Improving delivery of clinical preventive services: a multi-year journey

Improving care for veterans' environmental exposure concerns: applications of the consolidated framework for implementation research in program evaluation

BACKGROUND

Healthcare systems, like the US Department of Veterans Affairs (VA), need policies and procedures for delivering care to special populations including those with environmental exposure concerns. Despite being common and pervasive, especially among Veterans, environmental exposures are largely overlooked by healthcare providers. To successfully implement care for Veterans with military environmental exposure concerns, an understanding of contextual factors impeding care on the provider (e.g., knowledge and beliefs) and organizational (e.g., leadership's priorities) level is needed. Our goal was to conduct an operational needs assessment of providers to examine provider educational needs regarding Veterans' military environmental exposure concerns.

METHODS

In 2020, we surveyed 2,775 VA medical and behavioral health providers. Our cross-sectional assessment was informed by the Consolidated Framework for Implementation Research (CFIR) and assessed barriers and facilitators to the uptake and application of knowledge regarding interdisciplinary care for environmental exposure concerns. The web-based survey was emailed to providers across the United States representing a variety of disciplines and practice settings to reflect the interdisciplinary approach to care for environmental exposures. We used bivariate statistics to investigate the intervention setting, inner setting, and individual characteristics of providers regarding care for environmental exposure concerns.

RESULTS

Approximately one-third of VA medical and behavioral health clinicians report low to no knowledge of environmental exposure concerns. We find 88% of medical and 91% of behavioral health providers report they are ready to learn more about environmental exposures. Half of medical and behavioral health providers report they have access to information on environmental exposures and less than half report care for environmental exposures is a priority where they practice.

CONCLUSIONS

Our findings suggest interdisciplinary providers' knowledge of and discussion with Veterans about environmental exposures may be influenced by contextual factors at the organizational level. Considering individual-level factors and organizational culture is important to consider when supporting care for environmental exposures. Since this needs assessment, VA established targeted programs to improve care related to military environmental exposures in response to legislation; future exploration of these same variables or contextual factors is warranted.

Association between race and receipt of counselling or medication for smoking cessation in primary care

BACKGROUND

Previous evidence of race disparities in smoking cessation treatment has been limited to mostly survey studies which increase the potential for recall bias. We examined if African American versus white patients in primary care are less likely to receive any treatment or if race disparities are specific to the type of treatment offered using data pulled from a large electronic health record system.

METHODS

Medical record data from 3510 white and 2707 African American patients were available from primary care encounters between 2008 and 2015 and was used to define smoking status, cessation treatments (counselling and medication), and covariates. The association between race and type of smoking cessation treatment offered was measured by logistic regression models before and after adjusting for covariates.

RESULTS

Smoking cessation counselling was offered to 9.3% of African American and 7.8% of white patients, and a prescription for smoking cessation medication was offered to 12.3% of African American and 16.4% of white patients. After adjusting for covariates in logistic regression models, whites were significantly less likely than African American patients to receive smoking cessation counselling [odds ratio (OR) = 0.81; 95% confidence interval (CI) = 0.65-0.99] and were significantly more likely to receive a prescription for a smoking cessation medication (OR = 1.23; 95% CI = 1.03-1.47).

CONCLUSIONS

Less than 20% of smokers received any type of therapy to assist in smoking cessation. We observed a race disparity in type of smoking cessation therapy provided to white and African American primary care patients. Further research is needed to increase treatment rates and eliminate disparities.

Preventive Care Quality of Medicare Accountable Care Organizations: Associations of Organizational Characteristics With Performance

BACKGROUND

Accountable Care Organizations (ACOs) are a delivery and payment model aiming to coordinate care, control costs, and improve quality. Medicare ACOs are responsible for 8 measures of preventive care quality.

OBJECTIVES

To create composite measures of preventive care quality and examine associations of ACO characteristics with performance.

DESIGN

This is a cross-sectional study of Medicare Shared Savings Program and Pioneer participants. We linked quality performance to descriptive data from the National Survey of ACOs. We created composite measures using exploratory factor analysis, and used regression to assess associations with organizational characteristics.

