ࡱ> 35,-./012q`bjbjqPqPB::b BXBXBX8zXVYL nc(ccccdd d$Qh8eeddee8ccBBBe ccBeBBv8cc `oBXsH."N$0еСDd0e"B1eMeddd88^dddeeee~Ġ~ OSOBE STARIJE }IVOTNE DOBI U ORDINACIJI OBITELJSKE MEDICINE Elderly Patients at Family Medicine Office Nevenka Kr mar, dr.med. ,Mihel, Sandra, dr.med, mr.sc.Teodora Not, Vianja Beai Barun, dr.med., Ivan Pristaa, dr.med. Arsen Stani, dr.med., Primarijus Dr.sc. Ranko Stevanovi, dr.med., Aleksandar Jovanovi, dr.med. SA}ETAK: Poveanje udjela starijih od 65 godina prerasporeuje i usmjerava sadr~aje zdravstvene skrbi, mijenja strukturu zdravstvene potroanje i zahtijeva nove javnozdravstvene, edukacijske, klini ke i druge pristupe. U odnosu na ukupan broj oboljelih, udio strarijih vei od 50% bilje~i za hipertenzivne bolesti, druge sr ane bolesti, aeernu bolest , artroze i druge ishemi ne bolesti srca. Mali broj preventivnih pregleda i kunih posjeta, govori da je djelatnost ope/obiteljske medicine zbog nedostatka mehanizma financiranja preventivnih djelatnosti, aktivne skrbi i kontrole te poticanja kvalitete rada sasvim postala pasivna zdravstvena djelatnost u odnosu na populaciju starijih od 65 i viae godina. Za navedene bolesti i stanja potrebno je izraditi algoritme, dijagnosti ke i terapijske smjernice koje treba postaviti unutar informacijskog ustava primarne zdravstvene zaatite. Uporabu dijagnosti kih i terapijskih smjernica te kontrolu kvalitete rada treba mjeriti koriatenjem pouzdanih podataka iz informacijskog sustava primarne zdravstvene zaatite te izraditi poseban sustav stimulacije, plaanja, edukacije i poticanja timova i obiteljske medicine koji bi na pravi na in donio poboljaanja ukupne zdravstvene skrbi za starije od 65 godina. Klju ne rije i: obiteljska medicina, stariji od 65 godina, sadr~aj rada, bolesti i stanja ABSTRACT: The increasing share of patients aged 65+ years rearranges and redirects health care activities, changing the structure of health consumptions and requiring new public health, educational, clinical and other approaches. The proportion of 65+ year old compared with the diseased total shows the share of 65+ year old to be higher than 50% in receiving care for hypertensive diseases, other heart diseases, diabetes mellitus, arthrosis and other ischaemic heart diseases. A small number of preventive medical examinations and home visits reveal that Family Medicine Service has become a completely passive health service in relation to the 65+-yearold population due to the shortcomings of the mechanism financing preventive medicine, active care and control, and work quality stimulation. It is necessary to develop the algorithms, diagnostic and therapeutic guidelines for these diseases and conditions to be placed within the information system of Primary Health Care. The use of diagnostic and therapeutic guidelines and work quality control should be measured by means of reliable data from the Primary Health Care information system. In addition, a separate system of incentives, payment methods, education and encouragement for family medicine teams should be elaborated that would bring improvements in the proper way to the health care of the patients aged above 65 years. Kew words: family medicine, 65+ year old, work content, diseases and conditions Uvod Zdravstvena zatita osoba starijih od 65 godina postaje sve vei problem u organiziranju zdravstvene zaatite. O ekuje se da e u zemljama Europske Unije do 2051. godine blizu 40% populacije initi osobe starije od 65 