Implementing preventive services: to what extent can we change provider performance in ambulatory care? A review of the screening, immunization, and counseling literature

Differences in the prescribing of medication for physical disorders in individuals with v. without mental illness: meta-analysis

BACKGROUND

There is some concern that patients with mental illness may be in receipt of inferior medical care, including prescribed medication for medical conditions.

AIMS

We aimed to quantify possible differences in the prescription of medication for medical conditions in those with v. without mental illness.

METHOD

Systematic review and random effects meta-analysis with a minimum of three independent studies to warrant pooling by drug class.

RESULTS

We found 61 comparative analyses (from 23 publications) relating to the prescription of 12 classes of medication for cardiovascular health, diabetes, cancer, arthritis, osteoporosis and HIV in a total sample of 1 931 509 people. In those with severe mental illness the adjusted odds ratio (OR) for an equitable prescription was 0.74 (95% CI 0.63-0.86), with lower than expected prescriptions for angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ACE/ARBs), beta-blockers and statins. People with affective disorder had an odds ratio of 0.75 (95% CI 0.55-1.02) but this was not significant. Individuals with a history of other (miscellaneous) mental illness had an odds ratio of 0.95 (95% CI 0.92-0.98) of comparable medication with lower receipt of ACE/ARBs but not highly active antiretroviral therapy (HAART) medication. Results were significant in both adjusted and unadjusted analyses.

CONCLUSIONS

Individuals with severe mental illness (including schizophrenia) appear to be prescribed significantly lower quantities of several common medications for medical disorders, largely for cardiovascular indications, although further work is required to clarify to what extent this is because of prescriber intent.

Do deficits in cardiac care influence high mortality rates in schizophrenia? A systematic review and pooled analysis

We have previously documented inequalities in the quality of medical care provided to those with mental ill health but the implications for mortality are unclear. We aimed to test whether disparities in medical treatment of cardiovascular conditions, specifically receipt of medical procedures and receipt of prescribed medication, are linked with elevated rates of mortality in people with schizophrenia and severe mental illness. We undertook a systematic review of studies that examined medical procedures and a pooled analysis of prescribed medication in those with and without comorbid mental illness, focusing on those which recruited individuals with schizophrenia and measured mortality as an outcome. From 17 studies of treatment adequacy in cardiovascular conditions, eight examined cardiac procedures and nine examined adequacy of prescribed cardiac medication. Six of eight studies examining the adequacy of cardiac procedures found lower than average provision of medical care and two studies found no difference. Meta-analytic pooling of nine medication studies showed lower than average rates of prescribing evident for the following individual classes of medication; angiotensin converting enzyme inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638-0.950, p = 0.0137), beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690-1.03, p = 0.1036) and statins (n = 5, aOR = 0.604, 95% CI = 0.408-0.89, p = 0.0117). No inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI = 0.7955-1.02, p = 0.382). Interestingly higher than expected prescribing was found for older non-statin cholesterol-lowering agents (n = 4, aOR = 1.55, 95% CI = 1.04-2.32, p = 0.0312). A search for outcomes in this sample revealed ten studies linking poor quality of care and possible effects on mortality in specialist settings. In half of the studies there was significantly higher mortality in those with mental ill health compared with controls but there was inadequate data to confirm a causative link. Nevertheless, indirect evidence supports the observation that deficits in quality of care are contributing to higher than expected mortality in those with severe mental illness (SMI) and schizophrenia. The quality of medical treatment provided to those with cardiac conditions and comorbid schizophrenia is often suboptimal and may be linked with avoidable excess mortality. Every effort should be made to deliver high-quality medical care to people with severe mental illness.

Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis

BACKGROUND

There has been long-standing concern about the delivery of preventive and screening services to patients with mental illness.

OBJECTIVE

We aimed to examine whether the quality of preventive care received by patients with mental health conditions differs from that received by individuals who have no comparable mental disorder. Our hypothesis was that patients with mental illness would be in receipt of lower quality or lower frequency of preventive care.

METHOD

Studies that examined the quality of care in those with and without comorbid mental illness were reviewed and comparative data extracted. By using only comparative studies we hope to ascertain whether inequalities in care existed by virtue of psychiatric diagnoses (or closely affiliated factors).

RESULTS

We identified 26 studies that examined preventive care in individuals with vs. without psychiatric illness. From these eligible studies, 61 comparisons were documented across 13 health care domains. These included mammography, cervical smears, vaccinations, cholesterol screening, lifestyle counseling, colonoscopy. Twenty-seven comparisons revealed inferior preventive health care in those with mental illness, but 10 suggested superior preventive health care and 24 reached inconclusive findings. Inferior preventive care was most apparent in those with schizophrenia and in relation to osteoporosis screening, blood pressure monitoring, vaccinations, mammography and cholesterol monitoring.

CONCLUSIONS

We conclude there is strong evidence to suggest that the quality of preventive and screening services received by patients with mental illness is often lower, but occasionally superior to that received by individuals who have no comparable mental disorder. More work must be done to improve the quality of medical and preventive care for individuals with mental illness.

