Delivery Of Clinical Preventive Services Research Articles

The Role of Chiropractic Care in Providing Health Promotion and Clinical Preventive Services for Adult Patients with Musculoskeletal Pain: A Clinical Practice Guideline.

Objective: To develop evidence-based recommendations on best practices for delivery of clinical preventive services by chiropractors and to offer practical resources to empower provider applications in practice. Design: Clinical practice guideline based on evidence-based recommendations of a panel of practitioners and experts on clinical preventive services. Methods: Synthesizing the results of a literature search for relevant clinical practice guidelines and systematic reviews, a multidisciplinary steering committee with training and experience in health promotion, clinical prevention, and/or evidence-based chiropractic practice drafted a set of recommendations. A Delphi panel of experienced practitioners and faculty, primarily but not exclusively chiropractors, rated the recommendations by using the formal consensus methodology established by the RAND Corporation/University of California. Results: The Delphi consensus process was conducted during January-February 2021. The 65-member Delphi panel reached a high level of consensus on appropriate application of clinical preventive services for screening and health promotion counseling within the chiropractic scope of practice. Interprofessional collaboration for the successful delivery of clinical preventive services was emphasized. Recommendations were made on primary, secondary, tertiary, and quaternary prevention of musculoskeletal pain. Conclusions: Application of this guideline in chiropractic practice may facilitate consistent and appropriate use of screening and preventive services and foster interprofessional collaboration to promote clinical preventive services and contribute to improved public health.

Understanding the Value of the Wellness Visit: A Descriptive Study

Clinical preventive services can reduce mortality and morbidity, but Americans receive only half of the recommended care. Although wellness visits protect time for clinicians to review needs and discuss care with patients, studies have not shown that having a wellness visit improves health outcomes. This study seeks to understand the types of discussions and volume of care delivered during wellness visits. Using a sample of 1,008 patients scheduled for a wellness visit from 22 primary care clinicians across 3 states from 2018 to 2019, electronic health records were reviewed, and a subset of visits was audio recorded. The discussion and delivery of clinical preventive services, as recommended by the U.S. Preventive Services Task Force, were measured, and new diagnoses were identified from the clinical preventive services. Analyses were completed in 2020. Even though patients were up to date with 80% of the recommended clinical preventive services 3 months after the visit, only 0.5% of patients were up to date with all the recommended clinical preventive services. On average, 6.9 clinical preventive service discussions occurred during each wellness visit on the basis of electronic health records review, and 7.7 clinical preventive services discussions occurred on the basis of audio recordings. An average of 0.4 new diagnoses was identified, including cancer diagnoses, cardiovascular risks, and infections. Wellness visits are an important time for patients and clinicians to discuss prevention strategies and to deliver recommended clinical preventive services, leading to the identification of previously unrecognized diagnoses. This will improve patients' health. Policies and incentives that promote wellness visits are important, and efforts are needed to deliver them to those most in need.

Confidentiality Discussions and Private Time With a Health-Care Provider for Youth, United States, 2016

PurposeThe objective of the study was to define factors associated with adolescent and young adult (AYA) experiences with private time and having discussed confidentiality and the impact of these experiences on improving delivery of clinical preventive services. MethodsIn 2016, a nationally representative sample of 1,918 US AYAs (13- to 26-year-olds) was surveyed. Survey questionnaire domains were based on prior research and Fishers' information-motivation-behavior skills conceptual model. Data were weighted to represent US households with AYA and analyzed to identify factors independently associated with ever experiencing private time and discussions of confidentiality with a regular health-care provider (HCP). We examined the association of these experiences on AYA attitudes about health care. ResultsFifty-five percent of female and 49% of male AYA reported ever having had private time with an HCP and 55% of female and 44% of male AYA had spoken to an HCP about confidentiality. Independent predictors of having experienced private time and confidentiality included older age, race, higher household income, gender of the provider, amount of years with the provider, and involvement in risk behaviors. AYA who had experienced private time and confidentiality discussions had more positive attitudes about their providers, were more willing and comfortable discussing sensitive topics, and thought that these discussions should happen at younger ages. ConclusionsAlthough confidentiality and private time are important to AYA, many are not experiencing these components of care. Providing private time and discussions of confidentiality can improve the delivery of health care for young people by enhancing positive youth attitudes about preventive care.

