Improving Performance on Preventive Health Quality Measures Using Clinical Decision Support to Capture Care Done Elsewhere and Patient Exceptions

Improving Colorectal Cancer Screening in a Regional Safety-Net Health System over a 10-Year Period: Lessons for Population Health

BACKGROUND

Despite national policy efforts to increase colorectal cancer (CRC) screening, rates in vulnerable populations remain suboptimal. Many types of interventions have been employed, but their impact on improving population-level rates of CRC screening over time is uncertain.

OBJECTIVE

Assess the impact of 10 years of different in-reach and outreach strategies to improve CRC screening and identify factors associated with being screen up-to-date (SUTD).

DESIGN

Observational cohort study.

PARTICIPANTS

Patients aged 50-74 years from 12 community-based primary care clinics in an integrated, regional safety-net health system.

INTERVENTIONS

Multiple system-level interventions were implemented over time (visit-based electronic health record [EHR] reminders, quality measurement, annual preventive service letters, and mailed fecal immunohistochemical stool tests [FIT]).

MAIN MEASURES

CRC SUTD rates by calendar year among those with a primary care (PC) visit in the prior 1 and 3 years and their multivariable correlates.

KEY RESULTS

The sample included 31,786-40,405 patients/year. In 2011, mean age was 58.9, 63.9% were women, 37.0% were Hispanic, 39.3% Black, 16.8% White, and 6.6% Asian/Other, and 60.5% were uninsured/Medicaid. Three-quarters of patients had ≥ 1 PC visit in the prior year. Lower-intensity interventions (EHR reminders, quality measurement, annual prevention letters) had limited impact on SUTD rates (2-3% rise). Implementing system-wide mailed FIT increased rates from 51.2 to 61.9% among those with a PC visit in the past year (40.5 to 46.8% with a PC visit ≤ 3 years). Stopping mailed FIT due to COVID wiped out these gains. Higher screening rates were associated with the following: older age; female; more comorbidities, PC clinic visits, and prior FITs; and better insurance coverage. Hispanics had the highest SUTD rates followed by Asians, Blacks, and Whites (p < 0.05).

CONCLUSIONS

Implementation of a system-wide mailed FIT program had the greatest impact on SUTD rates. Lower-intensity interventions (EHR reminders, quality measurement, and patient letters) had limited effects.

Further Progress Toward Automating Functional Analysis Interpretation

It is considered best practice to conduct a functional analysis and visually inspect data collected to determine the function of problem behavior, which then informs the intervention approaches applied. Visual inspection has been described as a "subjective" process that may be affected by factors unrelated to the data. Structured decision-making guidelines have been established to address some of these shortcomings. The current paper is a follow-up to earlier work describing positive outcomes related to the viability of a decision support system based on structured criteria from Roane et al. Here, we demonstrate important improvements in a computer script's interpretation of functional analysis data, including improvement in agreement between the updated computer script version and experienced human raters (89%) compared to our original agreement outcomes (81%). This paper further supports the use of decision support systems for functional analysis interpretation.

Increasing pneumococcal vaccine uptake in older adults: a scoping review of interventions in high-income countries

BACKGROUND

There is low uptake of the pneumococcal vaccination in eligible older adults, even in high-income countries that offer routine and universal vaccination programs.

OBJECTIVE

To systematically characterize interventions aimed at improving pneumococcal vaccine uptake in older adults.

DESIGN

We conducted a scoping review following PRISMA-SCr guidelines of five interdisciplinary databases: Medline-Ovid, Embase, CINAHL, PsychInfo, and Cochrane Library. Databases were searched from January 2015 until April 2020. The interventions were summarized into three pillars according to the European Union Conceptional Framework for Action: information campaigns, prioritization of vaccination schemes, and primary care interventions.

