Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital

AHRQ 2009 ConferenceAlice 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

Outreach Materials

Slide courtesy of Albert Yu and Mike Potter

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Before collecting your stool, please read the following:

• You will collect stool samples from 3 bowel movements.

• Do not collect your stool if you have a bleeding hemorrhoid.

• Women: Do not collect your stool during a menstrual period.

For a few days before the test, you may have to make some changes in your medicines or diet.

MedicinesStarting 7 days before you begin collecting your stool and until you are done collecting your stool samples, do not take ibuprofen (Advil, Motrin) or similar pain medicines. Do not take more than one aspirin per day. You do not have to stop taking acetaminophen (Tylenol), if that is a medicine that you usually take.

DietStarting 2 days before you begin collecting your stool and until you are done collecting your stool samples, do not eat meat unless it is well -done. Do not eat horseradish, cantaloupe, turnips, broccoli, cauliflower, radishes, or parsnips. Do not eat blood pudding or blood sausage.

Instructions for Collecting 3 Stool Samples:

1. Write the date you collected the stool oneach card.

2. Before the test, take out all toilet bowlcleaners and flush the toilet two

times so only plain water is there.

3. Collect the stool:a. Allow the stool to fall into the

water as usual.b. Use a stick from the kit to collect a

small sample of stool.c. On one stool

card, put avery small amount of stool as a thin smear in the box labeled “A.”

d. Take another very small amount from a different part of the stool and smear it in the box labeled “B.”

e. Let the card dry and close the front flap.

f. Do not let the card get wet.

4. Do the same for your next 2 bowel movements.

Stool Test for Colon Screening

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Before collecting your stool, please read the following:

• You will collect stool samples from 3 bowel movements.

• Do not collect your stool if you have a bleeding hemorrhoid.

• Women: Do not collect your stool during a menstrual period.

For a few days before the test, you may have to make some changes in your medicines or diet.

MedicinesStarting 7 days before you begin collecting your stool and until you are done collecting your stool samples, do not take ibuprofen (Advil, Motrin) or similar pain medicines. Do not take more than one aspirin per day. You do not have to stop taking acetaminophen (Tylenol), if that is a medicine that you usually take.

DietStarting 2 days before you begin collecting your stool and until you are done collecting your stool samples, do not eat meat unless it is well -done. Do not eat horseradish, cantaloupe, turnips, broccoli, cauliflower, radishes, or parsnips. Do not eat blood pudding or blood sausage.

Instructions for Collecting 3 Stool Samples:

1. Write the date you collected the stool oneach card.

2. Before the test, take out all toilet bowlcleaners and flush the toilet two

times so only plain water is there.

3. Collect the stool:a. Allow the stool to fall into the

water as usual.b. Use a stick from the kit to collect a

small sample of stool.c. On one stool

card, put avery small amount of stool as a thin smear in the box labeled “A.”

d. Take another very small amount from a different part of the stool and smear it in the box labeled “B.”

e. Let the card dry and close the front flap.

f. Do not let the card get wet.

4. Do the same for your next 2 bowel movements.

Stool Test for Colon Screening

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e

大腸癌檢查 : 糞便檢查1. 在每張收集 ?上記下?收集糞便的日期(Date).

2. 收集糞便之前﹐取出馬桶內的清潔劑﹐並沖洗馬桶兩次﹐直至裡面只有清水，沒有清潔劑 .

3. 收集糞便的步驟 ﹕a. 讓糞便像往常一樣掉入水b. 使用信封內的小木棒，來收集小量的大便樣本.

c. 將小量糞便抹在標有“A”的地方.

d. 在糞便 ?一個位置上，取小量糞便，抹在“B”的地方.

e. 待收集 ?乾後﹐再關上前蓋f. 不要將收集 ?弄濕.

4. 按照同樣的步驟，收集 ?外兩次的糞便.

收集糞便之前﹐請閱讀以下提示﹕

需要收集三次大便樣本.如果有痔瘡出血症狀﹐請 要收集大便. 女士們﹕ 不要在月經期間集大便.

在檢查前幾天﹐您可能要在飲食或藥物上作些改變.藥物方面﹕從收集大便前七天開始﹐直到大便樣本收集結束期間﹐不要服用布洛芬類的止痛藥如Advil﹐Motrin。一天內不要服用超過一片阿司匹林。但如果?一直有服用醋 ?? (Tylenol) ﹐ 則無需要停止.

飲食方面 ﹕

從收集大便前兩天開始﹐直到大便樣本收集結束期間﹐不要吃未完全煮熟的紅肉。不要吃山葵﹐哈蜜瓜﹐白蘿蔔，西蘭花﹐椰菜花﹐小蘿蔔或防風草。亦不要吃豬紅或用豬血做成的香腸..

收集三次糞便的指示﹕

AB

AB

Dat

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ate

大腸癌檢查 : 糞便檢查

1. 在每張收集 ?上記下?收集糞便的日期(Date).

2. 收集糞便之前﹐取出馬桶內的清潔劑﹐並沖洗馬桶兩次﹐直至裡面只有清水，沒有清潔劑 .

3. 收集糞便的步驟 ﹕a. 讓糞便像往常一樣掉入水b. 使用信封內的小木棒，來收集小量的大便樣本.

c. 將小量糞便抹在標有“A”的地方.

d. 在糞便 ?一個位置上，取小量糞便，抹在“B”的地方.

e. 待收集 ?乾後﹐再關上前蓋f. 不要將收集 ?弄濕.

4. 按照同樣的步驟，收集 ?外兩次的糞便.

收集糞便之前﹐請閱讀以下提示﹕

需要收集三次大便樣本.如果有痔瘡出血症狀﹐請 要收集大便. 女士們﹕ 不要在月經期間集大便.

在檢查前幾天﹐您可能要在飲食或藥物上作些改變.藥物方面﹕從收集大便前七天開始﹐直到大便樣本收集結束期間﹐不要服用布洛芬類的止痛藥如Advil﹐Motrin。一天內不要服用超過一片阿司匹林。但如果?一直有服用醋 ?? (Tylenol) ﹐ 則無需要停止.

飲食方面 ﹕

從收集大便前兩天開始﹐直到大便樣本收集結束期間﹐不要吃未完全煮熟的紅肉。不要吃山葵﹐哈蜜瓜﹐白蘿蔔，西蘭花﹐椰菜花﹐小蘿蔔或防風草。亦不要吃豬紅或用豬血做成的香腸..

收集三次糞便的指示﹕

Slide courtesy of Albert Yu and Mike Potter

Designed at Request of CPHC Staff with Patient Input

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 Medicaid

HEDIS 2007 Commercial

*

* 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, UCSFMedical Director, Adult Medical Center, SFGH

achen@ medsfgh.ucsf.edu