Public Health Investment in Team Care: Increasing Access to Clinical Preventive Services in Los Angeles County

As part of federal and local efforts to increase access to high quality, clinical preventive services (CPS) in underserved populations, the Los Angeles County Department of Public Health (DPH) partnered with six local health system and community organization partners to promote the use of team care for CPS delivery. Although these partners were at different stages of organizational capacity, post-program review suggests that each organization advanced team care in their clinical or community environments, potentially affecting >250,000 client visits per year. Despite existing infrastructure and DPH’s funding support of CPS integration, partner efforts faced several challenges. They included lack of sustainable funding for prevention services; limited access to community resources that support disease prevention; and difficulties in changing health-care provider behavior. Although team care can serve as a catalyst or vehicle for delivering CPS, downstream sustainability of this model of practice requires further state and national policy changes that prioritize prevention. Public health is well positioned to facilitate these policy discussions and to assist health system and community organizations in strengthening CPS integration.

State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors, and Promote School Health.

The National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention funds a program to boost progress in reducing the prevalence and incidence of multiple chronic diseases and their associated risk factors. This article describes the program, State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors, and Promote School Health, and the program’s action model, design, and administration and management structure. This program is based on 4 domains of public health action: 1) epidemiology and surveillance, 2) environmental approaches, 3) health care system interventions, and 4) community programs linked to clinical services. The 4 domains of public health action leverage data to inform action, support healthy choices and behaviors, strengthen delivery of clinical preventive services, and help Americans better manage their health.

Contents Analysis of Clinical Preventive Services Delivery in the Out-Patient Clinic of the Department of Family Medicine

Contents Analysis of Clinical Preventive Services Delivery in the Out-Patient Clinic of the Department of Family Medicine

Quality measure performance in small practices before and after electronic health record adoption.

Introduction:To date, little research has been published on the impact that the transition from paper-based record keeping to the use of electronic health records (EHR) has on performance on clinical quality measures. This study examines whether small, independent medical practices improved in their performance on nine clinical quality measures soon after adopting EHRs.Methods:Data abstracted by manual review of paper and electronic charts for 6,007 patients across 35 small, primary care practices were used to calculate rates of nine clinical quality measures two years before and up to two years after EHR adoption.Results:For seven measures, population-level performance rates did not change before EHR adoption. Rates of antithrombotic therapy and smoking status recorded increased soon after EHR adoption; increases in blood pressure control occurred later. Rates of hemoglobin A1c testing, BMI recorded, and cholesterol testing decreased before rebounding; smoking cessation intervention, hemoglobin A1c control and cholesterol control did not significantly change.Discussion:The effect of EHR adoption on performance on clinical quality measures is mixed. To improve performance, practices may need to develop new workflows and adapt to different documentation methods after EHR adoption.Conclusions:In the short term, EHRs may facilitate documentation of information needed for improving the delivery of clinical preventive services. Policies and incentive programs intended to drive improvement should include in their timelines consideration of the complexity of clinical tasks and documentation needed to capture performance on measures when developing timelines, and should also include assistance with workflow redesign to fully integrate EHRs into medical practice.

Clinical and community delivery systems for preventive care: an integration framework.

Although clinical preventive services (CPS)-screening tests, immunizations, health behavior counseling, and preventive medications-can save lives, Americans receive only half of recommended services. This "prevention gap," if closed, could substantially reduce morbidity and mortality. Opportunities to improve delivery of CPS exist in both clinical and community settings, but these activities are rarely coordinated across these settings, resulting in inefficiencies and attenuated benefits. Through a literature review, semi-structured interviews with 50 national experts, field observations of 53 successful programs, and a national stakeholder meeting, a framework to fully integrate CPS delivery across clinical and community care delivery systems was developed. The framework identifies the necessary participants, their role in care delivery, and the infrastructure, support, and policies necessary to ensure success. Essential stakeholders in integration include clinicians; community members and organizations; spanning personnel and infrastructure; national, state, and local leadership; and funders and purchasers. Spanning personnel and infrastructure are essential to bring clinicians and communities together and to help patients navigate across care settings. The specifics of clinical-community integrations vary depending on the services addressed and the local context. Although broad establishment of effective clinical-community integrations will require substantial changes, existing clinical and community models provide an important starting point. The key policies and elements of the framework are often already in place or easily identified. The larger challenge is for stakeholders to recognize how integration serves their mutual interests and how it can be financed and sustained over time.

Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems.