godina (0). Poveanje udjela starijih od 65 godina prerasporeuje i usmjerava sadr~aje zdravstvene skrbi, mijenja strukturu zdravstvene potroanje i zahtijeva nove javnozdravstvene, edukacijske, klini ke i druge pristupe. Djelatnost obiteljske medicine s viae od dvije treine, a negdje i viae od 3/4 vremena, energije, medicinske opreme i lijekova osobito je zahvaena tom brzom tranzicijom. Cilj rada Cilj rada je da uka~e na probleme rada i patologiju, odnosno zabilje~ene bolesti i stanja koja iznadprosje no optereuju djelatnost obiteljske medicine te zdravstveni sustav u cjelini na ukupnoj hrvatskoj populaciji starijih od 65 godina. Svrha rada je da kvanitificira problme u radu i zdravstvenom stanju populacije starijih od 65 godinada te da specificira i inicira poticanje i razvoj pojedinih mjera i aktrivnosti te usmjeravanje dijagnostike i lije enja, osobito kroni nih bolesti i stanja u ovoj populaciji. Rezultati Prema broju doktora i osiguranika u djelatnosti, jedan tim skrbi za ukupno 1615 osiguranika u prosjeku. Broj osiguranika starije dobi po timu jako se razlikuje: od timova koji nemaju takvih osiguranika (timovi koji su 1994, godine iz djelatnosti akolske medicine preali u djelatnost ope medicine i nisu mijenjali populaciju, do timova koji imaju u skrbi viae od 50% osiguranika starijih od 65 godina). U odnosu na zdravstvenu zaatitu starijih od 65 godina, va~no je napomenuti da posljednjih godina raste broj pregleda a pada broj posjeta (ostalim zdravstvenim djelatnicima) ukupno u djelatnosti ope medicine. Broj pregleda u kui u djelatnosti ope/obiteljske medicine tijekom 2003. godine stagnira na niskoj razini (35% manje u odnosu na 1990. godini) ato takoer ukazuje na jedan od problema koji se odra~ava i na zdravstvenu zaatitu starijih od 65 godina. Poseban problem u zdravstvenoj zaatiti starijih od 65 godina u djelatnosti ope medicine jest smanjenje broja kunih posjeta ostalih zdravstvenih djelatnika koje iznosi 91% manje u odnosu na 1990. godinu. Od 1995. godine prati se broj upuivanja na specijalisti ke preglede. U 2003. godini zabilje~eno je 5,906.220 upuivanja od strane timova ope/obiteljske medicine, ili 4,6% viae nego u 2002. godini (jedno upuivanje specijalisti na tri obavljena pregleda). U odnosu na 1995. godinu, otkad se izvjeauje o broju upuivanja specijalistima, bilje~i se poveanje upuivanja na specijalisti ke preglede za viae od treine. U dobi od 65 i viae godina zabilje~eno je samo 27.628 preventivnih i 8.971 sistematskih pregleda, ato je u odnosu na blizu 700.000 osoba u dobi od 65 i viae godina, prema popisu iz 2001. godine, neznatni udio od 4% za preventivne, 1,3% za sistematske, odnosno 5,3% ukupno za sistematske, periodi ne i kontrolne preglede. Tijekom 2003. godine, u djelatnosti ope/obiteljske medicine ukupno u Republici Hrvatskoj, zabilje~eno je ukupno samo 99.798 sistematskih, periodi nih i kontrolnih pregleda odraslih, ili 3% manje nego u 2002. godini, a ak za 72% manje u odnosu na 1990. godinu. U 2003. godini, broj utvrenih bolesti i stanja zabilje~enih u djelatnosti ope/obiteljske medicine iznosi 7,281.289, ili za 5% viae u odnosu na 2002. godinu. Od toga broj utvrenih bolesti i stanja zabilje~enih za korisnike u dobi od 65 i viae godina 1,964.810 ili gotovo 27%, ato je gotovo dvostruko u odnosu na ukupni udio pu anstva starijeg od 65 godina (15,7%). Tablica 1. Utvrene bolesti ili stanja u djelatnosti OPE/OBITELJSKE MEDICINE u Hrvatskoj u 2003. godini u dobi od 65 i viae