RESULTS

Of 252 eligible ACOs, 246 reported on preventive care quality, 177 of which completed the survey (response rate=72%). In their first year, ACOs lagged behind PPO performance on the majority of comparable measures. We identified 2 underlying factors among 8 measures and created composites for each: disease prevention, driven by vaccines and cancer screenings, and wellness screening, driven by annual health screenings. Participation in the Advanced Payment Model, having fewer specialists, and having more Medicare ACO beneficiaries per primary care provider were associated with significantly better performance on both composites. Better performance on disease prevention was also associated with inclusion of a hospital, greater electronic health record capabilities, a larger primary care workforce, and fewer minority beneficiaries.

CONCLUSIONS

ACO preventive care quality performance is related to provider composition and benefitted by upfront investment. Vaccine and cancer screening quality performance is more dependent on organizational structure and characteristics than performance on annual wellness screenings, likely due to greater complexity in eligibility determination and service administration.

Promoting preventive health screening through the use of a clinical reminder tool: an accountable care organization quality improvement initiative

This quality improvement initiative was designed to increase clinical prevention performance rates in 11 Austin Regional Clinic primary care facilities as part of an accountable care initiative. The initiative was conducted between January 2011 and December 2011. The principal interventions included implementation of a care coordinator and care gap summary tool. The care gap summary includes recommended preventive healthcare services and serves as a prompt for healthcare providers. These interventions led to improvement in clinical prevention performance rates as demonstrated by aggregate organizational data. This initiative demonstrates that quality improvement initiatives including care gap summaries, workflow changes, and provider feedback can increase performance rates for clinical preventive services.

Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems

INTRODUCTION

Studies showing sustained improvements in the delivery of clinical preventive services are limited. Fewer studies demonstrate sustained improvements among independent practices that are not affiliated with hospitals or integrated health systems. This study examines the continued improvement in clinical quality measures for a group of independent primary care practices using electronic health records (EHRs) and receiving technical support from a local public health agency.

METHODS

We analyzed clinical quality measure performance data from a cohort of primary care practices that implemented an EHR at least 3 months before October 2009, the study baseline. We assessed trends for 4 key quality measures: antithrombotic therapy, blood pressure control, smoking cessation intervention, and hemoglobin A1c (HbA1c) testing based on monthly summary data transmitted by the practices.

RESULTS

Of the 151 practices, 140 were small practices and 11 were community health centers; average time using an EHR was 13.7 months at baseline. From October 2009 through October 2011, average rates increased for antithrombotic therapy (from 58.4% to 74.8%), blood pressure control (from 55.3% to 64.1%), HbA1c testing (from 46.4% to 57.7%), and smoking cessation intervention (from 29.3% to 46.2%). All improvements were significant.

CONCLUSION

During 2 years, practices showed significant improvement in the delivery of several key clinical preventive services after implementing EHRs and receiving support services from a public health agency.

Rural, suburban, and urban differences in factors that impact physician adherence to clinical preventive service guidelines

PURPOSE

Rural-urban disparities in provision of preventive services exist, but there is sparse research on how rural, suburban, or urban differences impact physician adherence to clinical preventive service guidelines. We aimed to identify factors that may cause differences in adherence to preventive service guidelines among rural, suburban, and urban primary care physicians.

METHODS

This qualitative study involved in-depth semistructured interviews with 29 purposively sampled primary care physicians (10 rural, 10 suburban, 9 urban) in Missouri. Physicians were asked to describe barriers and facilitators to clinical preventive service guideline adherence. Using techniques from grounded theory analysis, 2 coders first independently conducted content analysis then reconciled differences in coding to ensure agreement on intended meaning of transcripts.

FINDINGS

Patient epidemiologic differences, distance to health care services, and care coordination were reported as prominent factors that produced differences in preventive service guideline adherence among rural, suburban, and urban physicians. Epidemiologic differences impacted all physicians, but rural physicians highlighted the importance of occupational risk factors in their patients. Greater distance to health care services reduced visit frequency and was a prominent barrier for rural physicians. Care coordination among health care providers was problematic for suburban and urban physicians. Patient resistance to medical care and inadequate access to resources and specialists were identified as barriers by some rural physicians.

CONCLUSIONS

The rural, suburban, or urban context impacts whether a physician will adhere to clinical preventive service guidelines. Efforts to increase guideline adherence should consider the barriers and facilitators unique to rural, suburban, or urban areas.

