Increasing Preventive Service Delivery in Primary Care

Increasing Preventive Service Delivery in Primary Care Jim Mold, M.D., M.P.H. Dept. of Family and Preventive Medicine OUHSC, OKC

Cheryl Aspy, Ph.D. Zsolt Nagykaldi, Ph.D. Katy Smith, M.S. Crystal Turner, M.P.H. Emily Teasdale, M.P.H. Kevin Bonham, B.S. Millisa Ellefson, B.S. Michelle Roberts, B.A. 24 OKPRN clinicians: Aaron, Ahearn, Ballard, Bechtol, Brown, Burson, Cates, Darvin, Frazier, Garvin, Hulson, Jackson, King, Legako, O’Brien, Owens, Preslar, Samant, Stewart, Swami, Talley, Vick, Woods, Young Research Team

Funding Source Agency for Healthcare Research and Quality

Background There is convincing evidence that wellness visits, standing orders, and recall/reminder systems increase rates of delivery of preventive services in primary care. Yet many primary care practices still don’t use these methods consistently.

Research Question Can a multi-component QI intervention – performance feedback, academic detailing, practice facilitation, and IT support - facilitate adoption of three evidence-based strategies for increasing delivery of preventive services in primary care practices more effectively than performance feedback alone?

Intervention • Audit with performance feedback and benchmarking • Peer-to-peer education about the three methods (academic detailing) • Practice facilitation • Registry/recall/reminder software if wanted • IT support if needed

Evidence-Based Strategies • Wellness visits • Standing orders • Recall/reminder systems

Wellness Visits Specific types of visits (e.g. well child and well adult visits) and/or time periods (e.g. immunization clinics, prevention group visits) devoted primarily to provision of preventive services. These visits or time periods must be provided to a majority (more than 50%) of patients and must apply to more than a single immunization or preventive service.

Standing Orders Use of specific, formal protocols, policies, and procedures that authorize office nurses, medical assistants, other non-clinical office staff, or pharmacists affiliated with the practice to deliver immunizations and/or other preventive services without checking with the clinician first. The protocols, policies, and procedures must be in active use with a majority (more than 50%) of patients and must apply to more than a single immunization or preventive service. They need not be in written form.

Recall/Reminder System Paper-based or electronic techniques for reminding clinicians, nurses, and/or other clinic staff to recommend or perform preventive services when they are either due or overdue. Reminder systems may also be (but aren’t required to be) used to remind patients that they are due for preventive services. An auditable registry is desirable but not required. The prompt and reminder system or systems must be used for a majority of patients a majority (more than 50%) of the time and must apply to more than a single immunization or preventive service.

Design Randomized, controlled trial • 12 practices in each group • One clinician and nurse or MA team per practice • Six month intervention period

Design Main outcome measure: • # of evidence-based strategies implemented / opportunities to implement them • Potentially 6 opportunities per practice (3 for adults, 3 for children) if not using any of the methods at baseline • Determined by consensus of three blinded reviewers from transcripts of structured interviews with clinicians

Design Secondary outcome measures: • Change in proportion of children 2-3 years old up to date on DTaP#4, HepB#3, and MMR • Change in proportion of adults 50-75 years old up to date on pneumonia vaccination, CRC screening, and mammography

Design Practice facilitation: • Every one-two week visits by a practice enhancement assistant (PEA) for 6 months • Coordination of Plan-Do-Study-Act cycles • Assistance with implementation • Sharing of lessons learned by other practices

Results No significant differences between intervention and control practices at baseline for any of the clinician or practice factors Good mix of rural (12), suburban (7), and urban practices (5). Good mix of solo (12) and group practices (12). Size range: 1-8 Wide range of ACIC scores: 50% <5 (of a possible 11); range 2.4-10.1

Results • Significantly fewer opportunities for improvement in the control group (38 vs. 23 of a possible 6 X 12 = 72; p=0.01) • One control practice had no opportunities for improvement – was using all three methods for both adults and children at baseline (enrollment error)

Results

Results Implementation of the methods was not associated with baseline clinician or practice characteristics, baseline performance, PEA, number of PEA visits or contact hours, use of the recall/reminder software, or number of HIT support visits.

Results PEA field notes revealed that: • Few practices had a regular staff meeting or ongoing QI processes • Physician participation in PDSA cycles was sporadic • Clinician and staff illnesses, vacations, and other absences occurred frequently • Many of the practices were also implementing EHRs at the same time

Conclusions • The multi-component intervention was effective • Six month was barely enough time for the practices to make even simple changes in their processes of care • Standing orders was the easiest method to implement, wellness visits the most difficult

Conclusions • We were not able to shed any light on how to predict which practices will be successful with a QI initiative, but the study was probably under-powered for this. • The intervention would probably work even better in practices with a regular staff or QI meeting.

Limitations • The primary outcome measure was largely subjective • Blinding of clinicians was not possible, and post-intervention interviews might have reflected some degree of wishful thinking, more so in the intervention practices • We were unable to look at maintenance of the methods once the facilitator was gone

Questions

Increasing Preventive Service Delivery in Primary Care