IntroductionStudies showing sustained improvements in the delivery of clinical preventive services are limited. Fewer studies demonstrate sustained improvements among independent practices that are not affiliated with hospitals or integrated health systems. This study examines the continued improvement in clinical quality measures for a group of independent primary care practices using electronic health records (EHRs) and receiving technical support from a local public health agency.MethodsWe analyzed clinical quality measure performance data from a cohort of primary care practices that implemented an EHR at least 3 months before October 2009, the study baseline. We assessed trends for 4 key quality measures: antithrombotic therapy, blood pressure control, smoking cessation intervention, and hemoglobin A1c (HbA1c) testing based on monthly summary data transmitted by the practices.ResultsOf the 151 practices, 140 were small practices and 11 were community health centers; average time using an EHR was 13.7 months at baseline. From October 2009 through October 2011, average rates increased for antithrombotic therapy (from 58.4% to 74.8%), blood pressure control (from 55.3% to 64.1%), HbA1c testing (from 46.4% to 57.7%), and smoking cessation intervention (from 29.3% to 46.2%). All improvements were significant.ConclusionDuring 2 years, practices showed significant improvement in the delivery of several key clinical preventive services after implementing EHRs and receiving support services from a public health agency.

Developing an integrated strategy to reduce ethnic and racial disparities in the delivery of clinical preventive services for older Americans.

To determine the optimum strategy for increasing up-to-date (UTD) levels in older Americans, while reducing disparities between White, Black, and Hispanic adults, aged 65 years and older. Data were analyzed from the 2008 Behavioral Risk Factor Surveillance System, quantifying the proportion of older Americans UTD with influenza and pneumococcal vaccinations, mammograms, Papanicolaou tests, and colorectal cancer screening. A comparison of projected changes in UTD levels and disparities was ascertained by numerically accounting for UTD adults lacking 1 or more clinical preventive services (CPS). Analyses were performed by gender and race/ethnicity. Expanded provision of specific vaccinations and screenings each increased UTD levels. When those needing only vaccinations were immunized, there was a projected decrease in racial/ethnic disparities in UTD levels (2.3%-12.2%). When those needing only colorectal cancer screening, mammography, or Papanicolaou test were screened, there was an increase in UTD disparities (1.6%-4.5%). A primary care and public health focus on adult immunizations, in addition to other CPS, offers an effective strategy to reduce disparities while improving UTD levels.

Preventive Health Services Delivery to South Asians in the United States

There is limited information on the health status of South Asians. Our objective was to examine the delivery of clinical preventive services to South Asian adults. We used data from a 2001 mail survey to a nationwide sample of South Asians. We quantified the percentage of eligible adults who received screenings for colorectal cancer, cervical cancer, breast cancer, high blood pressure, lipid disorders, and vaccinations against influenza, pneumococcus, and tetanus. We also calculated the number of individuals who were up-to-date with all their recommended preventive healthcare. One-fourth of South Asians were up-to-date with their recommended preventive services, while more than half were not up-to-date with their services. Having a regular source of care was significantly associated with being up-to-date on recommended schedules. Despite their high level of education, the majority of South Asians in the US are not receiving the appropriate amount of preventive health services.

Health Information Systems in Small Practices: Improving the Delivery of Clinical Preventive Services

Despite strong evidence that clinical preventive services (CPS) reduce morbidity and mortality, CPS performance has not improved in adult primary care. In addition to implementing electronic health records (EHRs), key factors for improving CPS include providing actionable information at the point of care, technical support staff, and quality-improvement assistance. These resources are not typically available in small practices. Estimate the impact on CPS delivery after a software upgrade to embed a clinical decision support system and practice-level quality-improvement support services. Practices were recruited from the Primary Care Information Project, a citywide initiative assisting practices adopt health information technology. Data were collected in 2009 and 2010, and analyses were conducted in 2010 and 2011. Across two time periods, receipt of CPS was calculated for 56 practices. Period 1 measured CPS delivery 2-37 months following implementation of an EHR. Period 2 measured CPS delivery within the first 6 months after an EHR software upgrade. Substantial increases in the delivery of selected CPS were observed after the EHR software upgrades. Blood pressure control for patients with hypertension increased from 46.0% to 54.8%. Breast cancer screening, recorded BMI, and HbA1c testing for patients with diabetes also increased. More than half of the practices increased their patients' blood pressure control, recorded BMI, breast cancer screening, and HbA1c screening by ≥5 percentage points. Delivery of CPS can increase in small primary care practices that implement an EHR that includes comprehensive quality-improvement support.