godina i ukupno  Bolesti i stanja MKB 10 `ifra  65 i viae Ukupno Udio starijih od 65. godina1Zarazne bolesti probavnog sustava A00-A0910.55481.33713,02Tuberkuloza dinih putova - A15-A161.0713.26732,83Tuberkuloza drugih organa - A17-A199933629,54Hripavac (pertusis) - A3701170,05arlah (scarlatina) - A3801.8010,06Druge bakterijske bolesti (osim A37 i A38) - A20-A492.0497.83126,27Sifilis - SyphilisA50-A5363915,48Gonokokna infekcija - A5461075,69Varicela, morbili i rubeola B01, B05, B06019.2250,010Bolest ozrokovana HIV-om - B20-B240490,011Kandidijaza - B375.35924.47421,912Helmintijaze - B65-B831.30513.8339,413Ostale zarazne i parazit. bol. - 13.159111.60311,81.Ukupno zarazne i parazitarne bolesti (A00-B99)- 33.608264.01912,714Zloudna novotvorina ~eluca - C161.4302.68153,315Zloudna novotvorina zavranog debelog crijeva (rektuma) C202.5954.53557,216Zloudna novotvorina duanika (traheje), duanice (bronha) i plua - C33-C342.4004.83749,617Zloudni melanom ko~e - C439612.05946,718Zloudna novotvorina dojke - C504.33010.20942,419Zloudna novotvorina vrata maternice - C536162.01530,620Zloudne novotvorine limfnoga, hematopoeti nog i srodnog tkiva - C81-C971.6933.99342,421Ostale zloudne novotvorine - 8.88317.49550,822Novotvorine in situ i dobroudne novotvorine nepoznate prirode - D00-D4813.37356.80223,52.Ukupno Novotvorine (C00-D48) - 36.281104.62634,723Anemije zbog manjka ~eljeza - D5016.26193.61217,424Druge bolesti krvi i krvotvornog sustava - D51-D774.14211.06137,425Neki poremeaji imunoloakog sustava - D80-D891.4025.22126,93.Ukupno Bolesti krvi i krvotvornog sustava te odreene bolesti imunoloakog sustava (D50-D89) - 21.805109.89419,826Poremeaji atitnja e - E00-E0714.02561.52922,827Dijabetes melitus - E10-E1459.447121.55548,928Pretilost - E65-E6614.65740.43236,329Ostale endokrine bolesti, bolesti prehrane i bolesti metabolizma - 20.14060.48133,34.Ukupno Endokrine bolesti, bolesti prehrane i bolesti metabolizma ( E00-E90) - 108.269283.99738,130Demencija - F00-F037.2418.64483,831Duaevni poremeaji i porem. ponaaanja uzrokovani uzimanjem alkohola-F106.73524.01728,032Duaevni poremeaji i porem. ponaaanja uzrokovani psihoakt. tvarima - -F11-F195257.0937,433Shizofrenija, shizotipni i sumanuti poremeaji - F20-F295.27527.17019,434Neuroze i afektivni porem. povezani sa stresom i somatoformni porem. - F40-F4855.019193.44328,435Duaevna zaostalost - F70-F791.1425.60920,436Ostali duaevni poremeaji i poremeaji ponaaanja - 18.79963.75129,55.Ukupno Duaevni poremeaji i poremeaji ponaaanja (F00-F99)94.736329.72728,737Ekstrapiramidalni i poremeaji kretanja - G20-G265.7708.84365,238Epilepsija -G40-G414.41822.55219,639Migrena i ostali sindromi glavobolje - G43-G448.52742.02720,340Cerebralna paraliza i ostali paraliti ni sindromi - G80-G831.9135.74633,341Ostale bolesti i poremeaji ~iv anog sustava - 8.39326.42431,86.Ukupno Bolesti ~iv anog ustava (G00-G99)29.021105.59227,542Konjunktivitis - H1037.909148.03325,643Katarakta i druge bolesti lee - H25-H2822.81232.19870,844Glaukom - H40-H4217.03428.23760,345Strabizam - H49-H508936.82813,146Poremeaji refrakcije i akomodacije - H5226.196100.47426,147Ostale bolesti oka i adneksa - 19.80872.26927,47.Ukupno Bolesti oka i o nih adneksa (H00-H59)124.652388.03932,1Tablica 1. nastavak 1  Bolesti i stanja MKB 10 `ifra  65 i viae Ukupno Udio starijih od 65. godina48Upala srednjeg uha i druge bolesti srednjeg uha i mastoida - H65-H7519.336117.98416,449Oateenje sluha - H90-H9114.88127.22254,750Ostale bolesti