Improving our approach to preventive care

,; ,; ,

Applied Evidence

Improving our approach to preventive care

J Fam Pract. 2015 June;64(6):343,345-348

By

Gerald Liu, MD

Allen Perkins, MD, MPH

Lamar Duffy, MD

Many components of the chronic care model can be successfully applied to preventive care, evidence shows. Here’s how to do more with the resources you have.

PDF Download

References

1. Han P. Historical changes in the objectives of the periodic health exam. Ann Intern Med. 1997;127:910-917.

2. Mehrota A, Zaslavsky A, Anyanian J. Preventive health examinations and preventive gynecologic examinations in the United States. Arch Intern Med. 2007;167:1876-1883.

3. Jean CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract. 1994;38:166-171.

4. McGinnis JM, Foege WH. The immediate versus the important. JAMA. 2004;291:1263-1264.

5. Crabtree BF, Miller WL, Tallia AF, et al. Delivery of clinical preventive services in family medicine offices. Ann Fam Med. 2005;3:430-435.

6. US Department of Health and Human Services. August 28, 2013. Healthy People 2020. Available at: www.healthypeople.gov. Accessed September 13, 2013.

7. Pollak KI, Krause KM, Yarnall KS, et al. Estimated time spent on preventive services by primary care physicians. BMC Health Serv Res. 2008;8:245.

8. US Preventive Services Task Force. Guide to Clinical Preventive Services. 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996.

9. Field MJ, Lohr KN, Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academies Press; 1990.

10. Yarnell K, Pollak K, Ostbye T, et al. Primary care: is there enough time for prevention? Am J Public Health. 2003;93:635-641.

11. Butler CC, Simpson SA, Hood K, et al. Training practitioners to deliver opportunistic multiple behaviour change counselling in primary care: a cluster randomized trial. BMJ. 2013;346:f1191.

12. Yonas M, Nowalk M, Zimmerman R, et al. Examining structural and clinical factors associated with implementation of standing orders for adult immunization. J Healthcare Qual. 2012;34:34-42.

13. Donahue K, Plescia M, Stafford K. Do standing orders help with chronic disease care and health maintenance in ambulatory practice? J Fam Pract. 2010;59:226-227.

14. Glasgow R, Orleans T, Wagner E. Does the chronic care model serve also as a template for improving prevention? Milbank Q. 2002;79.

15. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clin Pract. 1998;1:2-4.

16. Barr V, Robinson S, Marin-Link B, et al. Chronic care model: an integration of concepts and strategies from population health promotion and the chronic care model. Hosp Q. 2003;7:73-83.

17. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775-1779.

18. Moore LG. Escaping the tyranny of the urgent by delivering planned care. Fam Pract Manage. 2006;13:37-40.

19. Tsai AC, Morton SC, Mangione CM, et al. A meta-analysis of interventions to improve care for chronic illnesses. Am J Managed Care. 2005;11:478-488.

20. Coleman K, Austin BT, Brach C, et al. Evidence on the chronic care model in the new millenium. Health Affairs. 2009;28:75-85.

21. Pearson ML, Mattke S, Shaw R, et al. Patient Self-Management Support Programs: An Evaluation. Final Contract Report. Publication No. 08-0011. Rockville, MD: Agency for Healthcare Research and Quality. November 2007.

22. Feder J. Restructuring care in a federally qualified health center to better meet patients’ needs. Health Affairs. 2011. Available at: http://content.healthaffairs.org/content/30/3/419.full.html. Accessed February 13, 2014.

23. Hung D, Rundall T, Tallia A, et al. Rethinking prevention in primary care: applying the chronic care model to address health risk behaviors. Milbank Q. 2007;85:69-91.

24. Lobach D, Sanders GD, Bright TJ, et al. Enabling Health Care Decisionmaking Through Clinical Decision Support and Knowledge Management. Evidence Report No. 203. Publication No. 12-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2012.

25. Kawamoto K, Houlihan C, Balas E, et al. Improving clinical practice using clinical decision support systems: a systemic review of trials to identify features critical to success. BMJ. 2005;330:765.

26. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. March 2007. American Academy of Family Physicians Web site. Available at: http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf. Accessed May 7, 2015.

27. Agency for Healthcare Research and Quality. The Patient-Centered Medical Home. Closing the Quality Gap: Revisiting the State of the Science: Evidence Report/Technology Assessment Executive Summary No. 208. Agency for Healthcare Research and Quality Web site. Available at: http://www.effectivehealthcare.ahrq.gov/ehc/products/391/1178/EvidReport208_CQGPatientCenteredMedicalHome_FinalReport_20120703.pdf. Accessed May 7, 2015.

28. Peikes D, Zutshi A, Genevro J, et al. Early Evidence on the Patient-Centered Medical Home. Final Report. Publication No. 12-0020-EF. Rockville, MD: Agency for Healthcare Research and Quality. February 2012.

29. Liu G, Perkins A. Using a lay cancer screening navigator to increase colorectal cancer screening rates. J Am Board Fam Med. 2015;28:280-282.

30. Baker N, Parsons M, Donnelly S, et al. Improving colon cancer screening rates in primary care: a pilot study emphasising the role of the medical assistant. Qual Saf Health Care. 2009;18:355-359.

31. Holden D, Jonas D, Portersfield D. Systematic review: enhancing the use and quality of colorectal cancer screening. Ann Intern Med. 2010;152:668-676.

