# Presentation: 159459

## Using evidence to inform and improve clinical prevention

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

## Presenters

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

## 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*

## 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

## 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

## 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

## 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

## 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)

**Notes:**
Presenter: Kathryn

## Who Ensures Prevention?

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

## 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.

**Notes:**
Speaker: Kathryn

## 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.**

**Notes:**
Kathryn

## The Purchaser’s Guide

**Notes:**
Presenter: Kathryn

## 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

**Notes:**
Speaker: Kathryn

## Part 1: 

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

**Notes:**
Speaker: Richard

## Rethinking Current Approaches

**80% of**
**Costs**

**Stem from **
**preventable **
**chronic conditions**

**75% of**
**costs**

**20% of**
**claimants**

**Primary cost drivers are chronic disease and serious acute conditions; many are preventable.**

**Notes:**
Presenter: Richard

## Rethinking Current Approaches

- Source:  CDC
- *All data are adjusted to 2005 U.S. population

- Percent of all deaths

**Causes of Death**
**in the United States**
**Most Common, 1999***

## Rethinking Current Approaches

**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.

- 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%

**Notes:**
Presenter: Richard

## 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. 

- 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.

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

**Notes:**
Presenter: Richard

## 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).

**Notes:**
Richard

## Part 2: 

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

## 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?

- 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?

- Summary Plan Description (SPD) Language

**Notes:**
Presenter: Kathryn

## Slide 22

**Notes:**
Presenter: Kathryn

## 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

**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

**Notes:**
Presenter: Kathryn

## 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

**Notes:**
Speaker: Kathryn

## Current Procedural Terminology (CPT) Codes

**Notes:**
Presenter: Kathryn

## Part 3:

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

## 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?

**Notes:**
Presenter: Richard

## 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*

**Notes:**
Presenter: Tricia

## 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)

**Notes:**
Tricia

## 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

**Notes:**
Presenter: Kathryn

## 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

**Notes:**
Presenter: Kathryn

## Slide 32

**Notes:**
Presenter: Kathryn

## The Problem

**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

## Uses of the Guide

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

## 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

## 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

## 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

## 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

**Notes:**
Again the task force (read above)
next

## 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*

**Notes:**
Presenter: Tricia

## 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.**

## 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](http://www.epss.ahrq.gov/)__ _

**Notes:**
Now I would like to talk to you about some of the resources that we provide for our different audiences. 

As Sec Leavitt mentioned in his key note address, today we released the electronic Preventive Services Selector tool. The ePSS is a quick hands-on tool designed to help primary care clinicians identify the screening, counseling, and preventive medication services that are appropriate for their patients. It is based on current recommendations of the U.S. Preventive Services Task Force and can be searched by specific patient characteristics, such as age, sex, and selected behavioral risk factors. The ePSS is available as a web-based tool and can also be downloaded to PDA devices. 

This tool can be accessed at www.epss.ahrq.gov. There is a bookmark in your bag with this web address on it. HOLD UP BOOKMARK. 

## Slide 42

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## Slide 46

**Notes:**
This is a screen shot of the PDA version of the tool as it would appear on a Pocket PC device. It can also be downloaded to Palm Devices. You can see that is has all of the same search capabilities as the web-based tool. 

## 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](http://www.preventiveservices.ahrq.gov/)_

## 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**

## 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

## 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

- _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

**Objectives**

**ON-TIME PREVENTION OF****        PRESSURE ULCERS IN NURSING HOMES**

## 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

## Long Term Care CPI ResultsOutcome: Develop Pressure Ulcer

**General**
** ****Assessment**

**Incontinence**
**Interventions**

**  ****Nutrition**
**Interventions**

**Staffing**
**Interventions**

**+ Age ******** 85**
**+ Male**
**+ Severity of Illness**
**+ History of PU**
**+ Dependency in **
**   ****>= 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 >=0 .5**
**- CNA hours per resident day >= 2.25**

**Medications**

**- SSRI + Antipsychotic**

**Horn et al, *****J. Amer Geriatric Soc***** March 2004; 52(3):359-367 **

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

## Common Challenges Across Facilities

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

## 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
**	**

## 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
**	**

## 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

## Slide 57

## Slide 58

## 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

## 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**

- _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
- >10% weight loss past 180 days
- Psychiatric medications received

**Example: Nutrition Report**

**Stratified by Risk**
**Provide ‘BIG picture’ over time, not just snapshot of one shift or one day**

## 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

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

**Example: Priority Report**

**Identifies residents at risk**

## 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

## 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

## 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

## Impact On Pressure Ulcer QMs

**Impact On Pressure Ulcer QMs**

- Source:  CMS Nursing Home Compare; Facility QM data reports

- 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

**Combined Facilities**

**National**** ****Norm**

**Q4 03 – Q3 05% Change =  - 33%**** **

## 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

## 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

## 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

## QUESTIONS?

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