Using evidence to inform and improve clinical prevention

1. Using evidence to inform and improve clinical prevention 2007 AHRQ Annual Conference Bethesda Maryland September 27, 2007

2. Presenters • Ron Finch • Susan D. Horn • William Spector • Tricia L. Trinité

3. Using prevention products and tools at different levels • Science informed policy and coverage decisions • A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage • Support clinical decision-making in primary care • electronic Preventive Services Selector (ePSS) • Guide to Clinical Preventive Services • Support redesign of healthcare delivery processes to improve quality of care • On-Time Prevention of Pressure Ulcers

4. One Source of Evidence:US Preventive Services Task Force • Supported by the Agency for Healthcare Research and Quality • Independent and multidisciplinary panel of experts in primary care and prevention • Provides evidence-based, impartial scientific reviews of preventive health services for use in primary healthcare delivery settings • Considered “gold standard” for evidence-based preventive services recommendations

5. USPSTF Process for Development of Recommendations • Define question and outcomes of interest • Search for benefits and harms of the service • Evaluate QUALITY of individual studies • Synthesize and judge STRENGTH of available evidence • Determine balance of BENEFITS and HARMS • Link recommendation to judgment about net benefits

6. Using prevention products and tools at different levels • Science informed policy and coverage decisions • A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage • Support clinical decision-making in primary care • Support redesign of healthcare delivery processes to improve quality of care

7. Science informed policy and coverage decisions A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage Ron Finch., EdD Vice-President National Business Group on Health

8. Background • Changing the paradigm • From a focus on treatment • To a focus on prevention and behavior change • Prevention • Primary (e.g., immunizations) • Secondary (e.g., hypertension treatment) • Tertiary (e.g., medical foods for children with PKU)

9. Who Ensures Prevention? • Healthcare companies innovate procedures and products • Consultants and employers design benefits • Employers purchase benefits • Plans and providers deliver services

10. Coverage Among Large (500+) Employers • Insurance coverage makes a difference in whether people receive preventive services • Coverage of physical exams, screening, and immunizations fair, coverage of lifestyle modification / counseling services poor: • Healthy diet -21% • Weight loss -18% • Alcohol misuse - 19% • Comprehensive tobacco treatment benefits – 4% Source: Results from survey completed by 2,180 employers in 2001.Bondi MA, Harris JR, et al. Employer coverage of clinical preventive services in the United States. American Journal of Health Promotion 2006; 20(3): 214-222.

11. Delivery and Utilization • Barely half (52%) of adults receive preventive care according to guidelines for their age and sex.1 • 2006 NCQA State of Healthcare Quality Report2 • 82% of women (18-64) screened for cervical cancer • 72% of women screening for breast cancer • 52% of adults 50+ screened for colorectal cancer • 36% of adults immunized against influenza • 34% of women (16-20) screened for Chlamydia Source: 1. The Commonwealth Fund Commission on a High Performance Healthcare System, Sept 2006;2. The State of health care quality: Industry trends and analysis. National Committee for Quality Assurance (NCQA). The state of health care quality: 2006. National Committee for Quality Assurance (NCQA); Washington, DC: 2006.

12. The Purchaser’s Guide

13. Purpose of the Purchaser’s Guide • Translate science into coverage • Promote preventive medical benefits that are based on evidence & shift benefit criteria from arbitrary thresholds and cost sensitivities to beneficiary need • Provide information needed to select, define, prioritize, and implement preventive medical benefits • SPDs, CPT codes, prioritization methods

14. Part 1: Knowledge The Role of Clinical Preventive Services in Disease Prevention and Early Detection

15. Rethinking Current Approaches Primary cost drivers are chronic disease and serious acute conditions; many are preventable. 20% of claimants 80% of Costs Stem from preventable chronic conditions 75% of costs

16. Rethinking Current Approaches Causes of Death in the United States Most Common, 1999* Percent of all deaths Source: CDC *All data are adjusted to 2005 U.S. population

17. Rethinking Current Approaches Underlying Causes of Death, United States 2000 • Causes of Death, United States 2000 • Diseases of the heart = 30.4% • Cancers = 23.0% • Stroke = 7% • COPD = 5.2% Source: Mokdad A, Marks JS, Stroup DE, Gerberding JL. Actual causes of death in the United States. JAMA 2004; 291(10):1238-1245. Correction published JAMA 2005; 293(3): 293-294.

