ACS Volunteer Appreciation Presentation

From “Bench to Bedlam” Translating Research into Primary Care

Scott M. Strayer, MD, MPHAssociate Professor of Family Medicine and Public Health SciencesUniversity of Virginia, Dept. of Family Medicine, School of Public HealthCenter for Information Mastery

“The message is simple: deliver evidence-based clinical preventive services to help keep people healthy and save lives.”

“Yet, research shows that even the most effective and accepted preventive services are not delivered regularly in the primary care setting.”

Preventive Service Delivery• Pneumococcal disease

− 10 to 14,000 deaths in 1997− Only 43% aged 65 and > received Pneumovax

(U.S. Department of Health and Human Services, 2000)

• Tobacco, alcohol, diet, exercise– 38% total deaths in 1990– Preventable morbidity– Health habit counseling < 10%

(Stange, KC etal. Preventive Medicine 2000; 31:167-176.)

• Colorectal Cancer Screening- <50% of patients are screened as recommended

Some facts• ¾ of population visit physician > 1 yearly• > 25% outpt visits to FP• Repeat visits & multiple opportunities• Belief in importance of prevention• Physicians over-estimate delivery of

preventive services• Actual performance less than desired

1000 people

800 have symptoms

327 consider seeking medical care

217 visit a physician’s office113 visit primary care physician’s office

65 visit CAM provider

21 visit a hospital outpatient clinic

14 receive home health care

13 visit an emergency department

8 are in a hospital

<1 is in an academic health center hospital

Green et al, NEJM 2001; 344: 2021-24.

New Ecology of Medical Care - 2000

Barriers• Physicians

– Competing demands– Conflicting recommendations– Lack of training

• Patients– Lack of knowledge– Fear of discomfort– Cost

• Office– Poor reimbursement– Lack of systems

USPSTF Recommendations• Screening

– BP, Pap, Mammo, CBE, Ht, Wt, Lipids, FOBT, Flex sig, Etoh abuse, Rubella, Vision, Hearing

• Counseling– Tobacco, Exercise, Seat belts, Helmets, Etoh

abuse, DUI, Diet, Calcium, STD, Contraception, Fire safety, Guns, Dental care, Falls, Hot water heater

• Immunizations– Td, Rubella, Pneumovax, Influenza

• Chemoprophylaxis– MVI, Folate, HRT discussion

Is there enough time for prevention?• Patient panel of 2500• Age and sex distribution similar to US pop.• To fully satisfy the USPSTF recs, it would

take 1067 hours per year or 4.4 hours per working day of a physician’s time

• If you include children and pregnant women: 1621 hours per year / 6.8 hours per day

Prioritizing clinical preventive services

• Clinically preventable burden (CPB)– Disease and injury prevented by CPS if

delivered 100% at recommended intervals– Reflects both burden of disease and

effectiveness of service– Quality adjusted life years saved (QALYs)– Time frame for 1-year birth cohort– Patient adherence (often estimated)– Designed to capture CPS total value

Cost effectiveness

• Net cost of CPS / QALYs saved

• Net cost of CPS = costs of prevention – costs averted

• For 13 of 30 CPS CE studies available

• 1995 dollars

• Panel on Cost Effectiveness in Health and Medicine

• USPSTF

Priorities among recommended clinical preventive services

Services CPB CE Total

Childhood vaccinations 5 5 10

Adult tobacco cessation counseling * 5 4 9

Vision screening > 65 yrs * 4 5 9

Pap test, sexually active > 18 yrs 5 3 8

Colorectal cancer screening > 50 yrs * 5 3 8

Newborn metabolic screen 3 5 8

Hypertension screening 5 3 8

Influenza vaccine > 65 yrs 4 4 8

Lipid screening; men 35-65; women 45-65

5 2 7

Pneumovax >65 yrs * 2 5 7

Services CPB CE Total

Assess /counsel adolescents on alcohol/drugs*

3 5 8 *

Adolescent tobacco cessation counseling *

4 4 8 *

Chlamydia screening women 15-24 yrs *

3 4 7 *

Problem drinking screening / counseling *

4 3 7 *

Breast cancer screening 50 – 69 yrs 4 2 6

Rubella screening/vaccination in women

1 1 2

Td boosters universal 1 1 2

Priorities among recommended clinical preventive services

Coffield AB, Maciosek MV, etal. Am J Prev Med 2001;21(1):1-9.

