Tema 40. Programas de Cribado y Salud Pública (PDF)

# Vigilancia en Salud Pública, Sistemas de Información Sanitaria y Cartera Común ## Tema 40. Programas de cribado y de salud pública. Bases y criterios del cribado. Programas de cribado poblacional del Sistema Nacional de Salud. Documento Marco sobre cribado poblacional. ### Introducción - In rece...

# Vigilancia en Salud Pública, Sistemas de Información Sanitaria y Cartera Común ## Tema 40. Programas de cribado y de salud pública. Bases y criterios del cribado. Programas de cribado poblacional del Sistema Nacional de Salud. Documento Marco sobre cribado poblacional. ### Introducción - In recent decades, there has been a growing need for a shift in healthcare service delivery. - This is due to the epidemiological transition (rise in chronic diseases and decline in infectious diseases) and the demographic transition (aging population). - Emphasis is placed on promoting health and preventing disease. - This involves a shift from clinical-based medicine to preventive and health-promoting medicine. - The **Ministry of Health (MS)** has developed a **National Strategy for Health Promotion and Disease Prevention**, highlighting prevention through early detection programs. - **Law 33/2011 General Health Law** mandates local authorities (AAPP) to implement secondary prevention actions such as early detection programs. - These actions ensure equal access for all citizens. - The law also states that screening tests must adhere to scientific criteria and public health principles like equity, health in all policies, relevance, precaution, evaluation, transparency, comprehensiveness, and safety. - This avoids implementing preventive measures without proven benefits. - **Screening programs** play a crucial role in improving population health outcomes. - They effectively prevent diseases, reduce disability, and decrease mortality when organized efficiently. ### Bases and criteria for screening: - **Screening program**: Set of activities aimed at early disease detection and treatment offered to susceptible individuals, regardless of symptoms or prior medical consultation. - These programs aim to modify the natural history of disease and improve outcomes. - Screening can be organized at the population level or individually as part of clinical care. - **WHO's definition of screening**: - Systematic use of a diagnostic test to identify individuals at high risk or sufficiently high risk to benefit from further investigation or preventive actions. - **Benefits of screening**: - Improved prognosis for detected cases - Less intensive treatment needed for early stage cases - Resource savings when evaluated over a long time - Increased peace of mind for those with negative results - **Risks of screening**: - Increased morbidity in cases without improved prognosis - Overtreatment of minor conditions with uncertain prognosis - Adverse reactions due to the screening process (tests and treatments) - False sense of security in cases with negative results - Anxiety for those with false positive results - Added costs ### Key characteristics of a screening program: 1. **Applies to asymptomatic individuals**: This means it targets people without symptoms of the disease being screened for. 2. **Benefits only a small portion of the population**: Usually, only a small percentage of the screened population will actually have the disease. 3. **Continuous process, not a single event**: Screening involves ongoing monitoring and follow-up. 4. **Part of a broader disease management plan**: It includes not just detection but also confirmation of diagnosis and treatment. ### Objectives of screening programs: - Reduce disease incidence. - Prevent premature death and/or disability related to the disease. - Improve prognosis. ### Types of screening: - **Organized:** Involves a structured program with clearly defined steps, target populations, and quality assurance mechanisms. - **Opportunistic:** This is a non-systematic approach where screening is offered during regular healthcare visits for other reasons. ## Early Detection Through Screening: - **Organized screening programs** are designed to systematically identify individuals at high risk for specific conditions. - **Opportunistic screening** is a less structured approach, often performed during routine healthcare visits. This type of screening may not provide the same level of benefit or quality assurance as organized programs. ### Organized screening programs in Spain's National Health System (SNS): - **The Interterritorial Council of the National Health System (CISNS)** established a "Working Group for the Development of the Basic Portfolio of SNS Services" in 2012. - This group focused on identifying and prioritizing services for early disease detection, leading to the publication of two reports in 2013. - The documents addressed neonatal screening and cancer screening. - In 2014, the **Order SSI/2065/2014** was issued, encompassing the core set of services for these screening programs. - The **CISNS Public Health Commission** created the **Population Screening Commission** in 2017. - This commission provides professional advice on screening, ensuring transparency, guaranteeing coordination of programs, and improving the quality and consistency of nationwide screening. - The **Population Screening Commission** approved various approaches for different screening programs and reviewed the evidence base for SNS screening activities in 2019. - This led to the publication of "State of evidence and recommendations on screening activities in the SNS," covering both organized and non-standardized programs. ### Core screening programs within the SNS: 1. **Cancer screening:** - Breast, colorectal, and cervical cancer screening 2. **Neonatal screening:** - Endocrine and metabolic diseases (Hypothyroidism, phenylketonuria, cystic fibrosis, medium-chain acyl-CoA dehydrogenase deficiency, long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency, glutaric aciduria type 1, and sickle cell disease) 3. **Hearing screening:** - This program covers newborn hearing screening. 