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Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital. AHRQ 2009 Conference Alice Hm Chen, MD, MPH. SFGH Acknowledgements. Lisa Johnson, Medical Director for Quality Improvement Programs, Community Primary Care Fred Strauss, IS/Provider Liaison

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Improving preventive health care success stories uspstf and epss at san francisco general hospital l.jpg

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

AHRQ 2009 Conference

Alice Hm Chen, MD, MPH


Sfgh acknowledgements l.jpg
SFGH Acknowledgements ePSS

  • 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


Outline l.jpg
Outline ePSS

  • Background

  • SFGH delivery system and EMR

  • Case study: colorectal cancer screening

  • Case study: breast cancer screening


Why focus on preventive care l.jpg
Why focus on preventive care? ePSS

  • 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.


Barriers to screening in the safety net l.jpg
Barriers to Screening in the Safety Net ePSS

  • 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.


Whose guidelines should we be following anyways l.jpg
Whose guidelines should ePSS we 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


Sfgh approach l.jpg
SFGH Approach ePSS

  • 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


Colorectal cancer screening success l.jpg
Colorectal Cancer Screening “Success” ePSS

  • 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


Flu fobt program l.jpg
Flu-FOBT Program ePSS

  • 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


Outreach materials l.jpg

大腸癌檢 ePSS

大腸癌檢

糞便檢

糞便檢

Stool Test for Colon Screening

Stool Test for Colon Screening

:

:

Instructions for Collecting 3 Stool

Instructions for Collecting 3 Stool

收集三次糞便的指示

收集三次糞便的指示

Before collecting your stool,

Before collecting your stool,

請閱讀以下提

收集糞便之前

收集糞便之前

請閱讀以下提

Samples:

Samples:

please read the following:

please read the following:

1.

1.

Write the date

Write the date

每張收集?上記下

?收集

每張收集?上記下

?收集

1.

1.

you collected

you collected

You will collect stool samples from 3

You will collect stool samples from 3

需要收集三次大便樣本

需要收集三次大便樣本

the stool on

the stool on

糞便的日期

糞便的日期

.

.

(Date).

(Date).

bowel movements.

bowel movements.

each card.

each card.

如果有痔瘡出血症

如果有痔瘡出血症

Do not collect your stool if you have

Do not collect your stool if you have

Date

Date

Date

a bleeding hemorrhoid.

a bleeding hemorrhoid.

收集大便

收集大便

收集糞便之

收集糞便之

.

.

2.

2.

2.

2.

Before the

Before the

Women: Do not collect your stool

Women: Do not collect your stool

女士們

女士們

不要在月經期間

不要在月經期間

取出馬

取出馬

test, take out

test, take out

during a menstrual period.

during a menstrual period.

Date

Date

Date

大便

大便

all toilet bowl

all toilet bowl

內的

內的

.

.

cleaners and flush the toilet two

cleaners and flush the toilet two

﹐並

沖洗

﹐並

沖洗

For a few days before the test,

For a few days before the test,

times so only plain water is there.

times so only plain water is there.

前幾天

﹐您

在檢

可能要在

﹐您

前幾天

可能要在

在檢

you may have to make some

you may have to make some

馬桶兩次

馬桶兩次

直至裡面只有

直至裡面只有

changes in your medicines or

changes in your medicines or

食或藥物上作些改變

食或藥物上作些改變

潔劑

水,沒有

水,沒有

潔劑

.

.

.

.

3.

3.

Collect the stool:

Collect the stool:

diet.

diet.

a.

a.

Allow the stool to fall into the

Allow the stool to fall into the

藥物方面

藥物方面

water as usual.

water as usual.

直到

從收集大便前七天開始

直到

從收集大便前七天開始

步驟

收集糞便的

收集糞便的

步驟

3.

3.

b.

b.

Use a stick from the kit to collect a

Use a stick from the kit to collect a

Medicines

Medicines

不要

大便樣本收集結束期間

大便樣本收集結束期間

不要

讓糞便像往常一樣掉入水

讓糞便像往常一樣掉入水

a.

a.

small sample of stool.

small sample of stool.

Starting 7 days before you begin

Starting 7 days before you begin

服用布洛芬類的止痛藥如

服用布洛芬類的止痛藥如

內的小木棒,來收

內的小木棒,來收

使用信封

使用信封

b.

b.

c.

c.

On one stool

On one stool

collecting your stool and until you are

collecting your stool and until you are

card, put a

card, put a

。一天

內不要服

。一天

內不要服

集小量的大

集小量的大

Advil

Advil

Motrin

Motrin

done collecting your stool samples, do

done collecting your stool samples, do

very small

very small

not take ibuprofen (Advil, Motrin) or

not take ibuprofen (Advil, Motrin) or

用超過一片阿司匹林。但如果

用超過一片阿司匹林。但如果

便樣本

便樣本

.

