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

Improving Clinical Preventive Services: A Discussion with AHRQ Centers for Excellence. Moderator: Iris Mabry-Hernandez, MD, MPH, Agency for Healthcare Research and Quality. Why Isn’t Prevention Working?. Prevention efforts in the US are fragmented

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

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  1. Improving Clinical Preventive Services: A Discussion withAHRQ Centers for Excellence Moderator: Iris Mabry-Hernandez, MD, MPH, Agency for Healthcare Research and Quality

  2. Why Isn’t Prevention Working? • Prevention efforts in the US 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

  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

  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

  5. Centers for ExcellenceHealth 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

  6. Centers for ExcellenceHealth 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

  7. Centers for ExcellencePatient 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

  8. Town HallPresentation 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

  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

  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

  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

  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

  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

  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

  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

  16. CRISP Projects • Project 1: Comparative Effectiveness Trial Comparing Reminder/Recall Methods to Increase Immunization Rates in Young Children; 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

  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

  18. Influenza Vaccine Delivery: The Perfect Storm

  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

  20. Capacity Problems: Expansion of Childhood Influenza Recommendations Vaccination encouraged, 6-23 months Universal vaccination, 6-23 months Universal vaccination, 6-59 months Universal vaccination, 6 mos-18 yrs 2001 2002 2003 2004 2005 2006 2007 2008 2009

  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

  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

  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

  24. Conceptual Framework: Influenza Iz Delivery

  25. Conceptual Framework: Influenza Iz Delivery

  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?

  27. Let’s talk amongst ourselves… Discuss…

  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

  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.

  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.

  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

  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

  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

  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

  35. Conceptual Framework: CRC Screening

  36. 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

  37. 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?

  38. 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?

  39. 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?

  40. Research Center for Excellence in Clinical Preventive Services Russell Harris, MD, MPH Center Director Noel Brewer, PhD Collaborative Scientific Lead

  41. Problem: Inattention to Harms of Clinical Preventive Services (CPS) • Leads to overuse • Leads to wasted resources • Leads to harms for patients

  42. 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

  43. Our Goals(education and dissemination) • Develop and test educational materials for med students, residents, practicing physicians about use of harms information in decision-making • Work with policymakers to increase use of harms information in their decision-making

  44. 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

  45. S C I E N T I F I C A S S E S S M E N T Appropriate Probably Inappropriate Inappropriate Low importance High importance Low importance High importance to patient or physician ( G O A L S ) ( G O A L S ) ( G O A L S ) Empowerrment •Knowledge • Values • Decision Empowerrment •Knowledge • Values • Decision Empowerrment •Knowledge • Values • Decision Screening > Not screening Not Screening > Screening

  46. 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

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

  48. 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 decision-making

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