Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital

Slide presentation from the AHRQ 2009 conference.

On September 15, 2009, Alice Hm Chen, MD, MPH made this presentation at the 2009 Annual Conference. Select to access the Microsoft PowerPoint file Microsoft PowerPoint version - 6.76 MB .


Slide 1

Slide 1. Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital

Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital

AHRQ 2009 Conference
Alice Hm Chen, MD, MPH

Slide 2

Slide 2. SFGH Acknowledgements

SFGH Acknowledgements

  • Lisa Johnson, Medical Director for Quality Improvement Programs, Community Primary Care
  • Fred Strauss, IS/Provider Liaison
  • Winnie Tse, Analyst, Community Primary Care
  • Flu-FOBT Project: Michael Potter, Professor of Clinical Family and Community Medicine and Albert Yu, Medical Director of Chinatown Public Health Center

Slide 3

Slide 3. Outline

Outline

  • Background
  • SFGH delivery system and EMR
  • Case study: colorectal cancer screening
  • Case study: breast cancer screening

Slide 4

Slide 4. Why focus on preventive care?

Why focus on preventive care?

  • Only 10% of female Medicare beneficiaries received all of 5 recommended preventive care measures (cervical, breast and colorectal cancer screening; pneumovax and influenza vaccines).
  • Significant disparities in receipt of preventive care services among racial/ethnic groups and poor. 

General Accounting Office congressional testimony on 3/23/02, available at: www.gao.gov/cgi-bin/getrpt?GAO-02-777T.

Slide 5

Slide 5. Barriers to Screening in the Safety Net

Barriers to Screening in the Safety Net

  • Financial barriers (lack of insurance, co-pays)
  • System resource constraints, e.g.
    • Lack of ability to offer screening colonoscopies
    • Difficulty hiring mammographers
  • Literacy, language, and cultural barriers
  • Conflicting guidelines for PCPs
  • 7.4 hours/day to provide all USPSTF “A” and “B” services

Yarnell KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: Is there enough time for prevention? American Journal of Public Health 2003; 635-641.

Slide 6

Slide 6. Whose guidelines should we be following, anyways?

Whose guidelines should you be following, anyways?

  • Proliferation of guidelines
  • “Eminence” based versus evidence based
  • Internal versus external
    • Ability to tailor to resources
    • Time consuming to develop
    • Need for ongoing updates

Image of an editorial in 2009 JAMA titled "Reassessment of Clinical Practical Guidelines: Go Gently Into That Good Night".

Slide 7

Slide 7. SFGH Approach

SFGH Approach

  • Agreement on evidence-based guidelines (USPSTF), tailored to our system’s resource constraints
  • Harnessing information technology
    • Electronic medical record
    • AHRQ Electronic Preventive Services Selector (ePSS)
    • Patient registries
  • Systems interventions
    • Standing orders
    • Panel management
    • Culturally and linguistically appropriate outreach

Slide 8

Slide 8. San Francisco Safety Net

San Francisco Safety Net

Image of a flow chart. 12 SF DPH primary care clinics (~45,000 patients); 5 UCSF-staffed primary care clinics (~30,000 patients); and 10 independent primary care clinics (~70,000 patients) who are comprised of 17% Medicare, 27% Medi-Cal, and 36% Uninsured, feed into the San Francisco General Hospital and Trauma Center Comprehensive Specialty Services with Full-time Academic UCSF Faculty & Trainees, >500,000 ambulatory visits annually with 29% receiving specialty care and 20% diagnostics.

Slide 9

Slide 9. Screen Capture of Clinical Alerts page

Screen shot of a clinical alert page for a patient.

Slide 10

Slide 10. Screen Capture of the Female Health Maintainance Screen

Screen shot of a web page showing data on a patient's female health maintenance.

Slide 11

Slide 11. Screen Capture of the Treatment and Referral Guidelines

Screen shot of treatment and referral guidelines for SFGH and COPC clinics.

Slide 12

Slide 12. Screen Capture of the Health Maintenance screen

Screen shot of a web page showing screening tests that were done for a patient, when and links to USPSTF guidelines.

Slide 13

Slide 13. Screen Capture of the Health Maintenance screen continued

Screen shot of a web page showing screening tests that were done for a patient, when and links to USPSTF guidelines. An arrow is pointing to where you can enter data.

Slide 14

Slide 14. Screen Capture of the Health Maintenance screen continued

Screen shot of a web page where screening tests can be ordered for a patient.

Slide 15

Slide 15. Screen Capture of the Browse Topic screen

Screen shot of the Browse by Topic page of AHRQ's ePSS Web site.

Slide 16

Slide 16. Screen Capture of the Search for Recommendation screen

Screen shot from the ePSS Web site where you can search for recommendations by age, sex, tobacco user, and sexual activity.

