Improving Clinical Preventive Services: A Discussion with AHRQ Centers for Excellence

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Slide 1

Improving Clinical Preventive Services (CPS): A Discussion with AHRQ Centers for Excellence

Moderator: Iris Mabry-Hernandez, MD, MPH,
Agency for Healthcare Research and Quality (AHRQ)

Slide 2

Why Isn't Prevention Working?

• Prevention efforts in the U.S. are fragmented.
• Prevention efforts are underfunded and not adequately incentivized.
• Data systems often inadequate to track prevention efforts in populations.
• People not sufficiently informed about CPS and don't feel empowered to make decisions.
• Problems with both inadequate access to CPS and overuse of CPS.

Slide 3

National Prevention Strategy

Working together to improve the health and quality of life for individuals, families and communities by moving the nation from a focus on sickness and disease to one based on prevention and wellness.

Image: A circle is shown. At the center is a set of icons representing people of all types and ages, from an infant in a baby carriage to a person in a wheelchair; the caption reads "Increase the number of Americans who are healthy at every stage of life." Around this central image is a circular band divided into four equal sections, each fitted into the adjacent section like pieces of a jigsaw puzzle. These sections are captioned "Health and Safety Community Environments," "Clinical and Community Preventive Services," "Elimination of Health Disparities," and "Empowered People." Around this band is another, solid circular and with text at regularly spaced intervals: "Tobacco Free Living," "Preventing Drug Abuse and Excessive Alcohol Use," "Healthy Eating," "Active Living," "Mental and Emotional Well-being," "Reproductive and Sexual Health," and "Injury and Violence Free Living."

Slide 4

AHRQ Centers for Excellence (CfE) Program

• CfE Mission:
  • Improve clinical preventive services in primary care.
  • Complement efforts of other Federal investments in prevention & public health.
  • Move forward the National Prevention Strategy.
• CfE Programmatic Focus Areas:
  • Health Equity.
  • Patient Safety.
  • Health Care Implementation.
• CfE Structure:
  • 3 research projects to address existing gaps in evidence.
  • Core activities: research development, education and training, dissemination, collaboration and evaluation.

Slide 5

Centers for Excellence Health Care Implementation

• Center for Research in Implementation Science & Prevention (CRISP):
  • Location: University of Colorado, Anschutz Medical Campus.
  • Research Goals: Increase use of CPS by focusing on collaboration between different health care delivery sectors and the use of innovative HIT.
  • Center Director: Allison Kempe, MD MPH.

Images: A photograph of Allison Kemp and the logo of the University of Colorado Center for Research in Implementation Science & Prevention (CRISP) are shown.

Slide 6

Centers for Excellence Health Equity

• Center for Advancing Equity in Clinical Preventive Services:
  • Location: Northwestern University, Chicago.
  • Research Goals: Reduce disparities in CPS by focusing on health literacy, health communication, quality improvement methods & health information technology.
  • Center Director: David Baker, MD MPH.

Images: A photograph of David Baker and the logos of the Center for Advancing Equity in Clinical Preventive Services ("Prevention for All") are shown.

Slide 7

Centers for Excellence Patient Safety

• Research Center for Excellence in Clinical Preventive Services (ReCPS):
  • Location: University of North Carolina at Chapel Hill.
  • Research Goals: Reduce potential harms to patients by promoting the appropriate use of CPS in primary care.
  • Center Director: Russell Harris, MD MPH.

Images: A photograph of Russell Harris and the logo of the University of North Carolina at Chapel Hill Research Center for Excellence in Clinical Preventive Services are shown.

Slide 8

Town Hall Presentation Objectives

• Introduce Research Centers for Excellence in Clinical Preventive Services and how they further the National Prevention Strategy.
• Provide the CfE's framework for improving population health through prevention.
• Provide examples of how the CfEs are using this framework to achieve their goals.
• Receive feedback from audience on the CfE's goals and research framework.

Slide 9

Step Back; Think Big

IMPROVING POPULATION HEALTH THROUGH PREVENTION

• TRANSFORMATIVE CHANGE NEEDED!
• Proposed framework for moving the National Prevention Strategy ahead through the use of the Plan, Do, Study, Act (PDSA) Improvement cycle.