.

B

B

B

amount of

amount of

A

A

A

similar pain medicines. Do not take

similar pain medicines. Do not take

?一直有服用醋??

?一直有服用醋??

將小量糞

將小量糞

(Tylenol

(Tylenol

)

)

c.

c.

stool as a thin

stool as a thin

more than one aspirin per day. You do

more than one aspirin per day. You do

B

B

B

則無需要停止

則無需要停止

便抹在標有

便抹在標有

.

.

A

A

A

smear in the box labeled

smear in the box labeled

A.

A.

not have to stop taking acetaminophen

not have to stop taking acetaminophen

d.

d.

Take another very small amount

Take another very small amount

的地方

的地方

.

.

(Tylenol), if that is a medicine that you

(Tylenol), if that is a medicine that you

A

A

from a different part of the stool

from a different part of the stool

usually take.

usually take.

食方面

食方面

在糞便?一個位置上,取小

在糞便?一個位置上,取小

d.

d.

and smear it in the box labeled

and smear it in the box labeled

量糞便,抹在

量糞便,抹在

的地方

的地方

B

B

.

.

B.

B.

Diet

Diet

從收集大便前兩天開始

直到

直到

從收集大便前兩天開始

待收集?乾後

再關上前蓋

待收集?乾後

再關上前蓋

e.

e.

Let the card dry and close the

Let the card dry and close the

e.

e.

Starting 2 days before you begin

Starting 2 days before you begin

front flap.

front flap.

不要

大便樣本收集結束期間

不要

大便樣本收集結束期間

不要將收集?弄濕

不要將收集?弄濕

f.

f.

.

.

collecting your stool and until you are

collecting your stool and until you are

f.

f.

Do not let the card get wet.

Do not let the card get wet.

吃未完全煮熟的紅肉。不要吃

吃未完全煮熟的紅肉。不要吃

done collecting your stool samples, do

done collecting your stool samples, do

not eat meat unless it is well

not eat meat unless it is well

-

-

done. Do

done. Do

山葵

哈蜜瓜

白蘿蔔,西蘭

哈蜜瓜

山葵

白蘿蔔,西蘭

步驟,收集?外

按照同樣的

步驟,收集?外

按照同樣的

4.

4.

4.

4.

Do the same for your next 2 bowel

Do the same for your next 2 bowel

not eat horseradish, cantaloupe,

not eat horseradish, cantaloupe,

小蘿蔔或防風草

椰菜花

小蘿蔔或防風草

椰菜花

兩次的糞便

兩次的糞便

movements.

movements.

.

.

turnips, broccoli, cauliflower,

turnips, broccoli, cauliflower,

紅或用

血做成

。亦不要吃

血做成

紅或用

。亦不要吃

radishes, or parsnips. Do not eat blood

radishes, or parsnips. Do not eat blood

的香腸

的香腸

pudding or blood sausage.

pudding or blood sausage.

.

.

.

.

Outreach Materials

Slide courtesy of Albert Yu and Mike Potter


Designed at request of cphc staff with patient input l.jpg
Designed at Request of CPHC Staff with Patient Input ePSS

Slide courtesy of Albert Yu and Mike Potter


Cphc preliminary results l.jpg
CPHC Preliminary Results ePSS

Efficacy among 50-80 year olds who came in for

primary care visit during flu shot season

Got Flu Shot Didn’t Get Flu Shot

(n=1286) (n=588)

Up to date 9-29-08 51.2% 60.2%

Up to date 3-31-09 75.2% 64.8%

Change +25.0% +4.6%

Slide courtesy of Albert Yu and Mike Potter


Sf dph screening rates l.jpg
SF DPH Screening Rates ePSS

U.S average

(NHIS 2000)


Breast cancer screening challenges l.jpg
Breast Cancer Screening Challenges ePSS

  • 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


Sf dph mamography rates l.jpg
SF DPH Mamography Rates ePSS

Percent of women ages 42-69 who have had a mammogram in the past 2 years.

Excludes “not indicated” but does not give credit for “declined.”

HEDIS 2007 Commercial

HEDIS 2007 Medicaid

*

* Historically not held to requirement for CBE.


Conclusions l.jpg
Conclusions ePSS

  • 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.


Questions l.jpg
Questions? ePSS

Alice Hm Chen, MD, MPH

Assistant Professor of Medicine, UCSF

Medical Director, Adult Medical Center, SFGH

achen@ medsfgh.ucsf.edu


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