32. Dexheimer JW, Talbot TR, Sanders DL, et al. Prompting clinicians about preventive care measures: a systematic review of randomized controlled trials. J Am Med Inf Assoc. 2008;15:311-320.

33. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. J Am Med Inf Assoc. 1996;3:399-409.

34. Chaudhry B, Wang J, Wu S, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med. 2006;144:742-752.

35. Future of Family Medicine Leadership Committee. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2(Suppl 1):S3-S32.

36. Porterfield D, Hinnant L, Kane H, et al. Linkages Between Clinical Practices and Community Organizations for Prevention: Final Report. Rockville, MD: Agency for Healthcare Research and Quality. October 2010.

37. deBeaumont Foundation, Duke Community and Family Medicine, Centers for Disease Control and Prevention. A Practical Playbook. Available at: https://practicalplaybook.org. Accessed March 29, 2015.

38. Physician Quality Reporting System. Centers for Medicare and Medicaid Services. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS. Accessed March 29, 2015.

39. RTI International. Accountable Care Organization 2014 Program Analysis Quality Performance Standards Narrative Measure Specifications. 2014. Centers for Medicare and Medicaid Services Web site. Available at: http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/sharedsavingsprogram/Downloads/ACONarrativeMeasures-Specs.pdf. Accessed May 7, 2015.

40. Koh K, Sebelius K. Promoting prevention through the Affordable Care Act. N Engl J Med. 2010;363:1296-1299.

41. Rosenbaum S. The patient protection and affordable care act: Implications for public health policy and practice. Public Health Rep. 2011;126:130-135.

PRACTICE RECOMMENDATIONS

› Avoid scheduling annual visits exclusively for preventive care. A
› Institute simple practice changes to improve the preventive services you provide, such as implementing standing orders for influenza vaccines. A
› Adopt components of the chronic care model for preventive services wherever possible—using ancillary providers to remind patients to undergo colorectal cancer screening and recommending apps that support self-management, for example. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

For well over a century, the periodic health exam has been associated with the delivery of preventive services¹—a model widely accepted by physicians and patients alike. Approximately 8% of ambulatory care visits are for check-ups, and more than 20% of US residents schedule a health exam annually.²

Periodic health exams, however, do not result in optimal preventive care. Evidence suggests that important preventive services, such as dietary counseling, occur at only 8% of such visits; that just 10 seconds, on average, is devoted to smoking cessation; and that 80% of the preventive services patients receive are delivered outside of scheduled health exams.² Because physicians and patients alike understandably prioritize acute problems, any discussion of health maintenance issues during a periodic check-up is likely to occur despite the visit’s agenda, not as part of it.^3-7

Primary care physicians and practices are increasingly being held accountable for their performance on preventive measures. With that in mind, being familiar with evidence-based guidelines relating to the delivery of preventive services in ambulatory care settings, such as those developed by the US Preventive Services Task Force (USPSTF),⁸ is crucial. Identifying elements of the chronic care model that can be effectively applied to preventive care—and recognizing that the reactive acute care model is ineffective for both chronic illness and preventive services—is essential, as well.

Preventive care that's evidence-based

Good practice guidelines should have the following features, according to the Institute of Medicine:⁹• Validity. Application would lead to the desired health and cost outcomes.
• Reliability/reproducibility. Others using the same data/interpretation would reach the same conclusion.
• Clinical applicability. Patient populations are appropriately defined.
• Clinical flexibility. Known or generally expected exceptions are identified.
• Clarity. Guideline uses unambiguous language with precise definitions.
• Multidisciplinary process. Developed with the participation of all key stakeholders.
• Scheduled review. Periodically reviewed and revised to incorporate new evidence/changing consensus.
• Documentation. Procedures used in development are well documented.

It’s estimated that a primary care physician with an average-sized patient panel would need an additional 7.4 hours per day to achieve 100% compliance with all of the USPSTF recommendations.

The USPSTF guidelines are consistent with these attributes.⁸

Some brief interventions fail

Guidelines are useful as practice standards for establishing preventive care goals, but their existence alone does not ensure the delivery of high-quality preventive services in an office setting. One key factor is time. It is estimated that a primary care physician with an average-sized patient panel would require an additional 7.4 hours per day to achieve 100% compliance with all of the USPSTF recommendations.¹⁰

Counseling, in particular, is an intervention that may be more effective in theory than in practice. Evidence suggests that even when primary care providers are trained in preventive counseling (and many are not), many brief interventions are not effective at creating sustained behavior change or health improvement.¹¹

Others are effective

That’s not to say that there’s little that can be done. Use of standing orders for influenza vaccination is one example of an effective and easily implemented preventive measure that requires little or no additional physician time. Yet some doctors are resistant, fearing loss of control or lawsuits. In fact, the National Vaccine Injury Compensation Program specifically provides protection against vaccinerelated malpractice claims.¹² A standing order for office staff to arrange a screening mammogram is another effective intervention; it has been shown to improve screening rates by as much as 30%.¹³

Lessons from chronic illness management

Chronic illness care and preventive care have much in common.¹⁴ Both acknowledge the need for proactive screening and counseling to bring about behavior change. In addition, both require ongoing care and follow-up, as well as depend on links to community resources. And finally, both are resource-intensive—too resource-intensive, some say, to be delivered in a cost-effective manner.

The Chronic Care Model has been proposed as a framework for improving preventive services (TABLE).^15,16 Evidence suggests adopting some key components of chronic care can lead to significant gains in the delivery of preventive care, with the largest improvement seen when multiple components are used simultaneously.^17-20