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Putting Prevention into Practice. Using the United States Preventive Services Task Force Recommendations. Acknowledgements. Robert M. Gum, DO, MPH, FACPM , Statewide Campus Regional Assistant Dean, WVSOM
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Putting Prevention into Practice Using the United States Preventive Services Task Force Recommendations
Acknowledgements • Robert M. Gum, DO, MPH, FACPM, Statewide Campus Regional Assistant Dean, WVSOM • James F. Cawley, MPH, PA-C, Professor and Vice Chair, Department of Prevention and Community Health School of Public Health and Health Services The George Washington University • V. James Guillory, DO, MPH, FACPM, Professor of Public Health, Public Health Program, KUMC • John C. Pellosie, Jr., D.O., MPH, FAOCOPM, Chair of Preventive Medicine, NSUCOM • H.S. Teitelbaum, DO, PhD, MPH, Professor and Chair, Department of Preventive and Community Medicine, LMU-DCOM
Thoughts on Prevention • "To find health should be the object of any doctor. Anyone can find disease.“ • ---Andrew Taylor Still, D.O. • “Prevention is one of the few known ways to reduce demand for health and aged care services. “ • ---Julie Bishop, JD • “The purpose of risk assessment is not to categorize individuals according to a test result nor even as to their overall risk, but rather to identify those who can be helped, or helped most, by preventive action.” • ---Geoffrey Rose, MD, PhD
Objectives Slide # • Encourage focus on prevention 04 • Identify basic health screening principles 06 • Discuss the role of evidence-based medicine 12 • Define the USPSTF grading system 14 • Implement wellness intervention 24 • Discuss counseling and delivery to patients 27 • Describe new federal initiatives 30 • Demonstrate USPSTF-related Resources 32
Why Prevention? • In prevention the goal is to preserve and promote health and well being • Prevention in public health moves interventions from the individual level to a population level • Effective prevention leads to a healthier community • Why Now? • Federal support exists for prevention
Levels of Prevention* • Primary Prevention • Avoidance/prevention of disease or injury (inclusive of mental health) • Immunizations • Secondary Prevention • Early detection and treatment • Mammography • Tertiary Prevention • Reduction of disability and prompt rehabilitation • Management of existing conditions. • End-stage renal failure • *Leavell and Clark 1965
Primary Prevention • Immunizations • Sanitation • Clean water • Hand washing • Workplace Safety • Seatbelts • Helmets • Education • Diet
Secondary Prevention • Halt or slow progress of a disease • Screening at risk individuals • Identification of risks • Screening tests
Tertiary Prevention Examples: • Care of an active disease that keeps a problem from getting worse • Renal failure-slowing progression • Mental health • Cardiac/Stroke rehabilitation
When Prevention? • Screening Tests/Circumstances that must exist for screening tests to be useful: • Condition has significant impact on the individual and society • Effective treatment in asymptomatic phase • Asymptomatic period for detection and treatment • Acceptable screening tests at reasonable costs • Disease burden justifies cost The clinician and patient should share in decision-making.
The Role of Evidence Based Medicine • The USPSTF reviews the scientific evidence regarding the effectiveness, risks, and benefits of specific health care services. • A conclusion that there is no evidence of the effectiveness of a service is different from a conclusion that the service is ineffective.
Defining the USPSTF • The U.S. Preventive Services Task Force (USPSTF) is an independent, non-governmental panel of experts in prevention and primary care that is convened by the Agency for Healthcare Research and Quality (AHRQ). • The work of the USPSTF supports AHRQ's mission, which is "to improve the quality, safety, efficiency, and effectiveness of health care for all Americans."
Defining the USPSTF (2) • The Federal Government established the USPSTF in 1984 to make prevention recommendations for the country. • The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications.
USPSTF Mission • Since its inception the USPSTF has worked to fulfill its mission of: • Evaluating the benefits and harms of preventive services in healthy populations based on age, gender, and risk factors for disease; and • Making recommendations about which preventive services should be incorporated routinely into primary care practice. • In making its recommendations, the USPSTF assesses: • the quality of evidence supporting a specific preventive service; and • the magnitude of net benefit in providing the service.
USPSTF Evidence Review Each recommendation is based on a review of the evidence that includes: • Creation of an analytic framework and a set of key questions that determine the scope of the literature review. • Systematic review of the relevant literature to answer the key questions. • Quality ratings of bodies of research literature supporting each key question. • Estimation of benefits and harms. • Determination of the balance of benefits and harms of the preventive service.
USPSTF Letter Grades • The recommendation is linked to a letter grade that reflects the magnitude of net benefit and the strength of the evidence supporting the provision of the specific preventive service. The recommendation is graded from “A” (strongly recommended) to "D" (recommended against). When the evidence is insufficient to determine net benefit, the Task Force assigns a grade of “I.”