uha i mastoidnog nastavka - 487817.03963.50926,88.Ukupno Bolesti uha i mastoidnog nastavka (H60-H95) - 51.256208.71524,651Akutna reumatska groznica - I00-I0242488448,052Kroni ne reumatske sr ane bolesti - I05-I094.2768.48150,453Hipertenzivne bolesti - I10-I15220.107467.58047,154Akutni infarkt miokarda - I21-I237.89416.49447,955Druge ishemi ne bolesti srca - I20, I24-I2546.04882.83155,656Druge sr ane bolesti - I26-I5259.48593.69963,557Cerebrovaskularni inzult - I60-I6413.28520.47864,958Druge cerebrovaskularne bolesti - I65-I687.60013.70255,559Posljedice cerebrovaskularne bolesti-.I6910.49216.22564,760Ateroskleroza - I7019.21629.32665,561Bolesti vena (embolija, tromboza, varices) - I80-I8731.60177.80940,662Ostale bolesti cirkulacijskog sustava - 10314.86835.16142,39.Ukupno Bolesti cirkulacijskog sustava (I00-I99) - 435.296862.67050,563Akutne infekcije gornjega dinog sustava - J00-J06141.6511.260.26011,264Gripa (influenca) - J10-J1115.674110.71414,265Pneumonija - J12-J1817.00446.45736,666Akutni bronhitis i akutni bronhiolitis - J20-J2136.947159.57423,267Bronhitis, emfizem, astma i druge kroni ne opstruktivne bolesti plua - J40-J44, J4743.913107.56040,868Plune bolesti uzrokovane vanjskim agensima, pneumokonioze - J60-J707992.12337,669Ostale bolesti dianog sustava - 23.274110.11921,110.Ukupno Bolesti dianog sustava (J00-J99) - 279.2621.796.80715,570Bolesti usne aupljine, ~lijezda slinovnica i eljusti - K00-K149.32245.84620,371Ulkus ~eluca i duodenuma (gastroduodenalni) - K25-K2723.17172.23732,172Akutna upala crvuljka (apendicitis) - K358126.69812,173Preponska kila (ingvinalna hernija) - K405.14913.45338,374Ostale hernije trbuane aupljine - K41-K462.8976.99541,475Bolesti jetre - K70-K7710.96731.77734,576}u ni kamenci i upala ~u njaka - K80-K8114.28039.27936,477Ostale bolesti probavnog sustava - 1145633.414114.55629,211.Ukupno Bolesti probavnog sustava K00-K93 100.012330.84130,278Infekcije ko~e i potko~noga tkiva - L00-L0824.407113.60221,579Dermatitis, egzemi i urtikarije - L20-L30, L5041.286206.06320,080Ostale bolesti ko~e i potko~noga tkiva - 17.69782.59621,412.Ukupno Bolesti ko~e i potko~noga tkiva (L00-L99) - 83.390402.26120,781Reumatoidni artritis i druge upalne poliartropatije - M05-M1415.97341.86038,282Artroze - M15-M1955.796108.75051,383Kifoza, skolioza i lordoza - M40-M418.92131.49228,384Spondilopatije M45-M4917.37945.77838,085Bolesti intervertebralnih diskova i ostale dorzopatije - M50-M54106.018362.52529,286Osteoporoza i osteomalacija - M80-M8324.12945.35953,287Ostale bolesti miaino-koatanog sustava - 29.277116.54825,113.Ukupno Bolesti miaino-koatanog sustava i vezivnoga tkiva (M00-M99)l257.493752.31234,288Glomerulske bolesti bubrega - N00-N081.4024.37632,089Tubulointersticijske bol. bubrega - N10-N164.79314.62232,890Bubre~na insuficijencija - N17-N193.3626.97748,291Urolitijaza (mokrani kamenci) - N20-N2310.74936.17929,792Upala mokranog mjehura (cistitis) - N3061.105217.02928,293Druge bolesti urinarnog sustava (vx , P @ | ~ 2 4 6 B D H J V X ` b t v x ɽɽɱɥɚppppapUah]FCJaJmH sH hWh]FCJaJmH sH hWh2CJaJmH sH h}4CJaJmH sH hv h2CJaJmH sH h9hWCJaJhI 56CJ\aJh0O56CJ\aJh*56CJ\aJh9h0O56CJ\aJh}4h}456CJ\aJh+5CJ\aJhWhW5CJ\aJx~ H?DJ L ` f$h$|$ $da$gdY$Ld^`La$gd}4 $da$gd}4$Ld^`La$gdv  $da$gdv  $da$gdW $da$gd0O $da$gd}4 $da$gdW     " $ , . : @ B N P R T V ^ ` 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`ifra  65 i viae Ukupno Udio starijih od 65. godina95Druge bol. muakih spol. org. - N41-N515.76023.35824,796Poremeaji