Prioritizing clinical preventive services

• Attempt to provide relative values• Top ranking services with low delivery

rates may be higher priority• Tailor to local realities• Does not account for resources needed to

increase delivery rates• Focus on high CPB ?• How to define the “greatest good” ?• Individual in the context of a population

What do patients actually want?• Advice / counseling

• Personalized plan

• Scheduling additional appt for follow-up

• Referrals to experts (e.g. nutritionist)

• Informational materials (e.g. brochures)

• Telephone or email follow-up

Massett HA, Wolff LS. Barriers and opportunities to promoting prevention in the primary care setting. Presented September 12, 2003. RWJF P4H Annual Meeting.

How well do physicians address smoking cessation?

– Smoking cessation only occurs at 23 to 46% of primary care visits

– Only 35% of physicians assist with smoking cessation attempts

– Less than 10% arrange follow-up for smoking patients

•Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by physicians. JAMA 1998; 279:604-608

•Lewis CE, Clancy C, Leake B, Schwartz JS. The counseling practices of internists. Ann Intern Med 1991; 114:54-58.

•Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking cessation counseling practices. Prev Med 1998; 27:720-729.

What We Know…

Leveraging 1 Minute for Prevention1 minute is the realistic average amount

of time that primary care providers can

devote to prevention during a typical

office visit

Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The power of leveraging to fulfill the promise of health behavior counseling. Am J Prev Med, 2002; 22:320-323.

Opportunities for Intervention

• Most people visit a primary care doctor about three times per year.

• Even 2-3 minute interventions are effective, especially when followed up with telephone, e-mail, nurse calls, referrals, 1-800 numbers, etc.

• Many primary care providers provide 2-3 minute health promotion/behavior interventions at every outpatient visit.

Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The power of leveraging to fulfill the promise of health behavior counseling. Am J Prev Med, 2002; 22:320-323.

Behavioral Change Theories

• 5 A’s

• Stages of Change----assess patient’s readiness to change and then deliver stage-appropriate interventions

• Motivational Interviewing---a non-confrontational technique for helping patients change their health behavior

Integrating the Behavioral Theories

• Ask• Advise

• Assess

• Assist

• Arrange

Not Stage-dependent

Use Motivational Interviewing

Stages of ChangeMotivational Interviewing

Smoking and BMI asVital signs

Stage-based interventionsMotivational Interviewing

Local and nationalresources

Development of the MLIT

• Operationalize the Stages of Change

• Identify stage based interventions

• Scripted motivational interviewing

• Risk calculators

• Pharmacotherapy info

• Local and national resources

• Modular design

What we found with seasoned clinicians• More likely to advise patients to stop smoking

(p = 0.049)

• Increased overall use of the "5 A's" during patient encounters for both smoking cessation (p = 0.031)

• Increased general counseling behaviors – frequency of counseling, provision of behavior

specific information, and use of pharmacotherapy and referrals for smoking cessation (p = 0.047)

More results

• Improved self-efficacy in counseling patients regarding smoking cessation (p = 0.006)

• Increased comfort in providing follow-up to help patients sustain their efforts at smoking cessation (p = 0.042)

ACS Volunteer Appreciation Presentation

QuitAdvisorMDPDA-based clinical assessment and

smoking cessation tool

Content Development

• Adapted from Public Health Service Guidelines (Fiore et al 2000), Stages of Change (Prochaska and Diclemente) and Motivational Interviewing (Miller and Rollnick) for use at the Point-of-Care

• Iterative, collaborative process between UVa & Silverchair

• Much consideration of “scripting” versus “guiding”

• Result: 1) Algorithm and 2) Clinician’s Reference

Technology Development

• Silverchair’s staff adapted our platforms to create an IT Ecosystem:

