Using evidence to inform and improve clinical prevention

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Using evidence to inform and improve clinical
prevention

• 2007 AHRQ Annual Conference
• Bethesda Maryland
• September 27, 2007

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Presenters

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

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Using prevention products and tools at different
levels

• Science informed policy and coverage decisions
• A Purchasers 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

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One Source of EvidenceUS 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

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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

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Using prevention products and tools at different
levels

• Science informed policy and coverage decisions
• A Purchasers 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

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Science informed policy and coverage decisions

• A Purchasers Guide to Clinical Preventive
  Services Moving Science into Coverage

Ron Finch., EdD Vice-President National Business
Group on Health
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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)

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Who Ensures Prevention?

• Healthcare companies innovate procedures and
  products
• Consultants and employers design benefits
• Employers purchase benefits
• Plans and providers deliver services

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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.
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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.
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The Purchasers Guide
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Purpose of the Purchasers 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

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Part 1

• Knowledge
• The Role of Clinical Preventive Services in
  Disease Prevention and Early Detection

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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
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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
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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.
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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.

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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).

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Part 2

• Coverage
• Summary Plan Description (SPD) Language
  Statements for Recommended Clinical Preventive
  Service Benefits

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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?

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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

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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

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Current Procedural Terminology (CPT) Codes
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Part 3

• Evidence
• Evidence-Statements for Recommended Clinical
  Preventive Service Benefits

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Forms of Evidence Used in the Purchasers 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?

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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

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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)

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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

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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

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The Problem

• The use of tobaccoconquers men with a certain
  secret pleasure so that those who have once
  become accustomed thereto can hardly be
  restrained therefrom.
• Sir Francis Bacon 1622AD

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Uses of the Guide

• Downloaded over 300,000 times
• Gap Analysis
• Business Planning
• Health and Productivity Plans and Services
• Environment of Business Setting

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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

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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
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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

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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

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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

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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.
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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

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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
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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

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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 801-466-5
595 (T) 801-466-6685 (F) shorn_at_isisicor.com
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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

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Research Based Best Practices Nursing Home Study
(NPULS) 1996-1997

• 6 long-term care provider organizations
• 109 facilities
• 2,490 residents studied
• 1,343 residents with pressure ulcer 1,147 at
  risk
• 70 female, 30 male
• Average age 79.8 years
• Funded by Ross Products Division, Abbott
  Laboratories

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Long Term Care CPI ResultsOutcome Develop
Pressure Ulcer
Horn et al, J. Amer Geriatric Soc March 2004
52(3)359-367
Incontinence Interventions
Nutrition Interventions
Staffing Interventions
General Assessment
Age ? 85 Male Severity of Illness History
of PU Dependency in gt 7 ADLs Diabetes
History of tobacco use Dehydration Weight
loss
Mechanical devices for the containment of urine
(catheters) - Disposable briefs - Toileting
Program
- RN hours per resident day gt0 .5 - CNA hours
per resident day gt 2.25

• - Fluid Order
• - Nutritional Supplements
• standard medical
• - Enteral Supplements
• disease-specific
• high calorie/high
• protein

Medications
- SSRI Antipsychotic
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Common Challenges Across Facilities

• Inefficient Processes
• Incomplete Documentation
• CNAs untapped resource
• Communication Breakdowns / Lack Standard
  Processes
• Clinical Decision Support Needs

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Step 1 Build Partnerships

• Empower all members of a facility team
• Front-line workers actively participate in QI
  activities, including CNAs bottom-up approach
• Share across facilities

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Step 2 Standardize Documentation

• Comprehensive documentation for front-line
  workers
• Redesign work flow consolidate documentation
• Allow individual facility customization
• Encourage inter-facility sharing
• Observe facilities come to consensus over time

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Comprehensive Standardized Documentation

• CNA
• Daily flow sheet
• Single form replaced multiple logs, clipboards,
  bedside charts
• Reduced redundant documentation document one
  time, in one place

• PrU Tracking Sheet
• Wound RN standardized PrU documentation tracks
  resident risk and pressure ulcer status
• Information used to compile summary reports