Health information systems in small practices. Improving the delivery of clinical preventive services

BACKGROUND

Despite strong evidence that clinical preventive services (CPS) reduce morbidity and mortality, CPS performance has not improved in adult primary care. In addition to implementing electronic health records (EHRs), key factors for improving CPS include providing actionable information at the point of care, technical support staff, and quality-improvement assistance. These resources are not typically available in small practices.

PURPOSE

Estimate the impact on CPS delivery after a software upgrade to embed a clinical decision support system and practice-level quality-improvement support services.

METHODS

Practices were recruited from the Primary Care Information Project, a citywide initiative assisting practices adopt health information technology. Data were collected in 2009 and 2010, and analyses were conducted in 2010 and 2011. Across two time periods, receipt of CPS was calculated for 56 practices. Period 1 measured CPS delivery 2-37 months following implementation of an EHR. Period 2 measured CPS delivery within the first 6 months after an EHR software upgrade.

RESULTS

Substantial increases in the delivery of selected CPS were observed after the EHR software upgrades. Blood pressure control for patients with hypertension increased from 46.0% to 54.8%. Breast cancer screening, recorded BMI, and HbA1c testing for patients with diabetes also increased. More than half of the practices increased their patients' blood pressure control, recorded BMI, breast cancer screening, and HbA1c screening by ≥5 percentage points.

CONCLUSIONS

Delivery of CPS can increase in small primary care practices that implement an EHR that includes comprehensive quality-improvement support.

The financial and nonfinancial costs of implementing electronic health records in primary care practices

The incentives in the American Recovery and Reinvestment Act to expand the "meaningful use" of electronic health record systems have many health care professionals searching for information about the cost and staff resources that such systems require. We report the cost of implementing an electronic health record system in twenty-six primary care practices in a physician network in north Texas, taking into account hardware and software costs, as well as the time and effort invested in implementation. For an average five-physician practice, implementation cost an estimated $162,000, with $85,500 in maintenance expenses during the first year. We also estimate that the HealthTexas network implementation team and the practice implementation team needed 611 hours, on average, to prepare for and implement the electronic health record system, and that "end users"-physicians, other clinical staff, and nonclinical staff-needed 134 hours per physician, on average, to prepare for use of the record system in clinical encounters.

Reasons for not meeting coronary artery disease targets of care in ambulatory practice

INTRODUCTION

Four targets of care: control of blood pressure, control of low-density lipoprotein cholesterol level, taking aspirin daily, and not using tobacco improve outcomes for patients with coronary artery disease (CAD). We sought to identify why, in a large multispecialty group, these targets were not being met in patients with CAD.

METHODS

We thus conducted a retrospective review of patient records in the group practice's CAD registry, which is updated quarterly.

RESULTS

Of a random selection of 14,973 patients in the CAD registry, 353 charts were consecutively reviewed until theoretic saturation was achieved-that is, until no new information was found. We could not find any evidence of CAD in 14 patients, and we considered that all four targets had been met for 169 patients. The most frequent reasons for not meeting all targets of care among the 170 remaining patients were 1) the patient was in for a visit and the care team failed to address an unmet target of care (n = 98), 2) the patient was asked to come back for follow-up care but did not (n = 28), and 3) the patient declined an intervention that was offered (n = 14). Blood pressure and low-density lipoprotein cholesterol levels were the targets that were most frequently out of range.

CONCLUSION

Giving the health care team access to tools with which they can identify the concurrent care needs of their patients could significantly increase the proportion of patients with CAD for whom care targets are met. Lists generated by these tools would also be significantly more accurate than lists generated from quarterly reports.

What should we do in China to close the implementation gap in health promotion? A response to the WHO's Nairobi Call to Action

In response to the WHO’s Nairobi Call to Action, the paper presents results of a SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) of current health promotion activities in China, and makes recommendations for putting into practice the Call to Action, based on China’s reality and culture.