Slide 10

Step 1: Plan

• Create multi-stakeholder community "Prevention Partnerships"—start with groups organized around "Health People" initiatives.
• Use HIT to develop community data.
• Collect community-level data.
• Establish community priorities.

Slide 11

Step 2: Do

• Determine best strategies to deliver priority preventive services by developing and studying strategies in small areas/groups.
• Bundle preventive service delivery to make prevention more convenient and efficient.
• Build with sustainability in mind.
• Inform and empower individuals and groups about what preventive services they need (or do not need).
• Use HIT to communicate with individuals.

Slide 12

Step 3: Study

• Use population-level data collection systems to analyze success of strategies implemented.
• Feed back results to all stakeholders in the Prevention Partnerships.
• Undertake targeted approaches to understand failures, including targeted analyses on sub-populations that did not improve even if a strategy was successful overall.

Slide 13

Step 4: Act

• Scale up strategies/combinations of strategies that proved successful.
• Target approaches to improve outcomes in sub-populations that initially fail to improve.
• Using information systems, monitor effects of implementation over time.

Slide 14

Center for Research in Implementation Science and Prevention (CRISP)

Allison Kempe, MD, MPH
Professor of Pediatrics
Director, Children's Outcomes Research Program
University of Colorado School of Medicine

Slide 15

CRISP Mission

To enhance implementation of effective preventive care in diverse populations by:

• Conducting multidisciplinary research that links primary care, public health and community prevention efforts.
• Broadly disseminating implementation research findings.
• Providing education and training in implementation science.

Slide 16

CRISP Projects

• Project 1: Comparative Effectiveness Trial Comparing Reminder/Recall Methods to Increase Immunization Rates in Young Children; Principle Investigator (PI): Allison Kempe, MD, MPH.
• Project 2: Improving Cardiovascular Screening and Management through a Bidirectional Personal and Technological Interface; PI: Jack Westfall, MD, MPH.
• Project 3: Community Outreach—Obesity Prevention Trial (CO-OPT) in children; PI: Art Davidson, MD, MPH.

Slide 17

CRISP Projects

• Collaboration between different health care delivery sectors:
  • Private practices.
  • Public health.
  • Community (community health workers, advisory groups).
• Use of HIT to identify who needs CPS, interface with patients and between health care sectors:
  • Immunization Information systems (IIS) and disease registries.
  • EHRs.
  • Bidirectional text messaging and autodialer.

Slide 18

Influenza Vaccine Delivery: The Perfect Storm

Image: A ship is shown caught up in an enormous wave.

Slide 19

Ideal Approach to Prevention of Influenza in Entire Populations

• Primary focus on school-aged children likely to be most effective and cost-effective.
• Given narrow window of opportunity, vaccination within multiple sectors optimal:
  • Primary care sites.
  • Community clinics sponsored by public health entities.
  • Schools.
  • Support from community.
• Coordination and documentation are key.

Slide 20

Capacity Problems: Expansion of Childhood Influenza Recommendations

Slide 21

Additional Children Needing Vaccination

• Children recommended for vaccination:
  • 2007-08 season: ~40 million children.
  • 2008-09 season and beyond: ~74 million children.
• Immunizing 6 month-18 year olds:
  • 50% coverage rate: ~300% increase in # of children vaccinated.
  • 90% coverage rate: ~500% increase.

Ref: Erhard, J Pediatr 2004; Schwartz, J Infect Diseases 2006; ACIP Influenza Vaccination Recommendations, MMWR 2007.

Slide 22

Collaborative Models

• Joint collaborative clinics between PH and private practices:
  • Community-based, ideally with active involvement of community.
  • Based at either entity but co-sponsored.
• Referral to PH clinics from practices.
• School-based delivery with support of private practices.