USPSTF and the ePSS The information presented in the ePSS is abridged from the full Recommendation Statements published by the USPSTF. The complete Recommendation Statements and supporting evidence reviews and/or summaries can be accessed at www.uspreventiveservicestaskforce.org The USPSTF hopes that you will find these recommendations useful as you care for your patients.
USPSTF and Clinical Decision-Making • The recommendations made by the USPSTF are intended for use in primary care settings. • The USPSTF realizes clinical decision-making with patients involves more complex considerations than the evidence alone. • It is important that clinicians understand the evidence, but also that decision-making be tailored to the specific patient and situation. • The "Clinical Considerations" section of each USPSTF Recommendation Statement offers information to be used by clinicians as they put the recommendations into practice with individual patients.
Prioritizing Risk Factors • How important is the target condition? • incidence and prevalence • morbidity and mortality • How important is the risk factor? • frequency and magnitude (absolute risk, relative risk, attributable risk) • Is the preventive service efficacious and effective? • ideal conditions vs. routine clinic setting • How accurately can the risk factor or target condition be identified? • must have a significant effect on the quality and quantity of life • sensitivity vs. specificity
Implementing Wellness Interventions • Work interprofessionally • Counsel patient effectively • Recognize the body is capable of self-healing and health maintenance • Using the ePSS program saves time and simplifies the task. • Work with legislators to support wellness services
Interprofessional Healthcare • Healthcare is a complex activity that demands that health and social care professionals work together for maximal effectiveness. • Collaborative team behavior reduces the error rate in healthcare.
Counseling Strategies • Tailor teaching to patients needs • Purpose, effects and when to expect effects • Suggest small changes • Use influence of profession • Encourage comments from patient • Combine strategies • Involve office staff • Monitor progress • Be specific • Add new behaviors rather than eliminate established behaviors • Link the new to old behaviors • Listening • Assess readinessfor change • Cultural sensitivity • Community resources • Refer appropriately
Improving Delivery • Pamphlets, posters and reading materials • Short questionnaires • Assess patient’s readiness to change • Early behavior: information • Ready for change: counseling and behavior modification • Changed: support and follow-up • Community programs and resources
New Federal Initiatives Change in Reimbursements • Reimbursement for services has been an impediment to consistently providing preventive/wellness services in a busy clinic environment. Recent legislation has removed this barrier. • Free Preventive Care Under Medicare—Eliminates co‐payments for preventive services and exempts preventive services from deductibles under the Medicare program. Effective beginning January 1, 2011. • Free Preventive Care Under New Private Plans—Requires new private plans to cover preventive services with no co‐payments and with preventive services being exempt from deductibles. Effective 6 months after enactment [9/23/10]. • New England Journal of Medicine, Promoting Prevention through the Affordable Care Act, 10.1056/JEJM1008560
Tools for Different Audiences • Physicians and healthcare providers • Electronic and print resources and tools • Downloadable point of care prompts – electronic Preventive Services Selector: www.epss.ahrq.gov • How to: www.uspreventiveservicestaskforce.org • Patients • Explanation of recommendations • Checklists to monitor individual preventive needs • www.healthfinder.gov has tools for patients.
AHRQ’s Guide to Clinical Preventive Services • AHRQ publishes this pocket-sized Guide to use of clinical preventive services annually • At-a-glance charts of the recommendations appropriate for your patient • Updated 2010 Guide will be released at the AHRQ Annual Meeting AHRQ: Agency for HealthCare Research and Quality http://www.ahrq.gov/clinic/pocketgd.htm
Using the ePSS in a clinical setting—an example: • Patients are typically screened by a member of the health care team in initial portion of an encounter • A nurse typically takes vital signs and measures the patient’s height and weight prior to seeing the provider. • This provides an opportunity to complete a brief preventive medicine/wellness questionnaire • Print for inclusion in the health record or electronic review by the healthcare provider • Reviewed by the healthcare provider • Concurs or changes recommendations • Brief discussion with the patient for those answers or findings that require treatment or need to be addressed with a comment that a member of the clinic staff will address some concerns in more detail.
Using the ePSS in a clinical setting—an example: • Designated member of the health care team reviews in greater detail • Further counseling is provided by a member of the clinic staff • Printed instructions should be provided to the patient for further reference and explanation of the healthcare team recommendations. • The VA Model is a working example similar to what was just described. • A member of the healthcare team completes an in-depth screening using the VA electronic medical records system. The patient answers are documented for the healthcare provider’s review. • The healthcare provider reviews the patient responses and addresses the health risks with the patient, recommending lifestyle modification and/or treatment. • When appropriate the patient returns to the nurse for further discussion and counseling. Referral is made as indicated to a specialist.