A Qualitative Comparative Analysis of factors associated with trends in narrowing health inequalities in England

This study explores why progress with tackling health inequalities has varied among a group of local authority areas in England that were set targets to narrow important health outcomes compared to national averages. It focuses on premature deaths from cancers and cardiovascular disease (CVD) and whether the local authority gap for these outcomes narrowed. Survey and secondary data were used to create dichotomised conditions describing each area. For cancers, ten conditions were found to be associated with whether or not narrowing occurred: presence/absence of a working culture of individual commitment and champions; spending on cancer programmes; aspirational or comfortable/complacent organisational cultures; deprivation; crime; assessments of strategic partnership working, commissioning and the public health workforce; frequency of progress reviews; and performance rating of the local Primary Care Trust (PCT). For CVD, six conditions were associated with whether or not narrowing occurred: a PCT budget closer or further away from target; assessments of primary care services, smoking cessation services and local leadership; presence/absence of a few major programmes; and population turnover. The method of Qualitative Comparative Analysis was used to find configurations of these conditions with either the narrowing or not narrowing outcomes. Narrowing cancer gaps were associated with three configurations in which individual commitment and champions was a necessary condition, and not narrowing was associated with a group of conditions that had in common a high level of bureaucratic-type work. Narrowing CVD gaps were associated with three configurations in which a high assessment of either primary care or smoking cessation services was a necessary condition, and not narrowing was associated with two configurations that both included an absence of major programmes. The article considers substantive and theoretical arguments for these configurations being causal and as pointing to ways of improving progress with tackling health inequalities.

Physicians' colorectal cancer screening discussion and recommendation patterns

BACKGROUND

Primary care physician (PCP) actions are pivotal to colorectal cancer (CRC) screening performance, and guidelines recommend discussion with patients about test options and potential benefits and harms. This article profiles patterns of discussion about and recommendations for screening and explores potential associations with multilevel factors (patient, clinician, practice, and environment).

METHODS

In 2009, we analyzed data from 1,266 physicians responding to the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (absolute response rate=69.3%; cooperation rate=75.0%). Descriptive statistics examined physicians' reports of discussion and recommendations. Multivariate analyses assessed the associations of these practices with multilevel factors.

RESULTS

Although few respondents reported discussion of all options, 46% usually discuss more than one option; the vast majority of these respondents discuss fecal occult blood testing (FOBT) and colonoscopy (49%) or FOBT, sigmoidoscopy, and colonoscopy (32%). Of physicians who discuss more than one option, a majority reported usually recommending one or more test options, most commonly colonoscopy alone (43%) and FOBT and colonoscopy (43%). Several personal characteristics (specialty), perceived patient characteristics (prefer physician to decide), practice characteristics (geographic location), and community barriers (specialist availability) were independently associated with discussion and/or recommendation patterns.

CONCLUSIONS

PCPs do not discuss the full menu of test options, but many report selecting one or two options for discussion and recommendation. To ensure that patients' perspectives and concerns are elicited and considered, patient decision-making approaches should be considered.

IMPACT

Attention to informed decision making in CRC screening will be important for enhancing patient-centered quality care.

The quality of preventive health care delivered to adults: results from a cross-sectional study in Southern Italy

BACKGROUND

It is assumed that providing clinical preventive services to patients can identify or detect early important causes of adult mortality. The aim of this study was to quantify access to preventive services in Southern Italy and to assess whether and how the provision of preventive care was influenced by any specific characteristics of patients.

METHODS

In a cross-sectional study adults aged 18 years and over attending primary care physician (PCP) offices located in Southern Italy were interviewed from June through December 2007. Quality indicators of preventive health care developed from RAND's Quality Assessment Tools and Behavioral Risk Factor Surveillance System (BRFSS) were used. Multivariate analysis was performed to identify and to assess the role of patients' characteristics on delivery of clinical preventive services.

RESULTS

A total of 1467 subjects participated in the study. Excepting blood pressure preventive check (delivered to 64.4% of eligible subjects) and influenza vaccination (recommended to 90.2% of elderly), the rates of delivery of clinical preventive services were low across all measures, particularly for screening and counseling on health habits. Rates for providing cancer screening tests at recommended times were 21.3% for colonoscopy, 51.5% for mammography and 52.4% for Pap smear. Statistical analysis showed clear disparities in the provision of clinical preventive services associated with age, gender, education level, perceived health status, current health conditions and primary care access measures.

CONCLUSIONS

There is overwhelming need to develop and implement effective interventions to improve delivery of routine clinical preventive services.

How to scale up primary care transformation: what we know and what we need to know?

