Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital AHRQ 2009 Conference Alice Hm Chen, MD, MPH
SFGH Acknowledgements • Lisa Johnson, Medical Director for Quality Improvement Programs, Community Primary Care • Fred Strauss, IS/Provider Liaison • Winnie Tse, Analyst, Community Primary Care • Flu-FOBT Project: Michael Potter, Professor of Clinical Family and Community Medicine and Albert Yu, Medical Director of Chinatown Public Health Center
Outline • Background • SFGH delivery system and EMR • Case study: colorectal cancer screening • Case study: breast cancer screening
Why focus on preventive care? • Only 10% of female Medicare beneficiaries received all of 5 recommended preventive care measures (cervical, breast and colorectal cancer screening; pneumovax and influenza vaccines). • Significant disparities in receipt of preventive care services among racial/ethnic groups and poor. General Accounting Office congressional testimony on 3/23/02, available at: www.gao.gov/cgi-bin/getrpt?GAO-02-777T.
Barriers to Screening in the Safety Net • Financial barriers (lack of insurance, co-pays) • System resource constraints, e.g. • Lack of ability to offer screening colonoscopies • Difficulty hiring mammographers • Literacy, language, and cultural barriers • Conflicting guidelines for PCPs • 7.4 hours/day to provide all USPSTF “A” and “B” services Yarnell KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: Is there enough time for prevention? American Journal of Public Health 2003; 635-641.
Whose guidelines should we be following, anyways? • Proliferation of guidelines • “Eminence” based versus evidence based • Internal versus external • Ability to tailor to resources • Time consuming to develop • Need for ongoing updates
SFGH Approach • Agreement on evidence-based guidelines (USPSTF), tailored to our system’s resource constraints • Harnessing information technology • Electronic medical record • AHRQ Electronic Preventive Services Selector (ePSS) • Patient registries • Systems interventions • Standing orders • Panel management • Culturally and linguistically appropriate outreach
Colorectal Cancer Screening “Success” • Practice based on USPSTF guidelines, tailored to system resource constraints (no screening colonoscopy) • SF DPH recommends annual home FOBT, with diagnostic colonoscopy for abnormals • Systems intervention: Flu-FOBT program • Culturally and linguistically appropriate outreach
Flu-FOBT Program • Strategy: offer FOBT in combination with flu shots • Initial pilot results • Flu only: 52.9% 57.3% eligible completed FOBT • Flu + FOBT: 54.5% 84.3% eligible completed FOBT • Difference of 25.4 points, p<0.001 Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh J. Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates. Annals of Family Medicine 2009; 7:17-23. • SF DPH program at Chinatown Public Health Center led by Mike Potter and Albert Yu, funded by CDC Slide courtesy of Albert Yu and Mike Potter
大腸癌檢 查 大腸癌檢 查 查 查 糞便檢 糞便檢 Stool Test for Colon Screening Stool Test for Colon Screening : : Instructions for Collecting 3 Stool Instructions for Collecting 3 Stool 收集三次糞便的指示 收集三次糞便的指示 ﹕ ﹕ Before collecting your stool, Before collecting your stool, 請閱讀以下提 ﹐ 收集糞便之前 收集糞便之前 ﹐ 請閱讀以下提 Samples: Samples: please read the following: please read the following: 示 示 ﹕ ﹕ 1. 1. Write the date Write the date 每張收集?上記下 ?收集 在 每張收集?上記下 在 ?收集 1. 1. you collected you collected • • You will collect stool samples from 3 You will collect stool samples from 3 需要收集三次大便樣本 需要收集三次大便樣本 the stool on the stool on 糞便的日期 糞便的日期 . . (Date). (Date). bowel movements. bowel movements. each card. each card. 如果有痔瘡出血症 ﹐ 請 狀 請 ﹐ 狀 如果有痔瘡出血症 要 要 • • Do not collect your stool if you have Do not collect your stool if you have Date Date Date a bleeding hemorrhoid. a bleeding hemorrhoid. 收集大便 收集大便 收集糞便之 收集糞便之 . . 2. 2. 2. 2. Before the Before the • • Women: Do not collect your stool Women: Do not collect your stool 女士們 女士們 ﹕ ﹕ 不要在月經期間 不要在月經期間 集 集 取出馬 ﹐ 前 ﹐ 前 取出馬 test, take out test, take out during a menstrual period. during a menstrual period. Date Date Date 大便 大便 all toilet bowl all toilet bowl 內的 潔 桶 內的 清 清 潔 桶 . . cleaners and flush the toilet two cleaners and flush the toilet two 劑 劑 ﹐並 沖洗 ﹐並 沖洗 For a few days before the test, For a few days before the test, times so only plain water is there. times so only plain water is there. 前幾天 查 ﹐您 飲 在檢 可能要在 ﹐您 查 前幾天 可能要在 飲 在檢 you may have to make some you may have to make some 馬桶兩次 馬桶兩次 清 ﹐ ﹐ 清 直至裡面只有 直至裡面只有 changes in your medicines or changes in your medicines or 食或藥物上作些改變 食或藥物上作些改變 潔劑 水，沒有 水，沒有 潔劑 清 清 . . . . 3. 