Finding a BETTER Way

1. Finding a BETTER Way A Program to Facilitate Chronic Disease Prevention and Screening in Primary Care Donna Manca, Carolina Aguilar, Kami Kandola, Kris Aubrey-Bassler, Denise Campbell-Scherer, Nicolette Sopcak, Christopher Meaney, Julia Baxter, Melanie Heatherington, and Eva Grunfeld CPHA Conference Toronto - May 27, 2014

2. Acknowledgements & Disclaimer Production of this presentation has been made possible through a financial contribution from Health Canada, through the Canadian Partnership Against Cancer. The views expressed herein represent the views of the BETTER 2 Coalition and do not necessarily represent the views of the project funders.

3. Background • Primary care is an ideal setting for most chronic disease prevention and screening (CDPS) activities • Evidence-based tools and strategies are inconsistently applied • It would take an additional 7.4 hours/day to address prevention1 • Plethora of guidelines - many lack rigor,2 conflicting guidelines confuse primary care providers • Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) - informed by the Chronic Disease Framework – developed and tested effective approach to CDPS • Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? American journal of public health 2003;93:635-41. • Graham ID, Beardall S, Carter AO, et al. What is the quality of drug therapy clinical practice guidelines in Canada? CMAJ 2001;165:157-63.

4. The BETTER Trial • Setting - 8 Primary Care Teams (PCTs) • Two interventions • Patient Level Intervention: Prevention Practitioner (PP), 1 per PCT • Prevention visits with individual patients, prepare prevention prescription tailored to each patient • Practice Level Intervention: Practice Facilitator (PF), 1 per 4 PCTs • Enable EMR (invitation letters, audit and feedback, decision support), “prevention prescriptions” tailored to the circumstances of each PCT • Patient level (PP) intervention -most effective  BETTER 2 Program (expansion & deepen impact)

5. The BETTER Trial Results Grunfeld E, Manca D, Moineddin R, Thorpe KE, Hoch JS, Campbell-Scherer D, Meaney C, Rogers J, Beca J, Krueger P et al: Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial. BMC family practice 2013, 14(1):175.

6. Objectives of the BETTER Program • Overall Objective of the BETTER: • Improve CDPS in the primary care team setting for: heart disease, diabetes, & cancers including their associated lifestyle risk factors • Integrated knowledge translation - research, practice & policy • Desired long-term goals of the BETTER: • Improved clinical outcomes • Reduced burden of chronic disease • Improved sustainability of the health care system through improved CDPS in primary care

7. BETTER 2 ProgramTarget Audiences • Patients at risk for chronic disease: adults aged 40 – 65, a population eligible for most CDPS maneuvers • Increased knowledge, self-management & access to CDPS resources • Primary care providers, researchers and policy makers: To improve CDPS in adults aged 40-65 • Develop comprehensive source of tools and transform practice through a patient-level intervention using practice facilitation via a patient level intervention by a health care professional within the practice (PP) • Primary Care Groups and Organizations: • Facilitate change by dedicating resources (e.g. PPs) to CDPS

8. The Prevention Practitioner – A New RoleTargets both at risk populations & individual patients Manca DP, Greiver M, Carroll JC, et al: Finding a BETTER way: A qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice. BMC family practice 2014, 15(1):66.

9. Guideline Harmonization through Integrated Knowledge TranslationClinicians, Researchers & Policy Working Together Campbell-Scherer D, Rogers J, Manca D, Lang-Robertson K, Bell S, Salvalaggio G, Greiver M, Korownyk C, Klein D, Carroll JC et al: Guideline harmonization and implementation plan for the BETTER trial: Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice. CMAJ Open 2014, 2(1):E1-E10.

10. Spaghetti DiagramBETTER Developed Tools to Address the Modifiable Risk Factors Haydon E, Roerecke M, Giesbrecht N, Rehm J, Kobus-Matthews M. (2006, March). Chronic disease i Ontario and Canada: Determinants, risk factors and prevention priorities: Summary of full report. Prepared for the Ontario Chronic Disease Prevention Alliance & the Ontario Public Health Association. Available from: http://www.ocdpa.on.ca/docs/CDP-SummaryReport-Mar06.pdf

11. Preparing for a Prevention Visit The Health Survey is filled in by patients before the visit and includes tools to capture a detailed prevention and screening history including risks such as • Smoking • Exercise • Diet • Alcohol • Family History An assessment of • Readiness to change

12. Prevention Visit Form Extracts information from the patients’ surveys, health record and physical measures to determine eligibleCDPS maneuvers & develop an approach informed by the individuals’ risks (lifestyle, family history, etc.)

14. Algorithm

16. Prevention Prescription

17. Program EvaluationRE-AIM Evaluation of Effectiveness & Sustainability: • REACH • Representativeness & proportion participating • EFFECTIVENESS • Impact on outcomes including a composite index of met/eligible outcomes • ADOPTION in different settings • IMPLEMENTATION • Adaptations and how the intervention was delivered • MAINTAINthe approach • How BETTER is adapted and maintained in different settings • Time and cost of the intervention will be captured

18. Questions?

21. BETTER 2 Logic model

22. BETTER Tools