An Evaluation of the Delivery of Clinical Preventive Services in the Joint Task Force National Capital Region Medical

The Walter Reed Army Institute of Research General Preventive Medicine Residency conducted a performance improvement study to evaluate clinical preventive services (CPSs) in the National Capital Region. This study focused on enhancing medical care through quality management of both the process and measurement of service delivery, thereby improving the overall quality of a service by examining its constituent parts. Screening mammography and pneumococcal immunization were the CPSs selected for evaluation, and 9 of 40 military treatment facilities (MTFs) were visited. Mammography completion ranged from 64% to 81%. The process of providing mammography to eligible enrollees varied greatly among MTFs, and the majority did not utilize all identified steps deemed critical for mammography completion. Pneumococcal immunization ranged from 0% to 21%. There was a positive correlation between CPS completion, the number of eligible enrollees, and the use of critical steps. Recommendations include using critical steps to evaluate and improve MTFs' CPS processes.

Does Receiving Clinical Preventive Services Vary across Different Types of Primary Healthcare Organizations? Evidence from a Population-Based Survey

To measure the association between primary healthcare (PHC) organizational types and patient coverage for clinical preventive services (CPS). Study conducted in Quebec (2005), including a population-based survey of patients' experience of care (N=4,417) and a survey of PHC clinics. Patient-reported CPS delivery rates and CPS coverage scores. Multiple logistic regressions used to assess factors associated with higher probability of receiving CPS. CPS delivery rates were higher among patients with a regular source of PHC. Higher CPS score was associated with having a public (OR 1.79; 95% CI 1.35-2.37) or mixed (OR 1.22; 95% CI 1.01-1.48) type of organization as source of PHC compared to a private one, and having had a high number of visits to the regular source of PHC in the past two years (≤6: OR 1.83; 95% CI 1.41-2.38) compared to a single visit. Public and mixed PHC organizations seem to perform better. CPS delivery is strongly associated with having a regular source of care.

The quality of preventive health care delivered to adults: results from a cross-sectional study in Southern Italy

BackgroundIt is assumed that providing clinical preventive services to patients can identify or detect early important causes of adult mortality. The aim of this study was to quantify access to preventive services in Southern Italy and to assess whether and how the provision of preventive care was influenced by any specific characteristics of patients.MethodsIn a cross-sectional study adults aged 18 years and over attending primary care physician (PCP) offices located in Southern Italy were interviewed from June through December 2007. Quality indicators of preventive health care developed from RAND's Quality Assessment Tools and Behavioral Risk Factor Surveillance System (BRFSS) were used. Multivariate analysis was performed to identify and to assess the role of patients' characteristics on delivery of clinical preventive services.ResultsA total of 1467 subjects participated in the study. Excepting blood pressure preventive check (delivered to 64.4% of eligible subjects) and influenza vaccination (recommended to 90.2% of elderly), the rates of delivery of clinical preventive services were low across all measures, particularly for screening and counseling on health habits. Rates for providing cancer screening tests at recommended times were 21.3% for colonoscopy, 51.5% for mammography and 52.4% for Pap smear. Statistical analysis showed clear disparities in the provision of clinical preventive services associated with age, gender, education level, perceived health status, current health conditions and primary care access measures.ConclusionsThere is overwhelming need to develop and implement effective interventions to improve delivery of routine clinical preventive services.

Advancing Aspirin Utilization: A Review of Clinical and Systems-Based Interventions

Underuse of clinical preventive services (CPS) such as low-dose aspirin therapy leads to tens of thousands of preventable deaths per year. The authors examined the current literature related to delivery of CPS and then provided the results to a preventive medicine expert panel who identified best practices to improve aspirin counseling and use. An exploratory literature search was conducted in PubMed using keywords associated with preventive health interventions. The review included articles published between January 2000 and March 2009. More than 200 articles were identified for review, and 35 met inclusion criteria. Interventions that increased patient-provider contact and physician interactive educational programs were most likely to improve delivery of CPS. The expert panel recommended a prevention systems cascade of reinforcing strategies and tools to maximize appropriate aspirin use. This model emphasizes important interrelationships of clinical practice settings and how they affect aspirin use.

Patient outcomes at 26 months in the patient-centered medical home National Demonstration Project.