Slide 23

Framework Concepts Addressed

• Step 1: Plan:
  • Create multi-stakeholder community partnerships.
  • Use HIT to develop community data.
• Step 2: Do:
  • Determine best strategies to deliver priority preventive services by developing and studying strategies in small areas/groups.
  • Use HIT to communicate with individuals.
  • Build with sustainability in mind.

Slide 24

Conceptual Framework: Influenza Iz Delivery

Slide 25

Conceptual Framework: Influenza Iz Delivery

Slide 26

Your Input Needed!

• How do we facilitate or incentivize primary providers and PH departments to work together?
  • How to protect providers against economic losses?
  • How to get around the problem of public versus private sources of vaccine?
  • How should PH efforts be funded?
• How should school-located immunization programs be structured and funded?
  • Is billing in schools feasible?
  • How could primary providers and schools work together in this effort?

Slide 27

Let's talk amongst ourselves...

Discuss...

Image: A photograph of Michael Myers dressed as his talk-show hostess character "Linda Richman" from Saturday Night Live is shown.

Slide 28

Center for Advancing Equity in Clinical Preventive Services

David W. Baker, MD, MPH
Michael A. Gertz Professor in Medicine
Chief, Division of General Internal Medicine & Geriatrics
Feinberg School of Medicine, Northwestern University

Slide 29

Our Mission

• We work to expand and accelerate the development, testing, and dissemination of innovative, practical, effective, generalizable interventions to increase equity of access to and use of clinical preventive services.

Images: The logos of the Center for Advancing Equity in Clinical Preventive Services and Northwestern University's Feinberg School of Medicine are shown.

Slide 30

Overarching Principle

• Multiple factors lead to disparities.
  Multifaceted solutions are needed.
• It's not about just doing the right thing.
  It's doing everything right.

Slide 31

Reduce Disparities in Primary Prevention of CVD

• Use EMR data to identify patients at high risk for cardiovascular disease not on a statin.
• Conduct outreach to patients and present tailored risk information and how to reduce this.
• Offer to arrange visit with primary care provider.

Image: A screenshot shows a "Current Project: Reducing Disparities in Primary Prevention of Cardiovascular Disease."

Slide 32

Reduce Disparities in Pneumococcal Vaccination

• Qualitative research with patients who refuse.
• Develop informational video that addresses key issues, emphasizes vx across life course.
• Deliver video through EMR to patients who are about to turn 65 years old.

Image: A screenshot shows a "Current Project: Understanding Rates of Pneumonia Vaccination."

Slide 33

Reduce Disparities in Colorectal Cancer Screening & Mortality

• Focus on long-term adherence to FOBT.
• Use EMR to identify patients due for FOBT.
• Text, voice notification. Mail FIT to home.
• Plain language, pictorial instructions.
• Navigator calls if incomplete after 3 months.

Image: A screenshot shows a "Current Project: Improving Rates of Repeat Colorectal Cancer Screening."

Slide 34

Guiding Principles Applied to Research in Health Equity

• Determine best strategies to deliver services.
  • Design strategies to overcome access barriers.
• Inform and empower individuals.
  • Develop plain language materials.
• Use HIT to communicate with people.
  • Cell phone > patient portal to EMR.
• Build with sustainability in mind.
  • Be aware of financial constraints of CHCs.

Slide 35

Conceptual Framework: CRC Screening

Slide 36

Conceptual Framework: CRC Screening

Slide 37

Image: An illustrated card provides instructions on how to do a home fecal smear test.

Slide 38

Guiding Principles Applied to CRC Screening Study

• Determine best strategies to deliver services.
  • Remove need to come for care. Mail FIT kit.
• Inform and empower individuals.
  • Plain language instructions, need for repeat testing.
• Use HIT to communicate with people.
  • Text message, telephone reminder.
• Build with sustainability in mind.
  • Automated messaging. Navigator only if fails. Economic analysis of marginal value of navigator.

Slide 39

Dissemination

• If successful, we will develop materials that address all aspects of implementing a comprehensive program for CRC screening.
  • Economic analysis of possible options.
• Where should these be placed to maximize visibility and uptake? USPSTF, AHRQ, NACHC, Primary Care Societies?
• What other things can we do to foster research and maximize implementation?