u menopauzi - N951.24826.8334,797Ostale bolesti ~enskih spolnih organa - 8.58367.40712,714.Ukupno Bolesti genitourinarnog sustava (N00-N99) - 131.788473.96327,898Poba aj- O00-O0803.5550,099Poroaj- O80-O84013.5450,0100Ostala stanja u trudnoi, poroaju i babinjama - 022.7240,015.Ukupno Trudnoa, poroaj i babinje (O00-O99) - 039.8240,0101Odreena stanja nastala u perinatalnom razdoblju - P00-P9606890,016.Ukupno Odreena stanja nastala u perinatalnom razdoblju (P00-P96) 06890,0102Priroene malformacije cirkulacijskog sustava - Q20-Q28961.6875,7103Nespuateni testis - Q5301.0170,0104Ostale priroene malformacije - 3887.1385,417.Ukupno Priroene malformacije, deformiteti i kromosomske abnormalnosti (Q00-Q99) - 4849.8424,9105Senilnost - R549.34511.30782,6106Ostali simptomi, znakovi, klini ki i laboratorijski nalazi nesvrstani drugamo - 45.186222.71820,318.Ukupno Simptomi, znakovi i abnormalni klini ki i laboratorijski nalazi nesvrstani drugamo (R00-R99)54.531234.02523,3107Prijelomi - S x 213.28955.72723,8108Dislokacije, uganua i nategnua - S x 312.34181.20215,2109Opekline i korozije - T20-T324.91623.14921,2110Otrovanja lijekovima i bioloakim tvarima - T36-T502711.78515,2111Ostale ozljede, otrovanja i djelovanja vanjskih uzroka - 22.698144.61015,719.Ukupno Ozljede, otrovanja i ostale posljedice vanjskih uzroka (S00-T98) - 53.515306.47317,5112Osobe koje se koriste zdrav. slu~bom zbog pregleda i istra~ivanja -Z00-Z1319.565107.49818,2113Infekcija HIV-om bez simptoma - Z210210,0114Druge osobe s opasnoau po zdravlje zbog zaraznih bolesti - Z20, Z22-Z2932.96080.43641,0115Postupci u vezi sa sprje avanjem ne~eljene trudnoe - Z3005.3240,0116Osobe koje se koriste zdrav. slu~bom zbog specif. postupaka i njege - Z40-Z541.9609.53120,6117Osobe koje se koriste zdrav. slu~bom zbog psihosoc. i socioek. razloga -Z55-Z656.15934.98217,6118Osobe koje se koriste zdrav. slu~bom zbog obiteljskih razloga- Z70-Z995.18723.71021,9119Ostali imb. koji utje u na stanje zdravlja i kontakt sa zdrav. slu~bom - 3.58015.47123,121.Ukupno imbenici koji utje u na stanje zdravlja i kontakt sa zdravstvenom slu~bom (Z00-Z99)-69.411276.97325,1UKUPNO BOLESTI I STANJA (bez V01-Y98) 1.964.8107.281.28927,0120Nesree pri prijevozu - V01-V993.39824.02114,1121Ostali vanjski uzroci slu ajnih ozljeda - W00-X5930.905172.57817,9122Namjerno nanesene ozljede - X85-Y093983.05813,0123Ratne ozljede - Y3661683,6124Ostali vanjski uzroci ozljeda i otrovanja - 18.808106.64817,620.Ukupno Vanjski uzroci morbiditeta i mortaliteta (V01-Y98) - 53.515306.47317,5 Tablica 2. Rang i udio vodeih 10 utvrenih bolesti ili stanja u djelatnosti obiteljske medicine u Hrvatskoj u 2003. godini u dobi od 65 i viae godina i ukupno Rang Bolesti i stanja MKB 10 `ifra 65 i viae Udio 65 i viae godinaUkupno RangUdio 1Hipertenzivne bolesti I10-I15220.10711,2467.5802 6,42Akutne infekcije gornjega dianog sustava J00-J06141.6517,21.260.2601 17,33Bolesti intervertebralnih diskova i ostale dorzopatije M50-M54106.0185,4362.5253 5,04Upala mokranog mjehura (cistitis) N3061.1053,1217.0294 3,05Druge sr ane bolesti I26-I5259.4853,093.699> 10 1,36Dijabetes melitus E10-E1459.4473,0121.55510 1,77Artroze M15-M1955.7962,8108.750> 10 1,58Neuroze i afektivni porem. povezani sa stresom i somatoformni poremeaji F40-F4855.0192,8193.4436 2,79Druge ishemi ne bolesti srca I20, I24-I2546.0482,382.831> 10 1,110Bronhitis, emfizem, astma i druge kroni ne opstruktivne bolesti pluaJ40-J44, J4743.9132,2107.560> 