18. The Role of Clinical Preventive Services in Disease Prevention and Early Detection • The importance of preventing chronic disease • General information on the value of prevention • Employer Action • Offer a structured set of clinical preventive service benefits. • Inform employees, dependents, and retirees about the availability of preventive benefits and promote consistent and appropriate use. • Implement programs that promote healthy lifestyles and provide opportunities for employees to engage in disease prevention and health promotion outside of the clinical setting. • Support community-based and worksite-based preventive service interventions.

19. The Role of Clinical Preventive Services in Disease Prevention and Early Detection • Health Plan Action • Offer preventive medical benefits in “off the shelf” plans for small and medium-sized employers. • Encourage large/self-funded employers to incorporate preventive benefits in all plan types. • Ensure providers offer recommended clinical preventive services to patients. • Educate beneficiaries/plan participants on available services (reminders, etc).

20. Part 2: Coverage Summary Plan Description (SPD) Language Statements for Recommended Clinical Preventive Service Benefits

21. Summary Plan Description (SPD) Language • Federal regulation and preventive services • Preventive medications and preventive treatments • Employers can shape plans to promote delivery and use • HDHPs and “safe-harbor” coverage • Waive deductible and eliminate copays • Waive deductible and reduce copays • Waive plan deductible and require standard copay • Apply standard deductible but provide separate financial benefit for preventive services • Implications for health plans?

23. Summary Plan Description (SPD) Language Tobacco Use Treatment • Screening • Coverage begins at age 18 (coverage provided for younger populations depending on medical need) • Eligible at every medical encounter • Counseling • Brief counseling (in-person) and intensive counseling (in-person or telephonic) • 2 courses of 6 counseling session each calendar year (total of 12 sessions per year) • Treatment • All FDA-approved nicotine replacement products and tobacco cessation medications, as prescribed by a clinician

24. Summary Plan Description (SPD) Language Breast Cancer: Normal Risk • Screening • Mammography and CBE for average risk women aged 40 to 80 once per calendar year. Younger women may qualify for screening if medically indicated. Breast Cancer: High-Risk • Counseling on Testing & Preventive Medication and Preventive Treatment • Counseling provided as medically indicated and at least once before and once after a BRCA mutation test • BRCA Mutation Testing • Once per lifetime • Preventive Treatment • Surgical removal of the breast(s) with or without reconstructive surgery • Surgical removal of the ovaries • Preventive Medication • All FDA-approved breast cancer preventive medications (e.g., tamoxifen) for 5 years - may be extended if medically necessary

25. Current Procedural Terminology (CPT) Codes

26. Part 3: Evidence Evidence-Statements for Recommended Clinical Preventive Service Benefits

27. Forms of Evidence Used in the Purchaser’s Guide • U.S. Preventive Service Task Force (USPSTF) recommendations • CDC • Other U.S. Department of Health and Human Services • U.S. Public Health Service • U.S. Surgeon General • National Heart, Lung, and Blood Institute (NHLBI) • Professional Organizations • American Academy of Pediatrics (AAP) • American Academy of Family Physicians (AAFP) • Many others • Respected associations • Why use evidence as a criterion?