Slide 17

Slide 17. Colorectal Cancer Screening "Success"

Colorectal Cancer Screening "Success"

  • Practice based on USPSTF guidelines, tailored to system resource constraints (no screening colonoscopy)
  • SF DPH recommends annual home FOBT, with diagnostic colonoscopy for abnormals
  • Systems intervention: Flu-FOBT program
  • Culturally and linguistically appropriate outreach

Slide 18

Slide 18. Screen Capture of search result of colorectal cancer screening

Screen shot of a web page showing screening test history and an arrow pointing to the link for the USPSTF screening for colorectal cancer guidelines.

Slide 19

Slide 19. Screen Capture of Screening for Colorectal Cancer screen

Screen shot of the Task Force Screening for Colorectal Cancer topic page.

Slide 20

Slide 20. Screen Capture of the Colon Cancer Screening and Surveillance Guidelines

Screen shot of a Web page showing SFGH GI GastroIntestinal Clinic Colon Cancer Screening and Surveillance Guidelines.

Slide 21

Slide 21. Flu-FOBT Program

Flu-FOBT Program

  • Strategy: offer FOBT in combination with flu shots
  • Initial pilot results
    • Flu only: 52.9% →57.3% eligible completed FOBT
    • Flu + FOBT: 54.5% → 84.3% eligible completed FOBT
    • Difference of 25.4 points, p<0.001

      Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh J. Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates. Annals of Family Medicine 2009; 7:17-23.
  • SF DPH program at Chinatown Public Health Center led by Mike Potter and Albert Yu, funded by CDC Slide courtesy of Albert Yu and Mike Potter

Slide 22

Slide 22. Outreach Materials

Outreach Materials

Images of colon cancer screening test outreach materials in English and other languages.

Slide courtesy of Albert Yu and Mike Potter

Slide 23

Slide 23. Designed at Request of CPHC Staff with Patient Input

Designed at Request of CPHC Staff with Patient Input

Images of approved and nonapproved items you can use before testing.

Slide courtesy of Albert Yu and Mike Potter

Slide 24

Slide 24. CPHC Preliminary Results

CPHC Preliminary Results

Efficacy among 50-80 year olds who came in for primary care visit during flu shot season

 Got Flu Shot
(n=1286)
Didn't Get Flu Shot
(n=588)
Up to date 9-29-0851.2%60.2%
Up to date 3-31-0975.2%64.8%
Change+25.0%+4.6%

Slide courtesy of Albert Yu and Mike Potter

Slide 25

Slide 25. SF DPH Screening Rates

SF DPH Screening Rates

Graph showing percent of patients aged 51-75 with completed colorectal cancer screening.

The results are:

CPHC: 58%

OPHC: 66%

CHN Total: 42% (which is the same as the U.S. average - NHIS 2000)

Slide 26

Slide 26. Breast Cancer Screening Challenges

Breast Cancer Screening Challenges

  • Primary care quality improvement committee uses USPSTF guidelines, but specialty society (radiology) recommendations different
  • Difficulties hiring mammographers had led to significant wait times for both screening and diagnostic mammograms
  • Conflicting information given to patients
  • Low mammography rates due to CBE requirement

Slide 27

Slide 27. Screen Capture of the search results for Breast Cancer Screening

Screen shot showing a patient's testing history and an arrow pointing to the Task Force breast cancer screening recommendations.

Slide 28

Slide 28. Screen Capture of the Screening for Breast Cancer screen

Screen shot showing the Task Force screening for breast cancer topic page.

Slide 29

Slide 29. Screen Capture of the CHN Guideline for Use of Mammography in Breast Cancer Screening screen

Screen shot showing a page with the CHN guideline for use of mammography in breast cancer screening. 

Slide 30

Slide 30. Screen Capture of the Mammogram Referral screen

Screen shot showing information on how doctors can provide mammogram referrals.

Slide 31

Slide 31. Scanned image of a letter issued indicating the person had not had a mammogram in more than 1 year

Sample of the text used in a reminder letter for a mammogram in 5 different languages from the Community Health Network of San Francisco.

Slide 32

Slide 32. Breast Imaging Request Form, highlighting the date of last clinical breast exam

Image of a breast imaging request form.

Slide 33

Slide 33. SF DPH Mamography Rates

SF DPH Mammography Rates

Bar graph showing the percent of women ages 42-69 who have had a mammogram in the past 2 years. Excluding data "not indicated" but does not give credit for "declined."

Slide 34

Slide 34. Conclusions

Conclusions

  • USPSTF guideline process (rigorous, evidence-based, ongoing) critical to reliability and credibility.
  • AHRQ ePSS enables easy access to updated USPSTF guidelines, especially with linkages EMR.
  • Challenges remain with systems barriers that can only be addressed on an institutional level.

Slide 35

Slide 35. Questions?

Questions?

Alice Hm Chen, MD, MPH
Assistant Professor of Medicine, UCSF
Medical Director, Adult Medical Center, SFGH
achen@ medsfgh.ucsf.edu

Current as of December 2009
Internet Citation: Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital. December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2009/chen/index.html