for women at risk from which one returned with cancer and referred to specialists (Figure 1).

Discussion
The most effective way to reduce the incidence of these diseases would be the establishment of a national collective prevention strategy. In our work, we have tried to circumvent the pathologies whose prevention is possible and especially relevant in general medicine [5]. Three subjects were explored and defined by their risk factors; vascular accidents, cancers and anxiety and depression.

Evaluation of cardiovascular risk
Few figures are available on the prevalence and management of patients with HRCV. Our study identified 48 patients among the 313 to HRCV with a rate of 15%. Destombe C has established a rate of 30.4% for HRCV in their study including population aged 50 to 85 years [6]. Taking into account the addiction of risk factors, we will take the risk factors one by one and then propose a personalized prevention plan [7].

Obesity and sedentary lifestyle
Having 70% of women with a waist circumference>88 cm and 17% of men>102 cm represents a revealing indicator of a rather obese population. Our population is represented by 30.5% obese and the 5.7% overweight. At the same time, we found that 19% of the consultants maintain a daily physical activity of less than 30 min per week.

Smoking
In our population, tobacco affects 54% of men. Minimal advice or motivational supports were provided. According to the Heart and Stroke Foundation, by halting smoking, a person reduces the risk of a heart attack related to smoking by half after only one year [8,9].

The HTA
Since the questionnaire is not distributed on the day of chronic consultation, the patients generally come for acute pathologies. Among 23 patients with hypertension, we found 11 of them with systolic or diastolic greater than 14 or 9. Considering that adequate management of hypertension decreases the risk of stroke by 40% and that of infarction by 15%, our intervention was based mainly on therapeutic education. In addition, 39 of the 290 (13.5%) consultants who did not recognize themselves as hypertensive and in whom a 15 days profile under a salt free diet confirmed HTA.

Diabetes
Among our patients, 4.4% were diabetics, 42% of whom had HbA1c>to 7%. In addition, this preventive consultation was able to detect 7 new diabetics among the 299 non diabetics, which represents 2.3% of our population, and 6 cases of moderate fasting hyperglycemia. Hence the need for screening which according to the American Diabetes Association should be systematically performed in adults of any age who are overweight or obese and who have one or more risk factors for diabetes [10].

Dyslipidemias
We defined dyslipidemia as any increase in the ratio of CH/HDL>4 (SCORE scale). Our study found 64 consultants with dyslipidemia of which 90% did not take an adequate daily treatment. The multicenter study MONALISA showed that despite recommendations, 53% of patients with hypercholesterolemia received no treatment. During our work we encourage a hypo-lipid and a drug therapy was recommended [11,12].

Evaluation of the carcinogenic risk
In Tunisia, cancer accounts for 16% of all deaths [13].

Smoking
Chronic smoking is one of the leading causes of preventable mortality and is the cause of one in three cancers. Our intervention was with 19% of our consultants of which 14% were addressed to the department of Preventive Medicine of the Fattouma Bourguiba Hospital of Monastir.

Alcohol
Only 22 patients (7%) reported drinking alcohol. It appears that alcohol consumption appears to be very limited among the population. Our role was mostly educational.

Food
The International Agency for Research on Cancer (IARC) evaluated the results of 800 studies that examined the consumption of red meats or meats and cancer. According to the report, the risk increases by 17% for each 100 g of red meat consumed per day and 18% for each 50 g of processed meat consumed each day. Our study, with 51% of consultants who consumed meat and cold meats more than 15 times a month, allowed us to emphasize education in order to reduce this consumption and divert it to food protectors [13].

Overweight, obesity and physical inactivity
Several studies have attempted to establish the relationship between obesity and cancer. Our intervention was mainly based on weight reduction and the preservation of daily physical activity.

Other environmental factors
Other factors were investigated in our study in relation to some specific cancers such as; stomach, liver and cervix cancer. Breast cancer, is the leading cause of cancer death in women and the fourth leading cause of death among Tunisian women of reproductive age. Our study found that 2.2% of consultants had a family-based ATCD for breast cancer. Our intervention was essentially a therapeutic education with regard to hormone therapy, and para-clinical screening tests in this population at risk, which allowed us to detect 1 case of breast cancer on 71 mammograms requested.

Evaluation of depressive risk
Depression is one of the most common psychiatric disorders in adults and especially a dramatic increase in suicide mortality. Our study was based on the HAD scale, which is a structured questionnaire of 14 items. We found that 32% of patients were anxious and 23% reported depressive responses with a HADD score greater than 11.
These data prompt us to systematically detect the psychological problems of our patients on the front line as this is a main pillar in the preventive consultation.

Personalized Prevention Plan (PPP)
We have focused on three main areas of prevention:

Primary prevention
The focus has been on health education, aimed at changing behavior, lifestyles or the environment, in order to protect health. In our work, 16% and 49% of the consultants benefited from minimal advice and awareness of a tobacco-free environment. Food hygiene advice was provided to 72% and an incentive for daily physical activity was 100% indicated.

Secondary prevention
Such as technical prescriptive acts. In our work, 49% of consultants have benefited from various clinical examinations.

Tertiary prevention
It aims to reduce recurrences, complications and squeals, especially through therapeutic education of the patient. Since the launch of our consultation, group education sessions have been implemented on a daily and targeted basis and have attracted 15% of our population.

Conclusion
The general physician is a major player in preventive medicine. He is able to ensure the link between the individual and the community through his knowledge of individuals, their ability to assess the health status of a population in which he works. He relays, contextualizes and personalizes the public health messages of collective dimension in individualized messages, audible by each one because they are emitted in the language of each one. SPC has improved the knowledge and practices of patients. It also identified several risk factors and especially breast cancer at an early stage. We concluded that individual and collective prevention can be performed in GM to improve and promote health.