Self-management support. A growing body of evidence shows that self-management activities are associated with improved outcomes.21 Instituting a peer support group for pregnant women at a federally qualified health center, for example, led to a 7% absolute risk reduction in preterm births.22
Not all efforts to encourage self-management are effective, however, and evaluation is crucial to determine what works. In one large-scale trial, the use of patient reminder cards to facilitate a reduction in health risk behaviors such as tobacco use, risky drinking, unhealthy dietary patterns, and physical inactivity led to fewer health risk assessments being performed, fewer individual counseling encounters, and no change in these behaviors.23
Decision support. Clinical decision support systems, which generate patient-specific evidence-based assessments and/or recommendations that are actionable as part of the workflow at the point of care, have been found to improve care.24,25 An example of this is a prompt that reminds the physician to discuss chemoprevention with a patient at high risk for breast cancer.
Delivery system design. The patient-centered medical home (PCMH) is a well-known example of a redesign of health care delivery.26 Conversion to this model is associated with a small positive effect on preventive interventions.27 However, the persistence of a fee-for-service payment system—which does not include physician reimbursement for some of the added services incorporated into the PCMH—limits the implementation of the PCMH model.28
Many practices are improving health care delivery by using nonphysicians for various tasks related to preventive care. Care managers, for example, typically have smaller caseloads and focus on reducing unnecessary treatment for patients with high-risk conditions, such as congestive heart failure, while patient navigators generally have less clinical expertise but more knowledge of community services.
In one study, practice-initiated phone conversations with nonphysicians increased colorectal cancer screening by up to 40%.29 And in one pilot program, the use of ancillary providers led to an increase in colorectal cancer screening by as much as 123%.30 The human touch seems to be key to the success of these interventions. Passive reminders, such as videos being shown on waiting room televisions, have not proven to be effective.31
Clinical information systems. Early on, the power of electronic health records (EHRs) to improve practices’ delivery of preventive services was recognized. As early as 1995, the use of a reminder system to highlight such services during acute care visits was linked to improvements in counseling about smoking cessation and higher rates of cervical cancer screening, among other preventive measures.32,33 Overall, the use of EHRs alone has been shown to improve rates of preventive services by as much as 66%, with most practices reporting improvements of at least 20%.34
Today, EHRs that are Meaningful Use Stage 2-compliant have the tools needed to improve care. Requirements include the ability to generate patient registries of all those with a given disease and to identify patients on the registry who have not received needed care.35 To improve preventive care, registries should focus on the mitigation of risk factors, such as identifying—and contacting—patients with diabetes who are in need of, or overdue for, an annual eye exam.
Trials using the registry function, in combination with automated messaging to deliver targeted information to various patient groups (identified by the demographic information available from the EHR), are ongoing.
Community resources. Many clinicians have informal referral relationships with community organizations, such as the YMCA. Physician practices that establish links to community resources have the potential to have a large effect on unhealthy behaviors. (See “Putting theory into practice: 2 cases”.) However, a systematic review found that, while evidence to support such connections is mainly positive, research is limited and further evaluation is needed.36
The Practical Playbook (practicalplaybook.org)37 developed by the deBeaumont Foundation, Duke Department of Community and Family Medicine, and the Centers for Disease Control and Prevention, offers concrete examples of how physician practices are linking with community resources to improve the health of the population. For example, Duke University’s “Just for Us” program provides in-home chronic illness care to 350 high-risk elderly individuals. The LATCH program connects thousands of Latino immigrants to health care services and culturally and linguistically appropriate health education classes.37
Putting theory into practice: 2 cases
CASE 1
Dominic B, a 53-year-old patient, has scheduled a visit for a cough that has persisted for 4 weeks. The patient is a nonsmoker, is married, and has no first-degree relatives with cancer. But when you review his chart before the visit, you note that he missed his 6-month check-up for hypertension and hyperlipidemia. In addition, your electronic health record (EHR ) flags the fact that he has not undergone colorectal screening and that his immunizations are not current. Because you have standing orders in place, your medical assistant gives him a flu shot and a pamphlet providing information on colorectal cancer screening before you enter the room.
During the visit, Mr. B mentions that his father, age 82, recently had a heart attack. This event—reinforced by the postcards and phone messages he received from your office after he missed his 6-month follow-up—prompted him to reluctantly admit it was “time for a check-up.” You take the patient’s blood pressure (BP) and review his lipid panel (blood work was ordered prior to his visit) with him. He is relieved to know that he will not need to be on a statin and agrees to be screened for colorectal cancer using a sensitive stool study.
Before he leaves, the patient requests medication for erectile dysfunction—a problem he never reported before. You ask him to keep a diary and return in 2 months, and promise to discuss his erectile dysfunction at that time.
CASE 2
A review of your practice’s patient registry reveals that Gladys P, age 55, is behind on breast and cervical cancer screening. She has had only a few sporadic office visits, the last of which was for bronchitis 18 months ago. At that time, the patient’s systolic BP was 162 mm Hg. You told her you would recheck it in 6 weeks, but she failed to return for follow-up.
Ms. P smokes, but has no other chronic diseases and takes no medications. There is no record of a mammogram or Pap smear, and you don’t know whether she sees a gynecologist routinely. Your office contacts her and discovers that you are the only doctor she sees. The patient tells the medical assistant who placed the call that her car broke down but she has not had money to repair or replace it, so she has had no way to get to your office.
Your staff arranges for her to get a ride from a community volunteer group, first to the nearby hospital for a mammogram and then to your office, where you perform a Pap smear and address her elevated BP and smoking. You are rewarded for the counseling and preventive care with a letter and a bonus check from Ms. P’s insurance carrier, congratulating you on your quality improvement efforts.