HEMS 2013

1. HEMS 2013 Healthcare effectiveness management set

2. Prevention and screening

3. Cancer screening • Cervical Cancer Screening • ACOG and USPSTF agree on interval and age • 21-29: Cytology Q3 yrs. • 30-65: Cytology Q3yrs OR Cytology +HPV contesting Q5yrs • HEMS • 21-29: Cytology Q2yrs • 30-64: Cytology Q3yrs if history of 3 consecutive negative paps • Breast Cancer Screening • Colon Cancer Screening

4. Cervical cancer screening guidelines: at a glance

5. Cancer screening • Cervical Cancer Screening • Breast Cancer Screening • ACOG (B level recommendation) • Women >40 yo should be offered yearly mammography • USPSTF (B level recommendation) • Biennial mammography screening for Women 50-74 yo • HEMS • Yearly mammography ordered/completed in Women 40-74 yo • Colon Cancer Screening

6. National guideline clearinghouse http://www.guideline.gov/syntheses/synthesis.aspx?id=39251

7. National guideline clearinghouse http://www.guideline.gov/syntheses/synthesis.aspx?id=39251

8. Cancer screening • Cervical Cancer Screening • Breast Cancer Screening • Colon Cancer Screening • ACG • Colonoscopy Q10yrs >50 yo preferred cancer prevention test • Acceptable alternatives: Flex sig Q5-10yrs, CT colonography Q5yrs, Fecal Immunochemical occult test annually • USPSTF • Screen using fecal occult blood testing, sigmoidoscopy or colonoscopy in 50-75 yo (Grade A) • Recommend against screening >85 yo (Grade D) • Jury still out on 75-84 yo (Grade C) • HEMS • Fecal occult annually or flex sig Q5yrs or colonoscopy Q10yrs

9. ACG Colon cancer screening update 2009

10. NEW Measures: BMI • The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions. • Grade: B Recommendation. • June 2012 • Document BMI in visit diagnosis and problem list when discussed and put in your A/P • Weight management group classes • Refer/Appt to Health Education: indicate weight group class in drop down box • Nutritionist • Refer/Appt to Nutrition

11. NEW Measures: smoking • Document Tobacco abuse and or Smoking cessation/counseling when discussed in visit diagnosis and problem list • Smoking cessation aids: • Smoking cessation classes • Refer/Appt to Health Education: indicate smoking cessation in drop down box • Wellbutrin (Buproprion SR): 150mg QAM x 3 days then increase to 150mg BID • Chantix (Varenicline) • FCC restricted: failed Buproprion or nicotine replacement; referred to smoking cessation class; documented eval for mental health and SI; 30 days supply with 2 refills; limited to 24 weeks of tx • The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.  • Grade: A recommendation. • April 2009

12. Chronic condition management • Before we were just documenting whether tests were ordered now we are actually looking at interventions!

13. Diabetes comprehensive measures

14. Diabetes comprehensive measures • Things to remember: • Diabetic foot exam yearly • Should include sensation, pulses, and appearance • Can use .nexfeet for easy negative foot exam or .pexfoot for positive foot exam documentation • Can refer to podiatry if needed • Retinal exam yearly • Retinal exam can be done by retinal scan (camera) or dilated retinal eye exam by optometry/ophthalmology • Refer retinal scan • Refer/Appt to CHP Optometry/Ophthalmology

15. Pediatric measures

16. Obesity – pedi/adolescent Bmi • BMI should be documented in vitals and nursing note (READ NURSING NOTE) • During well checks document pediatric BMI in visit diagnosis and in problem list • Discuss issue with patient and family • Document counseling on diet and exercise and plan for follow up in A/P • Every child with BMI >= 85% with one fasting lipid before 10 yo • Same resources for nutrition exist for children • Refer weight management clinic at Pasadena PAHC for pediatric weight management specialty clinic

17. obesity/cholesterol screening in pedi/adolescents • The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. • Grade: B recommendation. • Updated in January 2010 • The USPSTF concludes that the evidence is insufficient to recommend for or against routine screening for lipid disorders in infants, children, adolescents, or young adults (up to age 20). • Grade: I Statement. • July 2007 • NIH/NHLBI: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents • Endorsed by AAP • Universal Screening lipid at age 9-11 yo and again at age 17-21 yo • November 2011

18. Pediatric hypertension – pedi/adolescent bp • Blood pressure should be documented in vitals and nursing notes on all pts >=3yo • If BP > 90%ile for age/height/sex then it should be repeated manually by nursing and documented in their note • READ NURSING NOTE • As the medical provider, you must address this issue in your note! At EVERY visit! • Yes we can/do treat pediatrics patients with essential and secondary hypertension • If needed referrals to renal and cardiology are available

19. USPSTF: Screening Htn in pedi/adolescents • USPSTF: Update in Progress (2013) • Draft recommendation statement (Feb 2013) • Currently open for public comment • The U.S. Preventive Services Task Force (USPSTF) concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood. • Grade I Statement

20. Pediatric immunizations

21. Summary/questions • Lots of differing opinions • Try to comply with system wide recommendations BUT primary goal is to prevent/detect disease, reduce morbidity and mortality for our patients all while maintaining or improving their quality of life • Quality measures will be apart of medical care in the 21st century (no matter what field you end up in!) • Questions ???