10 1,5Ukupno za 10 vodeih bolesti 848.589 (43% od ukupnog)100% 3,015.232 (41% od ukupnog)100%  *bolesti: Dermatitis, egzemi i urtikarije na petom su mjestu, bronhitis na sedmom, konjunktivitis na osmom i ozljede na devetom ukupno, ali se ne pojavljuju meu vodeih 10 bolesti u dobi 65 i viae godina  Tijekom 2003. godine redoslijed i udio 5 naju estalijih bolesti (utvrenih bolesti i stanja u djelatnosti ope/obiteljske medicine) u dobi od 65 i viae godina bio je: Hipertenzivne bolesti (220.107 ili 11,2% ukupnog broja utvrenih bolesti i stanja). Akutne infekcije gornjega dianog sustava (141.651 ili 7,2% ukupnog broja utvrenih bolesti i stanja). Bolesti miaino-koatanog sustava i vezivnog tkiva (106.018 ili 5,4% ukupnog broja utvrenih bolesti i stanja). Upala mokranog mjehura (cistitis) (61.105 ili 3,1% ukupnog broja utvrenih bolesti i stanja). i 6. Druge sr ane bolesti i aeerna bolest (59.485, odnosno 59.447 ili po 3,0% ukupnog broja utvrenih bolesti i stanja). Slijede: Artroze, Neuroze i afektivni poremeaji povezani sa stresom i somatoformni poremeaji, Druge ishemijske bolesti srca i Bronhitis, emfizem, astma i druge kroni ne opstruktivne bolesti plua, s udjelima od 2-3% ukupnog broja utvrenih bolesti i stanja).  Udjeli starijih od 65 godina u odnosu na ukupan broj za 10 naju estalijih zabilje~enih bolesti i stanja u Hrvatskoj u 2003. godini pokazuje da se udio starijih oboljelih vei od 50% bilje~i za: Hipertenzivne bolesti, Druge sr ane bolesti, `eernu bolest , Artroze i Druge ishemi ne bolesti srca.  U odnosu na ukupan broj zabilje~enih bolesti i stanja, udio pojedinih bolesti i stanja vei je u osoba starijih od 65 godina za: Hipertenzivne bolesti, Druge sr ane bolesti, `eernu bolest, Artroze, Druge ishemi ne bolesti srca i Bronhitis, emfizem, astmu i druge kroni ne opstruktivne bolesti plua. Diskusija Poveanje broja posjeta i broja pregleda u ordinaciji ope/obiteljske medicine, uz istodobno smanjenje broja kunih posjeta/pregleda starijima od 65 godina zna ajka su razdoblja od 1995. do 2003. godine. Mo~e se zaklju iti da je broj kunih posjeta pao ispod razine koja garantira kvalitetnu zdravstvenu zaatitu ovog stanovniatva. Iako Hrvatski zavod za javno zdravstvo ne raspola~e podacima o upuivanjima na specijalisti ke preglede prema dobi, mo~e se zaklju iti da se istodobno znatno poveao i broj upuivanja osoba starijih od 65 godina na specijalisti ke preglede. Tijekom 2003. godine, u djelatnosti ope/obiteljske medicine u Republici Hrvatskoj, zabilje~eno je ukupno samo 99.798 sistematskih, periodi nih i kontrolnih pregleda odraslih, ili 3% manje nego u 2002. godini, a ak za 72% manje u odnosu na 1990. godinu. Ovako mali broj preventivnih pregleda, isto kao i broj kunih posjeta, govori da je djelatnost ope/obiteljske medicine zbog nedostatka mehanizma financiranja preventivnih djelatnosti, aktivne skrbi i kontrole te poticanja kvalitete rada sasvim postala pasivna zdravstvena djelatnost u odnosu na populaciju starijih od 65 i viae godina. Ona samo utvruje i lije i bolesti i ne utje e aktivno na pozitivne promjene zdravlja populacije, kako je zakonski i deklarativno propisano. O ekuje se da e inicijativa Ministarstva zdravstva i socijalne skrbi u 2004. godini i preko 12.000 sistematskih pregleda starijih od 45 godina, kao i prvi ugovori HZZO i timova obiteljske medicine uope, potpisani za provoenje preventive u 2004. godini biti dobar po etak u poboljaanju preventivnih mjera za odraslo pu anstvo i starije od 