28. Evidence: USPSTF A - Strongly recommend Good evidence that the benefits substantially outweigh harms B - Recommend At least fair evidence that benefits outweigh harms C - USPSTF makes no recommendation Recommend against routinely providing X service for Y population. There may be considerations supporting the provision of the service in an individual patient. D - Recommend against routine use Ineffective or harms outweigh potential benefits I - Insufficient evidence to make a recommendation No evidence or poor quality evidence

29. Examples of USPSTF Recommendations • The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) • The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. (A Recommendation) • The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer. (D Recommendation)

30. Evidence-Statements for Recommended Clinical Preventive Service Benefits • 72 screening, counseling, testing, immunization, preventive medication, preventive treatment recommendations in 46 topic areas • Recommendation statement • Condition / disease specific information • Epidemiology • Risk factors

31. Evidence-Statements for Recommended Clinical Preventive Service Benefits • Value of prevention • Economic burden • Workplace burden • Economic benefit of preventive intervention • Estimated cost of preventive intervention • 2004 paid claims average from the Medstat Marketscan database (commercially insured population) • Cost-effectiveness / cost-benefit • Preventive intervention information • Purpose • Process • Benefits and risks of intervention • Population, initiation/cessation, frequency of benefit • Treatment information

33. The Problem “The use of tobacco…conquers men with a certain secret pleasure so that those who have once become accustomed thereto can hardly be restrained therefrom.” Sir Francis Bacon 1622AD

34. Uses of the Guide • Downloaded over 300,000 times • Gap Analysis • Business Planning • Health and Productivity Plans and Services • Environment of Business Setting

35. Using prevention products and tools at different levels • Science informed policy and coverage decisions • Support clinical decision-making in primary care • Point of Care decision support • Support redesign of healthcare delivery processes to improve quality of care

36. Support clinical decision-making at the point of care Guide to Clinical Preventive Services ePSS: electronic Preventive Services Selector CAPT Tricia L. Trinité, APRN, MSPH Director, Prevention Dissemination & Implementation Center for Primary Care, Prevention & Clinical Partnerships Agency for Healthcare Research & Quality

37. US Preventive Services Task Force • Provides evidence-based, impartial scientific reviews of preventive health services for use in primary healthcare delivery settings • Independent and multidisciplinary panel of experts in primary care and prevention • Supported by AHRQ

38. USPSTF • Makes recommendations on whether a clinical preventive service should be routinely delivered to a population without signs or symptoms of illness Recommendations include: • Screening tests • Health counseling delivered in clinical setting • Preventive medications

39. Communicating evidence-based recommendations from the USPSTF A - Strongly recommend Good evidence that the benefits substantially outweigh harms B - Recommend At least fair evidence that benefits outweigh harms C - USPSTF makes no recommendation Fair to good evidence that the benefits and harms are closely balanced D - Recommend against routine use Ineffective or harms outweigh potential benefits I - Insufficient evidence to make a recommendation No evidence or poor quality evidence

40. Annual Guide for Clinicians USPSTF recommendations adapted for a pocket-size book. Recommendations are presented in an indexed, easy-to-use format. Making it easier for clinicians to consult the recommendations in their daily practice. Focus group tested with primary care providers.

41. Electronic tool for Primary Care Clinicians • ePSS – electronic Preventive Services Selector • Search USPSTF recommendations by age, sex and risk factors • Available as a web-based tool or can be downloaded to your PDA • www.epss.ahrq.gov

47. Locating Clinical Decision Support Tools • AHRQ Conference Innovations Café • Annual Clinical Guide • www.ahrq.gov/clinic/pocketgd.htm • Electronic Preventive Services Selector (ePSS) • www.ePSS.ahrq.gov www.preventiveservices.ahrq.gov

48. Using prevention products and tools at different levels • Science informed policy and coverage decisions • Support clinical decision-making in primary care • Support redesign of healthcare delivery processes to improve quality of care

49. Support redesign of health care delivery processes to improve quality On-Time Prevention of Pressure Ulcers in Nursing Homes Susan D. Horn, PhD Institute for Clinical Outcomes Research 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282 801-466-5595 (T) 801-466-6685 (F) shorn@isisicor.com

50. ON-TIME PREVENTION OF PRESSURE ULCERS IN NURSING HOMES Objectives • Build partnerships / Develop interdisciplinary team capacity to promote faster QI in LTC • Integrate evidence-based research on pressure ulcer prevention into long term care daily workflow • Redesign clinical care planning processes using standardized documentation and timely feedback reports