4. **Prenatal screening:** - Chromosome abnormalities. ### Current status of screening programs in SNS: - **Cancer Screening:** - Breast, colorectal, and cervical cancer screening are currently offered as organized programs in all Spanish regions. - These programs are considered highly effective in reducing mortality and/or incidence of these diseases. - **Neonatal Screening:** - The program is a crucial element of the SNS's core service portfolio, ensuring that newborns are screened for various endocrine and metabolic disorders. ### Challenges and opportunities: - While screening programs are expanding in Spain, there are ongoing efforts to address some challenges, including ensuring equitable access, enhancing coordination across regions, and consistently improving quality. - There is continuous work on refining screening protocols and enhancing evidence-based approaches, particularly for lung cancer screening. ### Document Marco on population screening - The **Document Marco** serves as a valuable guide for regions in making strategic decisions about screening programs. - It provides a framework for making decisions, ensuring transparency, and clarifying criteria used in making these choices. - The document also promotes quality assurance, equity, and consistency within the SNS screening programs. ### Key principles for strategic decisions about screening programs: **1. Approving and implementing new screening programs:** - Defining target populations, screening tests, and frequency of testing. **2. Introducing changes to existing screening programs:** - Making significant changes based on new evidence regarding health outcomes and/or financial implications. **3. Discontinuing existing screening programs:** - This decision should be based on new scientific evidence, failure to achieve desired outcomes, or significant barriers to program effectiveness. ### Important aspects to consider: - **Scientific Evidence on Benefits and Risks**: Benefits must outweigh risks. - **Program Feasibility**: Ensure the program is realistic and financially sustainable. - **Ethical Considerations**: Address issues like potential discrimination and stigma. ### Principles guiding ethical decisions: - **Non-maleficence**: Minimize the potential for harm. - **Beneficence**: Demonstrate benefits for the population. - **Justice**: Ensure equitable access to screening and ensure that screening doesn't come at the expense of other health services. - **Autonomy**: Individuals must understand the implications of participating in the screening program. ### Criteria for making strategic decisions: 1. **Problem of Health:** - The target condition should be a major public health concern, based on mortality, morbidity, disability, and social cost. 2. **Disease Definition and Natural History:** - Establish clear diagnostic criteria for the condition and understand its progression over time. 3. **Detectable Latency Period:** - There should be a sufficient period between the early stages of the disease and its later stages, allowing for reliable screening. 4. **Cost-effective Interventions:** - Screenings should be financially justifiable when considering other public health interventions. 5. **Simple and Safe Screening Test:** - The initial screening test needs to be easy to perform and understand, with minimal potential side effects. 6. **Valid, Reliable, and Efficient Screening Test:** - The test should measure what it claims to measure with consistent results and be efficient in terms of cost and time required. 7. **Acceptable Screening Test:** - The test should be acceptable to the target population, taking into account cultural and social differences. 8. **Criteria for Selecting Mutations (if applicable):** - Clearly defined criteria should be used when screening for genetic mutations. ### Criteria related to diagnosis and treatment: 9. **Scientific Evidence for Diagnosis and Treatment:** - Ensure clear evidence-based guidelines for diagnosing individuals who test positive and for their treatment. 10. **Effective Treatment in the Pre-symptomatic Phase:** - Treatment should be more effective in the early stages of disease compared to later stages. 11. **Optimized Access to Care:** - Ensure timely and streamlined access to confirmation testing and treatment. ### Criteria related to program: 12. **Evidence of Efficacy:** - It should be clear that the program reduces mortality or morbidity. 13. **Benefits Outweigh Risks:** - Quantify both the benefits and risks, showing a clear benefit overall. 14. **Well-defined Target Population:** - Clearly define the target audience to maximize the program's impact. 15. **Balanced Costs:** - Conduct a thorough cost-effectiveness analysis to consider alternative interventions. 16. **Acceptable Program:** - Ensure the program is equitable, ethically sound, and that it doesn't exacerbate health disparities. 17. **Evaluation and Quality Assurance:** - Establish a system for regularly monitoring program effectiveness and achieving the desired outcomes. 18. **Feasibility Within the SNS:** - Assess the impact of the program on the healthcare system's resources and capacity. ### Requirements for Implementing Screening Programs: 1. **Population Coverage and Equity:** - Guarantee equitable access for all eligible individuals within the SNS. 2. **Operational Planning and Coordination:** - Develop a comprehensive plan for program implementation, including phases, resources, and coordination across regions. 3. **Program Information System:** - Establish a system for managing data and coordinating activities, including referral of suspected cases, monitoring program activity, and evaluating outcomes. 4. **Informed Decision-Making:** - Ensure that individuals have access to clear, concise information about the program so they can make informed decisions about participation. 5. **Data Privacy and Confidentiality:** - Implement robust safeguards to protect personal information. 6. **Quality Assurance and Evaluation:** - Develop a structured plan for evaluating the program's effectiveness and making adjustments accordingly. 7. **Professional Education and Public Awareness:** - Provide education and training for healthcare professionals and the public about screening programs and their benefits. ### Conclusion: - Screening programs are a cornerstone of preventative healthcare efforts. - Continued evaluation and refinement are necessary to maximize the benefits of these programs.