GP's consult and health behaviour change project. Developing a programme to train GPs in communication skills to achieve lifestyle improvements

OBJECTIVE

The European definition of General Practice states that GPs should use their core competence, amongst others, in their communication with patients. Their communication skills are particularly challenged in the field of lifestyle improvements. Most GPs feel they lack efficacy in achieving lifestyle changes. In November 2002 the Prevention Department of the Scientific Society of Flemish GPs (now Domus Medica) decided to start a project "consulting & behaviour change". Under this project, every Flemish GP should by the year 2007, have (amongst others things) a basic knowledge of the principles of lifestyle improvements and should be able to give a short advice to high risk patients.

METHOD

A literature search was conducted to make an inventory of models that could be used to train GPs. Experts at specific methods and topics were consulted to get acquainted with their specific approaches. Experts in the field of CME were gathered to discuss barriers and solutions to these barriers. During steering group meetings, several possible solutions were discussed.

RESULTS

The Trans Theoretical Model (TTM-as theoretical framework) and brief motivational interviews (MI-as communication skill) were evaluated as offering the best opportunities for adapting the work situation of the GP. We promoted this approach to the GPs as an ABC concept (Anamnesis/Ask; Be the guide/Decision tree ("Beslissingsboom" in Dutch); Continuity) applied on different topics (smoke stop, alcohol, healthy food, physical activity). In our guidelines we pay more attention to brief motivational interviews for health behaviour changes. Recently we started developing an e-learning website as part of a larger learning project, this in cooperaion with different Flemish partners and disciplines.

CONCLUSION

The Trans Theoretical Model and the brief motivational interviewing approach seem to be accepted by health care, educational and scientific organisations. The process of integrating this approach in the GP's daily practice has to be continued and needs better evaluation/follow up.

PRACTICE IMPLICATIONS

The integration of the brief motivational interviewing approach can facilitate health behaviour change in practice, without requesting more consultation time.

Does patient-centered care improve provision of preventive services?

OBJECTIVES

While patient-centered care (PCC) is desirable for many reasons, its relationship to treatment outcomes is controversial. We evaluated the relationship between PCC and the provision of preventive services.

METHODS

We obtained facility-level estimates of how well each VA hospital provided PCC from the 1999 ambulatory Veterans Satisfaction Survey. PCC delivery was measured by the average percentage of responses per facility indicating satisfactory performance from items in 8 PCC domains: access, incorporating patient preferences, patient education, emotional support, visit coordination, overall coordination of care, continuity, and courtesy. Additional predictors included patient population and facility characteristics. Our outcome was a previously validated hospital-level benchmarking score describing facility-level performance across 12 U.S. Preventive Services Task Force-recommended interventions, using the 1999 Veterans Health Survey.

RESULTS

Facility-level delivery of preventive services ranged from an overall mean of 90% compliance for influenza vaccinations to 18% for screening for seat belt use. Mean overall PCC scores ranged from excellent (>90% for the continuity of care and courtesy of care PCC domains) to modest (<70% for patient education). Correlates of better preventive service delivery included how often patients were able to discuss their concerns with their provider, the percent of visits at which patients saw their usual provider, and the percent of patients receiving >90% of care from a VA hospital.

CONCLUSION

Improved communication between patients and providers, and continuity of care are associated with increased provision of preventive services, while other aspects of PCC are not strongly related to delivery of preventive services.

Cervical cancer screening among U.S. women: analyses of the 2000 National Health Interview Survey

BACKGROUND

Cervical cancer screening is not fully utilized among all groups of women in the United States, especially women without access to health care and older women.

METHODS

Papanicolaou (Pap) test use among U.S. women age 18 and older is examined using data from the 2000 National Health Interview Survey (NHIS).

RESULTS

Among women who had not had a hysterectomy (n = 13,745), 83% reported having had a Pap test within the past 3 years. Logistic regression analyses showed that women with no contact with a primary care provider in the past year were very unlikely to have reported a recent Pap test. Other characteristics associated with lower rates of Pap test use included lacking a usual source of care, low family income, low educational attainment, and being unmarried. Having no health insurance coverage was associated with lower Pap test use among women under 65. Despite higher insurance coverage, being age 65 and older was associated with low use. Rates of recent Pap test were higher among African-American women.

CONCLUSIONS

Policies to generalize insurance coverage and a usual source of health care would likely increase use of Pap testing. Also needed are health system changes such as automated reminders to assist health care providers implement appropriate screening. Renewed efforts by physicians and targeted public health messages are needed to improve screening among older women without a prior Pap test.

Provider-staff discrepancies in reported immunization knowledge and practices

BACKGROUND

The purpose of the study was to compare immunization-relevant knowledge, certainty about knowledge, self-efficacy, vested interest, and reported practices of providers and clinical staff in the same clinics.

METHODS

A valid and reliable instrument measuring the aforementioned issues was developed and administered to a sample of 50 providers and 60 members of the clinical staff.