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Step 3 Timely Feedback Reports

• Use comprehensive standardized documentation data
• First reports provide feedback on documentation
  completeness
• Other reports target alerts for specific
  components of care
• Summarize clinical information in variety of
  formats for use by RNs, MDS coordinators,
  dieticians, CNAs, wound RN, etc.
• Reports contribute to individualized care
  planning processes

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Timely Reports focus on Pressure Ulcer Prevention

• Weekly Reports
• Nutrition Report / Weight Summary
• Behavior Report
• Pressure Ulcer Report
• Priority Report
• Monthly Reports
• Health Status Summary Report

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Example Nutrition Report
Stratified by Risk Provide BIG picture over
time, not just snapshot of one shift or one day

• Nutrition Summary
• Meal intake for 4 weeks
• Fluid intake for 4 weeks
• Diet order
• Supplement product
• Weight change since last week
• Psychiatric medications received

• Weight Summary
• Weight 180 days prior
• Weight 30 days prior
• Weight for each of past 4 weeks
• Weight change since last week
• 5-10 weight loss past 30 days
• gt10 weight loss past 180 days
• Psychiatric medications received

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Nutrition Report

• How to use the Nutrition Report?
• Identify which meals are not being eaten
• Promote use of nutritional supplements
• Identify need for consistent weights

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Example Priority Report
Identifies residents at risk

• Decreased meal intake
• Weight loss
• Increased incontinence episodes
• Increased behavior problems
• Existing red areas on skin
• History of pressure ulcer in last 90 days

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Benefits of Timely Feedback Reports

• Access to summarized information for clinical
  decision-making
• Improve response time between identification of
  resident need and intervention
• Identify residents at risk for pressure ulcer
  development
• Transform from paper to data culture
• Link reports to documentation elements

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Step 4 Integrate into Daily Workflow

• Comprehensive forms replace (not supplement)
  previous forms
• Importance of front-line CNA observations
  stressed
• Feedback is based on documentation
• Feedback contributes to care plan updates

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Results

• Decrease Pressure Ulcer Development
• Increase Adherence to Best Practices
• Increase Staff Accountability and Satisfaction
• Inclusion of front-line workers in QI efforts
• Comprehensive documentation at point of care
• Communication among care team improved
• Reduce Inefficiencies
• documentation forms for CNAs
• CNA time looking for documentation book
• Time to compile reports for State Regulators and
  MDS
• Time for Wound RN to summarize and report data
• Improve State Survey Process
• Establish a foundation for EHR

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Impact On Pressure Ulcer QMs
The combined facilities average shows an overall
reduction of 33 in the QM of high risk
residents with pressure ulcer from
pre-implementation to initial post-implementation
time periods
National Norm
Combined Facilities
Q4 03 Q3 05 Change - 33
Source CMS Nursing Home Compare Facility QM
data reports
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Summary of Key Program Benefits

• Improve Quality
• Improve clinical decision making integrate
  reports into day-to-day workflow
• Identify residents at high risk early
• Timely communication among multi-disciplinary
  team members
• QI Collaboration
• Receive technical assistance from QI experts
• Collaborate with peers to share experiences and
  best practices

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Summary of Key Program Benefits (cont)

• Improve CNA Documentation
• Consolidate current documentation
• Standardize data elements and eliminate
  redundancy
• Audit and train for accuracy
• Gain Efficiency
• Reduce time spent searching for multiple sources
  of information
• Automated reports replace manual compilation of
  resident information
• Increase Morale
• Empower multidisciplinary teams with CNAs as
  important members
• CNAs see importance of their work

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Available On-Time Tools

• CNA documentation
• http//ahrq.gov/research/ltc/pucnaform.pdf
• On-Time Reports
• http//ahrq.gov/research/ltc/pusamplerep.pdf
• Video and other resources
• http//ahrq.gov/research/puwebcast.htm

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QUESTIONS?

• Ron Finch National Business Group on Health
• Susan D. Horn - Institute for Clinical Outcomes
  Research
• William Spector AHRQ
• Tricia L. Trinité - AHRQ