Slide 40

Scalability

• "Bundle preventive service delivery."
• Can we really do text and voice mails to patients whenever they are due for preventive services? Will this cause "alert fatigue"?
• How can we most efficiently and effectively provide patients the comprehensive set of preventive services they need?

Slide 41

Questions

• Which services should be delivered outside of traditional health care (i.e., in the community)?
• How much effort should be spent on single topics vs. comprehensive strategies to increase all needed services?
• What is needed most to help providers address disparities in preventive services?
  • Literature reviews? Identification/dissemination of highest quality tools?
• What is the best way to identify research priorities?

Slide 42

Research Center for Excellence in Clinical Preventive Services

Russell Harris, MD, MPH
Center Director

Noel Brewer, PhD
Collaborative Scientific Lead

Image: The logo of the University of North Carolina at Chapel Hill Research Center for Excellence in Clinical Preventive Services is shown.

Slide 43

Problem: Inattention to Harms of Clinical Preventive Services (CPS)

• Leads to overuse.
• Leads to wasted resources.
• Leads to harms for patients.

Slide 44

Our Goals
(research we conduct, encourage, and monitor)

• Better understand patient/clinician thinking about harms.
• Develop effective ways of communicating about harms.
• Develop effective ways of reducing "inappropriate" use of CPS.

Slide 45

Our Goals
(education and dissemination)

• Develop and test educational materials for med students, residents, practicing physicians about use of harms information in decisionmaking.
• Work with policymakers to increase use of harms information in their decisionmaking.

Slide 46

Appropriateness
(key concept)

• "Appropriate" services: clear evidence that implementation would bring greater benefits than harms.
• "Definitely inappropriate" services: clear evidence that implementation would bring greater harms than benefits.
• "Probably inappropriate" services: either insufficient evidence or harms and benefits are closely matched.

Slide 47

Scientific Assessment

Image: A chart shows the following assessment criteria:

Appropriate Goals

Empowerment:

• Knowledge.
• Values.
• Decision.

↓

Screening > Not screening.

Probably Inappropriate Goals

High importance to patient or physician

↓

Empowerment:

• Knowledge.
• Values.
• Decision.

Low importance

↓

Not Screening > Screening

Inappropriate Goals

High importance

↓

Empowerment:

• Knowledge.
• Values.
• Decision.

Low importance

↓

Not Screening > Screening

Slide 48

UNC Role in the Framework

• Step 1. Plan:
  • Emphasis on prioritization. By finding ways to reduce "inappropriate" prevention, we hope to encourage efforts to increase "appropriate" prevention.
• Steps 2 and 3: Do and Study:
  • Emphasis on testing strategies to discourage (without coercion) inappropriate services and empowering people to make good decisions about prevention.

Slide 49

UNC Role in the Framework: Examples

• Project 1: (Stacey Sheridan, MD, MPH):
  • Randomized controlled trial (RCT) of effects of various communication strategies on intent to be screened for USPSTF-rated C, D, and I services.
• Project 2: (Maihan Vu, DrPH, MPH):
  • In-depth interviews and surveys of physicians to better understand how they think about the harms of screening for C, D, I services.

Slide 50

UNC Role in the Framework: Examples

• Project 3: (Carmen Lewis, MD, MPH):
  • RCT of effects of decision aid on screening older people for colorectal cancer.
• Education and dissemination activities:
  • Collaborations with Partnership for Prevention, Choosing Wisely, AHEC residencies, Roundtable.
  • Systematic reviews and conceptual papers to help researchers and evidence reviewers.
  • Developing case studies of using harms information in decisionmaking.

Slide 51

Questions

• How to define "appropriate"?
• Ideas for outcomes: "empowerment" as well as having screening.
• How can we help you as researchers and policymakers in raising awareness and use of harms information in decisionmaking?
  • Idea of "rolling systematic review" to monitor research and methods.

Slide 52

Additional Questions for Audience

• What do you think about the "framework" and how we are approaching the problem?
• What is missing from the framework?
• How can we help you improve prevention research and policy along the lines of this framework?