RESULTS

Providers were significantly more knowledgeable than staff (P < 0.001); however, they were not more certain about their knowledge (P = 0.52) nor were they more confident in their capability to properly immunize all children in their practice (P = 0.10). Providers reported lower vested interest in immunizations than clinical staff (P < 0.05). Both groups were equally likely to immunize a child with a cold. Providers were less likely to defer needed immunizations for a 15-month-old child, and they were more likely to administer multiple injections to an 18-month-old (both P < 0.05). Providers were more likely than staff to immunize during acute and chronic illness visits (both P < 0.001), and both groups were equally likely to immunize during preventive visits.

CONCLUSIONS

Discrepancies in reported immunization practices between providers and staff may be a barrier to full immunization.

Dissemination of diabetes care guidelines: lessons learned from community health centers

PURPOSE

This study was conducted to evaluate the impact of a provider problem-based learning (PBL) intervention on screening for complications of diabetes in community health centers.

METHODS

A successive sampling design was used to compare selected standards of diabetes care delivered preintervention with the care delivered postintervention at 2 community health centers and 1 comparison centers. Two randomly assigned intervention sites received a PBL intervention focused on care guidelines for prevention of diabetes complications, with telephone follow-up over 12 months. Effects of the intervention were determined from an audit of 200 charts from each site.

RESULTS

The odds of having a glycosylated hemoglobin test more than doubled from preintervention to postintervention, and the odds of having a foot examination more than tripled across centers. Measurement of creatinine and glycosylated hemoglobin were associated; the odds of having one test tripled when the other had been measured. Rates for documentation of patient education were significantly lower at the intervention site where free patient education booklets were distributed.

CONCLUSIONS

Improvements in diabetes care were not consistent among community health centers. Interventions involving system and policy changes may be more effective in implementing and sustaining improvements than just provider education.

A computerized tool for evaluating the effectiveness of preventive interventions

In identifying appropriate strategies for effective use of preventive services for particular settings or populations, public health practitioners employ a systematic approach to evaluating the literature. Behavioral intervention studies that focus on prevention, however, pose special challenges for these traditional methods. Tools for synthesizing evidence on preventive interventions can improve public health practice. The authors developed a literature abstraction tool and a classification for preventive interventions. They incorporated the tool into a PC-based relational database and user-friendly evidence reporting system, then tested the system by reviewing behavioral interventions for hypertension management. They performed a structured literature search and reviewed 100 studies on behavioral interventions for hypertension management. They abstracted information using the abstraction tool and classified important elements of interventions for comparison across studies. The authors found that many studies in their pilot project did not report sufficient information to allow for complete evaluation, comparison across studies, or replication of the intervention. They propose that studies reporting on preventive interventions should (a) categorize interventions into discrete components; (b) report sufficient participant information; and (c) report characteristics such as intervention leaders, timing, and setting so that public health professionals can compare and select the most appropriate interventions.

Implementing a dietary intervention in primary care practice: a process evaluation

OBJECTIVES

Physicians acknowledge the need to advise their patients about dietary habits, but they may not have the training or tools to do this efficiently. In the context of a randomized trial, we investigated the feasibility of enlisting physicians to implement a dietary intervention in the primary care setting.

METHODS

Physicians from 14 primary care practices were assigned via randomization to introduce a self-help booklet to promote dietary change at routine appointments. Delivery of the booklet was recorded by these intervention physicians at the clinic appointment; intervention participants were asked 3 months later in a telephone interview about whether they received and used the booklet.

RESULTS

According to physician documentation, 95% of intervention participants who kept an appointment (n = 935) received the booklet; among participants completing a 3-month interview (n = 890), 96% reported the same. However, only about 50% of participants reported receiving the booklet from their physician; the remainder received the booklet from other clinic staff. Overall, 93% reported reading at least part of the booklet. Use of the booklet varied little whether it was delivered by a physician or staff person, but it was more likely to be read as time spent discussing the booklet increased.

CONCLUSIONS

Physician cooperation and evidence of intervention effectiveness support the use of primary care for the delivery of interventions to change diet; training the entire health team and repeating dietary advice at subsequent visits may improve the success of such interventions.

Preventive care practices for diabetes management in two primary care samples

PURPOSE

To assess the level of physician performance on American Diabetes Association Provider Recognition Program (PRP) measures in two samples of primary care patients, as well as to identify patient, physician, and office characteristics related to performance levels.

METHODS

In the two studies, we surveyed 435 Type 2 diabetes patients, cared for by 47 different physicians, on their receipt of PRP preventive care activities.

RESULTS

Overall, patients in the two samples reported receiving 74% and 64% of recommended services. In both samples, performance of microvascular/glycemic control activities and cardiovascular lab checks (84% and 74%) was significantly higher than behavioral self-management/patient-focused activities (61% and 48%) (p<0.001). From a set of patient, physician, and practice setting characteristics, only the use of community resources for chronic illness management support was associated with service performance.

CONCLUSIONS

We found considerable variability in the levels of performance in providing PRP-recommended activities. Greater attention should be focused on self-management and patient-focused activities, given that these are delivered less frequently than medical/laboratory checks.