3. Collect the stool: Collect the stool: diet. diet. a. a. Allow the stool to fall into the Allow the stool to fall into the 藥物方面 藥物方面 ﹕ ﹕ water as usual. water as usual. 直到 從收集大便前七天開始 ﹐ 直到 ﹐ 從收集大便前七天開始 步驟 收集糞便的 收集糞便的 步驟 ﹕ ﹕ 3. 3. b. b. Use a stick from the kit to collect a Use a stick from the kit to collect a Medicines Medicines 不要 ﹐ 大便樣本收集結束期間 ﹐ 大便樣本收集結束期間 不要 讓糞便像往常一樣掉入水 讓糞便像往常一樣掉入水 a. a. small sample of stool. small sample of stool. Starting 7 days before you begin Starting 7 days before you begin 服用布洛芬類的止痛藥如 服用布洛芬類的止痛藥如 內的小木棒，來收 內的小木棒，來收 使用信封 使用信封 b. b. c. c. On one stool On one stool collecting your stool and until you are collecting your stool and until you are card, put a card, put a ﹐ ﹐ 。一天 內不要服 。一天 內不要服 集小量的大 集小量的大 Advil Advil Motrin Motrin done collecting your stool samples, do done collecting your stool samples, do very small very small not take ibuprofen (Advil, Motrin) or not take ibuprofen (Advil, Motrin) or 用超過一片阿司匹林。但如果 用超過一片阿司匹林。但如果 便樣本 便樣本 . . B B B amount of amount of A A A similar pain medicines. Do not take similar pain medicines. Do not take ?一直有服用醋?? ?一直有服用醋?? 將小量糞 將小量糞 (Tylenol (Tylenol ) ) c. c. stool as a thin stool as a thin more than one aspirin per day. You do more than one aspirin per day. You do B B B ﹐ ﹐ 則無需要停止 則無需要停止 便抹在標有 便抹在標有 . . A A A smear in the box labeled smear in the box labeled “ “ A. A. ” ” not have to stop taking acetaminophen not have to stop taking acetaminophen d. d. Take another very small amount Take another very small amount 的地方 的地方 . . (Tylenol), if that is a medicine that you (Tylenol), if that is a medicine that you “ “ A A ” ” from a different part of the stool from a different part of the stool usually take. usually take. 飲 飲 食方面 食方面 ﹕ ﹕ 在糞便?一個位置上，取小 在糞便?一個位置上，取小 d. d. and smear it in the box labeled and smear it in the box labeled 量糞便，抹在 量糞便，抹在 的地方 的地方 “ “ B B ” ” . . “ “ B. B. ” ” Diet Diet 從收集大便前兩天開始 ﹐ ﹐ 直到 直到 從收集大便前兩天開始 待收集?乾後 ﹐ 再關上前蓋 待收集?乾後 再關上前蓋 ﹐ e. e. Let the card dry and close the Let the card dry and close the e. e. Starting 2 days before you begin Starting 2 days before you begin front flap. front flap. 不要 大便樣本收集結束期間 不要 大便樣本收集結束期間 ﹐ ﹐ 不要將收集?弄濕 不要將收集?弄濕 f. f. . . collecting your stool and until you are collecting your stool and until you are f. f. Do not let the card get wet. Do not let the card get wet. 吃未完全煮熟的紅肉。不要吃 吃未完全煮熟的紅肉。不要吃 done collecting your stool samples, do done collecting your stool samples, do not eat meat unless it is well not eat meat unless it is well - - done. Do done. Do 山葵 ﹐ 哈蜜瓜 ﹐ 白蘿蔔，西蘭 ﹐ ﹐ 哈蜜瓜 山葵 白蘿蔔，西蘭 步驟，收集?外 按照同樣的 步驟，收集?外 按照同樣的 4. 4. 4. 4. Do the same for your next 2 bowel Do the same for your next 2 bowel not eat horseradish, cantaloupe, not eat horseradish, cantaloupe, ﹐ 小蘿蔔或防風草 ﹐ 花 ﹐ 花 椰菜花 小蘿蔔或防風草 椰菜花 ﹐ 兩次的糞便 兩次的糞便 movements. movements. . . turnips, broccoli, cauliflower, turnips, broccoli, cauliflower, 紅或用 血做成 豬 。亦不要吃 豬 血做成 紅或用 豬 。亦不要吃 豬 radishes, or parsnips. Do not eat blood radishes, or parsnips. Do not eat blood 的香腸 的香腸 pudding or blood sausage. pudding or blood sausage. . . . . Outreach Materials Slide courtesy of Albert Yu and Mike Potter
Designed at Request of CPHC Staff with Patient Input Slide courtesy of Albert Yu and Mike Potter
CPHC Preliminary Results Efficacy among 50-80 year olds who came in for primary care visit during flu shot season Got Flu Shot Didn’t Get Flu Shot (n=1286) (n=588) Up to date 9-29-08 51.2% 60.2% Up to date 3-31-09 75.2% 64.8% Change +25.0% +4.6% Slide courtesy of Albert Yu and Mike Potter
SF DPH Screening Rates U.S average (NHIS 2000)
Breast Cancer Screening Challenges • Primary care quality improvement committee uses USPSTF guidelines, but specialty society (radiology) recommendations different • Difficulties hiring mammographers had led to significant wait times for both screening and diagnostic mammograms • Conflicting information given to patients • Low mammography rates due to CBE requirement
SF DPH Mamography Rates Percent of women ages 42-69 who have had a mammogram in the past 2 years. Excludes “not indicated” but does not give credit for “declined.” HEDIS 2007 Commercial HEDIS 2007 Medicaid * * Historically not held to requirement for CBE.
Conclusions • USPSTF guideline process (rigorous, evidence-based, ongoing) critical to reliability and credibility. • AHRQ ePSS enables easy access to updated USPSTF guidelines, especially with linkages EMR. • Challenges remain with systems barriers that can only be addressed on an institutional level.
Questions? Alice Hm Chen, MD, MPH Assistant Professor of Medicine, UCSF Medical Director, Adult Medical Center, SFGH achen@ medsfgh.ucsf.edu