Becoming a medical home is a radical change, requiring both a new mental model for primary care and the skills and resources to accomplish it. Although numerous reports indicate practice change is feasible--particularly with technical support and either insulation from or alignment with financial incentives--sustained transformation appears difficult. We identified the following critical success factors: leadership, financial resources, personal and organizational relationships, engagement with patients and families, competence in management, improvement methods and coaching, health information technology properly applied, care coordination support, and staff development. Each factor raises researchable questions about what policies can facilitate achieving success so that transformation becomes mainstream rather than the province of the innovative few.

Physician champions are key to improving antibiotic prescribing quality

BACKGROUND

The previously reported IMPAACT study was a cluster randomized controlled trial of a patient and physician educational intervention designed to reduce antibiotic prescribing for acute respiratory tract infections (ARIs) in emergency departments (EDs) in the United States. On average, the intervention resulted in a modest improvement in antibiotic prescribing behavior at the end of Year 1 and further improvement after Year 2. Yet the intervention's impact was large at some sites but minimal or even negative at others. A study was undertaken to identify organizational factors that influenced the effectiveness (Organizational Effect Modifiers [OEMs]) of the intervention.

METHODS

Focus groups of nurses and ED staff and semistructured interviews of local project leaders, nurse managers, and quality improvement (QI) officers were performed at seven EDs across the United States. Effectiveness of the local project leader, institutional emphasis on patient satisfaction ratings, and institutional history with and approach to QI were initially identified as key potential OEMs. Two investigators independently read the transcripts for each site and, using prespecified rating scales, rated the presence of each OEM.

FINDINGS

The perceived effectiveness of the local project leader was most strongly linked to the effectiveness of the intervention. Perceived institutional emphasis on patient satisfaction and institutional history of and approach to QI (top down or bottom up) did not appear to be closely linked with intervention effectiveness.

DISCUSSION

An effective local leader to serve as a physician champion was key to the success of this project. Organizational factors modify the effectiveness of QI interventions targeting individual physician performance and should be addressed during program implementation.

Partnering care delivery and research to optimize health

A close partnership between care delivery and research organizations has the potential to provide essential elements needed to optimize health and health care. This clinical leadership panel, held during the 14th Annual Health Maintenance Organization Research Network (HMORN) Conference, identifies the value, opportunities and challenges of those close partnerships between three HMORN care delivery and research organizations. The objectives of this plenary session were: (1) identify the important facets of partnership that bring value to care delivery and research, (2) pinpoint the critical alignments of care delivery and research that are needed to fulfill the promised value between clinical and research organizations, and (3) recognize the challenges that clinical and research organizations need to address.

Optimizing practice through research: a new perspective to solve an old problem

Policy makers, researchers, clinicians, and the public are frustrated that research in the health sciences has not resulted in a greater improvement in patient outcomes. Our experience as clinicians and researchers suggests that this frustration could be reduced if health sciences research were directed by 5 broad principles: (1) the needs of patients and populations determine the research agenda; (2) the research agenda addresses contextual and implementation issues, including the development of delivery and accountability systems; (3) the research agenda determines the research methods rather than methods determines the research agenda; (4) researchers and clinicians collaborate to define the research agenda, allocate resources, and implement findings; and (5) the level of funding for implementation research is commensurate with and proportional to the magnitude of the task. To keep the research agenda focused on the task of improving health and to acknowledge that the effort must be seen as more comprehensive than translating or transferring research into practice (TRIP), we suggest that the task be reframed, using the term optimizing practice through research.

Impact of clinical preventive services in the ambulatory setting

Indicators of the performance of clinical preventive services (CPS) have been adopted in the ambulatory setting to improve quality of care. The impact of CPS was evaluated in a network of 49 primary care practices providing care to an estimated 245,000 adults in the Dallas-Fort Worth area through a sample chart review to determine delivery of recommended evidence-based CPS combined with medical literature estimates of the effectiveness of CPS. In this population in 2005, CPS were estimated to have prevented 36 deaths and 97 incident cases of cancer; 420 coronary heart disease events (including 66 sudden deaths) and 118 strokes; 816 cases of influenza and pneumonia (including 24 hospital admissions); and 87 osteoporosis-related fractures. Thus, CPS have substantial benefits in preventing deaths and illness episodes.