Server

Database

QuitAdvisorMD PDA

Download Software & Updates

Send Log DataCheck for Updates

Distribution Website Usage Reports

Technology Development

Technology Development

Technology Development

Product Demonstration

• Simulated Patient Encounter

• Point-of-Care Assessmentand Interview

Usability Testing

5 physician volunteers each in a 45-minute observed session

• Self-familiarization with the prototype, simulated patient interview, performance of three directed tasks, exit questions and solicited user feedback

• Resulted in 2 navigation modifications (Global Nav, preparation script), 1 content change (Action script)

Stages of Change Assessment• Stage of Change process used by all

– All evaluated smoking history before stages of change– Accessed and used by 3 of 4 physicians without help– 2 used tool immediately; 2 initiated on own first

• Future improvements based on observations:– MAXIMIZE USE OF STAGE OF CHANGE TOOL

• Add smoking history script to engage physicians immediately• Increase prominence of the Stage of Change Tool

– EMPHASIZE PRECISE WORDING AND FOLLOW-UP • Encourage precise use of script wording• Add follow-up questions about confidence to fully engage patient

– RECOMMEND SUMMARY STATEMENTS • Strengthen the use of summary statements/reflection for connecting with patient,

demonstrating empathy, and guiding process.

Motivational Interviewing• All participants used approach and scripts for at least a

portion of the interview• Participants in some cases reverted to paraphrasing

(sometimes incorrectly) and own scripts. – Non-tool scripts were often too directive or jumped stages

• Future improvements based on observations:– USE PROMPTS TO AID TRANSITIONS

• Assist physicians when transitioning between conversations (including integration of more summary and reflective statements)

– FACILITATE EASY PROGRESSION• Add links to other question alternatives and links to ease appropriate

progression to other stages (especially preparation) • Provide further guidance for closing remarks

Use of QuitAdvisorMD

• Approaches to using the tool in practice– All physicians would review tool before using clinically– Most imagine reviewing the tool prior to each clinical visit– Many describe using the tool as a guide during the visit– Some physicians would introduce the tool to patients

• Importance of training – All physicians noted the need for training and practice for

use of the tool at the point of care. – Many difficulties in first use observations would likely be

avoided once physicians were more familiar with the tool.

Feasibility Testing

• 6 week ‘in practice’ trial of QuitAdvisorMD– Pre and Post Knowledge Assessment– Mid-study feedback

• Added a patient role-play for physicians with limited use of tool clinically at study mid-point

– Satisfaction and Feedback assessed post study

– 7 physicians enrolled

Feasibility Testing

• Usage data:– Total Syncs: 19– Total Sessions: 42– Average Syncs/User: 3.2– Average Sessions/Sync: 2.1– Average Sessions/User: 7– Average Pages per Session: 8.3

Feasibility Results

• Our primary indicators for success were– >50% of physician users would be

satisfied or mostly satisfied with the tool, and

– >50% would use the prototype if modified according to suggestions

• 5/5 of physicians who responded were satisfied or mostly satisfied with the tool.

• 100% of physicians stated they would use the tool if modified according to feedback

Challenges & Barriers• Content Development – guide or script?

– Iterative development among content group– Usability Testing– Further Examination Possible

• IRB Approval – Human subject exception– Caused Project Delays (3 months)

• Prototype Technology – log data capture– Revised server based code

• Enrollment levels – VaPSRN physicians sensitized– Widened study to additional UVa departments and area practices

• Usage Levels– Conducted Midpoint “role play” training

Phase II Research Directions1. Extend the tool’s capability to run on additional hardware

platforms (e.g., smart phones, laptops, PC’s, Tablet PC’s, and PDAs); upgrade data logging and capture

2. Enable QuitAdvisorMD to accept updates that are “pushed” out automatically through Internet connectivity, ensuring that the user has access to the most up to date guidelines and resources at all times

3. Link to tailored patient support materials to help extend the intervention’s effect past the initial interview

4. Integrate CME and Reimbursement Capture to foster usage

5. Evaluate the efficacy and acceptance of the revised QuitAdvisorMD prototype in a large, randomized, controlled study comparing QuitAdvisorMD to usual care