65 godina. U poznatoj injenici da u patologiji starijih od 65 godina dominiraju kroni ne bolesti i stanja, va~no je istaknuti da se meu njima kao poseban  teret za timove obiteljske medicine izdvajaju slijedee podskupine: Hipertenzivne bolesti, Druge sr ane bolesti, `eerna bolest, Artroze, Druge ishemi ne bolesti srca i Bronhitis, emfizem, astma i druge kroni ne opstruktivne bolesti plua. Zaklju ci 1. Zdravstveni problemi osoba starijih od 65 godina sve ubrzanije poveavaju optereenja timova obiteljske medicine, preusmjeravaju sadr~aje i metode rada i mijenjaju kazuistiku 2. Nedostatak mehanizma financiranja preventivnih djelatnosti, aktivne skrbi, kontrole i stimuliranja kvalitete rada u inio je da je djelatnost obiteljske medicine sasvim postala pasivna zdravstvena djelatnost u odnosu na populaciju starijih od 65 godina. 3. Za pojedine bolesti i stanja, osobito za podskupine bolesti: hipertenzivne bolesti, druge sr ane bolesti, aeerna bolest, artroze, druge ishemi ne bolesti srca i bronhitis, emfizem, astma i druge kroni ne opstruktivne bolesti plua potrebno je izraditi algoritme, dijagnosti ke i terapijske smjernice koje treba postaviti unutar informacijskog ustava primarne zdravstvene zaatite. 4. Uporabu dijagnosti kih i terapijskih smjernica te kontrolu kvalitete rada treba mjeriti koriatenjem pouzdanih podataka iz informacijskog sustava primarne zdravstvene zaatite te izraditi poseban sustav stimulacije, plaanja, edukacije i poticanja timova i obiteljske medicine Literatura: McKeon Stosuy, M, Masnning B.R.M.  Joinig Up e-Health & e-Care HYPERLINK "http://bib.irb.hr/prikazi-rad?&rad=195807" \t "_blank" Development and Depoyment of a Health Information System in Transitional Countries (Croatian Experience) // Medical and Care Compunetics 2 / Bos, Lodewijk ; Lexminarayan, Swami ; March, Andy (ur.). Amsterdam : IOS Press, 2005. Toth M, `abljan D. Popis dijagnosti kih i terapijskih postupaka u zdravstvenim djelatnostima. Zagreb: Republi ki fond zdravstvenog osiguranja i zdravstva Hrvatske, 1992. Meunarodna klasifikacija bolesti i srodnih zdravstvenih problema (Deseta revizija), Svezak 1. Hrvatski zavod za javno zdravstvo. Zagreb. 1994. Meunarodna klasifikacija bolesti i srodnih zdravstvenih problema (Deseta revizija), Svezak 2. Priru nik za uporabu. Hrvatski zavod za javno zdravstvo. Zagreb. 1994. International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Volume 3. Alphabetical Index, WHO, Geneva, 1994. Hrvatski zdravstveno-statisti ki ljetopis za 1998. godinu. Zagreb: Hrvatski zavod za javno zdravstvo, 1999. Hrvatski zdravstveno-statisti ki ljetopis za 2000. godinu. Zagreb: Hrvatski zavod za javno zdravstvo, 2001. Hrvatski zdravstveno-statisti ki ljetopis za 2002. godinu. Zagreb: Hrvatski zavod za javno zdravstvo, 2003. Hrvatski zdravstveno-statisti ki ljetopis za 2003. godinu. Zagreb: Hrvatski zavod za javno zdravstvo, 2004. Kati M, Perinovi R, }alac D, Jovanovi A. Razlozi dolaska bolesniku bolesnika lije niku ope medicine. (Primjena Meunarodne klasifikacije za primarnu zaatitu). Med Fam Croat 1994;2:5-12. Stevanovi, Ranko; Pristaa, Ivan; Ivi evi  Uhernik, Ana; Stani, Arsen.  HYPERLINK "http://bib.irb.hr/prikazi-rad?&rad=195807" \t "_blank" Development and Depoyment of a Health Information System in Transitional Countries (Croatian Experience) // Medical and Care Compunetics 2 / Bos, Lodewijk ; Lexminarayan, Swami ; March, Andy (ur.). 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