The purpose of this study was to evaluate patient outcomes in the National Demonstration Project (NDP) of practices' transition to patient-centered medical homes (PCMHs). In 2006, a total of 36 family practices were randomized to facilitated or self-directed intervention groups. Progress toward the PCMH was measured by independent assessments of how many of 39 predominantly technological NDP model components the practices adopted. We evaluated 2 types of patient outcomes with repeated cross-sectional surveys and medical record audits at baseline, 9 months, and 26 months: patient-rated outcomes and condition-specific quality of care outcomes. Patient-rated outcomes included core primary care attributes, patient empowerment, general health status, and satisfaction with the service relationship. Condition-specific outcomes were measures of the quality of care from the Ambulatory Care Quality Alliance (ACQA) Starter Set and measures of delivery of clinical preventive services and chronic disease care. Practices adopted substantial numbers of NDP components over 26 months. Facilitated practices adopted more new components on average than self-directed practices (10.7 components vs 7.7 components, P=.005). ACQA scores improved over time in both groups (by 8.3% in the facilitated group and by 9.1% in the self-directed group, P <.0001) as did chronic care scores (by 5.2% in the facilitated group and by 5.0% in the self-directed group, P=.002), with no significant differences between groups. There were no improvements in patient-rated outcomes. Adoption of PCMH components was associated with improved access (standardized beta [Sbeta]=0.32, P = .04) and better prevention scores (Sbeta=0.42, P=.001), ACQA scores (Sbeta=0.45, P = .007), and chronic care scores (Sbeta=0.25, P =.08). After slightly more than 2 years, implementation of PCMH components, whether by facilitation or practice self-direction, was associated with small improvements in condition-specific quality of care but not patient experience. PCMH models that call for practice change without altering the broader delivery system may not achieve their intended results, at least in the short term.

Improving the Delivery of Preventive Services to Medicare Beneficiaries

CENTRAL TO US CONGRESSIONAL AND ADMINISTRAtion efforts to reform health care is a renewed focus on “investment in prevention and wellness.” Translating that commitment to investing in preventive care into improved health will require a strategy for separating effective prevention from that which is ineffective or even harmful, and aligning payment strategies with practices supported by the best evidence. However, existing federal and private insurance coverage does not adequately support the delivery of clinical preventive services associated with improved quality of life and reduced premature mortality. Medicare is both the largest US payer for adult health services and the standard by which many other payers model their coverage. It is thus a logical place to effect optimal coverage for preventive services. In this Commentary, we propose 3 steps by which Medicare could expand preventive care: by expanding preventive coverage, adopting payment reform to pay for the coordination of preventive care, and passing legislation allowing the Centers for Medicare & Medicaid Services (CMS) to discontinue coverage of nonbeneficial and potentially harmful preventive services.

Adolescent Immunizations and Other Clinical Preventive Services: A Needle and a Hook?

Advances in technology have led to development of new vaccines for adolescents, but these vaccines will be added to a crowded schedule of recommended adolescent clinical preventive services. We reviewed adolescent clinical preventive health care guidelines and patterns of adolescent clinical preventive service delivery and assessed how new adolescent vaccines might affect health care visits and the delivery of other clinical preventive services. Our analysis suggests that new adolescent immunization recommendations are likely to improve adolescent health, both as a "needle" and a "hook." As a needle, the immunization will enhance an adolescent's health by preventing vaccine-preventable diseases during adolescence and adulthood. It also will likely be a hook to bring adolescents (and their parents) into the clinic for adolescent health care visits, during which other clinical preventive services can be provided. We also speculate that new adolescent immunization recommendations might increase the proportion and quality of other clinical preventive services delivered during health care visits. The factor most likely to diminish the positive influence of immunizations on delivery of other clinical preventive services is the additional visit time required for vaccine counseling and administration. Immunizations may "crowd out" delivery of other clinical preventive services during visits or reduce the quality of the clinical preventive service delivery. Complementary strategies to mitigate these effects might include prioritizing clinical preventive services with a strong evidence base for effectiveness, spreading clinical preventive services out over several visits, and withholding selected clinical preventive services during a visit if the prevention activity is effectively covered at the community level. Studies are needed to evaluate the effect of new immunizations on adolescent preventive health care visits, delivery of clinical preventive services, and health outcomes.

Improving Delivery of Clinical Preventive Services: A Multi-Year Journey

Adults in the United States typically do not receive all recommended clinical preventive services (CPS) for which they are eligible, missing opportunities for prevention and/or early detection. A multi-year quality improvement initiative targeting CPS delivery in a fee-for-service ambulatory care network is described. Since 1999, HealthTexas Provider Network (HTPN) has implemented multiple initiatives to increase CPS delivery, including a flowsheet, a physician champion model, physician- and practice-level audit and feedback, and rapid-cycle quality improvement training. From 2000 to 2006, "recommended or done" CPS delivery increased from 68% to 92%, and "done" from 70% to 86% (2001 to 2006). "Perfect care" composite performance increased from 0.19 to 0.51 (2001 to 2006). Long-term, multistrategy approaches can achieve substantial sustained improvement in CPS delivery throughout a large ambulatory care provider network.