RESULTS

Our scoping review included 39 studies that summarized interventions related to pneumococcal vaccine uptake for older adults, encompassing 2,481,887 study participants (945 healthcare providers and 2,480,942 older adults) across seven countries. Examples of interventions that were associated with increased pneumococcal vaccination rate included periodic health examinations, reminders and decision-making tools built into electronic medical records, inpatient vaccination protocols, preventative health checklists, and multimodal educational interventions. When comparing the three pillars, prioiritization of vaccination schemes had the highest evidence for improved rates of vaccination (n = 14 studies), followed by primary care interventions (n = 8 studies), then information campaigns (n = 5 studies).

CONCLUSION

Several promising interventions were associated with improved outcomes related to vaccine uptake, although controlled study designs are needed to determine which interventions are most effective.

Measured Performance and Vaccine Administration After Decision Support and Office Workflow Changes for Influenza Vaccination

Influenza vaccination is underused. We examined changes in vaccination following decision support and workflow changes in a cross-sectional analysis of three vaccination seasons among adult primary care patients from 21 practices. Interventions included clinical decision support changes to facilitate documentation; changes to rooming workflow for medical assistants and licensed practical nurses to promote vaccination, prepare orders, document care done elsewhere; and record patient refusals. We measured rates for a national vaccination performance measure and receipt of onsite vaccination. Approximately 120,000 patients were eligible each season. Performance on the quality measure increased each year (40.6% to 62.5% to 76.4%). Corresponding rates of onsite vaccination were 27.7%, 28.8%, and 31.5%. The adjusted odds ratio for onsite vaccination in the second season compared with the first was 0.94 (95% confidence interval [CI] 0.92, 0.96). Onsite vaccination was more likely in the third season compared with either previous season-adjusted odds ratio for third versus second 1.14 (95% CI, 1.12, 1.16) or adjusted odds ratio for third versus first 1.07 (95% CI 1.05-1.09). Sequential changes in decision support and patient rooming process workflows were associated with large improvements in measured performance and with a significant increase in clinic-administered influenza vaccination by the third season.

Addressing common barriers in adult immunizations: a review of interventions

Introduction: Low levels of adult vaccination have been documented in the United States and globally. Research has been conducted to identify reasons for low immunization rates; however, the most useful studies are those that implemented interventions for identified barriers to evaluate their impact on rates of immunization. Identifying successful interventions provides immunization providers with evidence-based methods that can be utilized to increase the uptake of recommended vaccines.Areas covered: This review focuses on known barriers to adult immunizations and the interventions available in the literature to overcome these barriers. It outlines interventions that may increase vaccine uptake in the adult population through addressing barriers related to lack of vaccine knowledge, cost, access, provider and practice-based challenges, and racial and ethnic disparities.Expert opinion: Improving adult immunization rates is critical to protecting a population against vaccine-preventable diseases. Those interventions that appeared to increase immunization rates in the adult population included education and reminders about vaccination using text and telephone calls, low-cost or subsidized vaccines, easy access to immunization services, and understanding the cultural and social needs of different racial and ethnic populations. It is likely that an evidence-based multimodal approach using different categories of interventions is necessary to significantly improve adult immunization rates.

Association Of Medicare's Annual Wellness Visit With Cancer Screening, Referrals, Utilization, And Spending

Medicare's annual wellness visit was introduced in 2011 to promote evidence-based preventive care and identify risk factors and undiagnosed conditions in aging adults. Use of the visit has risen steadily since then, yet its benefits remain unclear. Using national Medicare data for 2008-15, we examined claims from fee-for-service Medicare beneficiaries attributed to practices that did or did not adopt the visit. We performed difference-in-differences analysis to compare differential changes in appropriate and low-value cancer screening, functional and neuropsychiatric care, emergency department visits, hospitalizations, and total spending. Examining 17.8 million beneficiary-years, we found modest differential improvements in rates of evidence-based screening and declines in emergency department visits. However, when we accounted for trends that predated the introduction of the visit, none of these benefits persisted. In sum, we found no substantive association between annual wellness visits and improvements in care.

The use of technology to promote vaccination: A social ecological model based framework

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.