Delivery Of Preventive Care Services Research Articles

A Parent Coach-Led Model of Well-Child Care for Young Children in Low-Income Communities: Protocol for a Cluster Randomized Controlled Trial.

BackgroundThe Parent-focused Redesign for Encounters, Newborns to Toddlers (PARENT) intervention was created as a team-based approach to well-child care (WCC) that relies on a health educator (Parent Coach) to provide the bulk of WCC services, address specific needs faced by families in low-income communities, and decrease reliance on the clinician as the primary provider of WCC services.ObjectiveThis study aims to evaluate the impact of PARENT using a cluster randomized controlled trial.MethodsThis study tested the effectiveness of PARENT at 10 clinical sites in 2 federally qualified health centers in Tacoma, Washington, and Los Angeles, California. We conducted a cluster randomized controlled trial that included 916 families with children aged ≤12 months at the time of the baseline survey. Parents will be followed up at 6 and 12 months after enrollment. The Parent Coach, the main element of PARENT, provides anticipatory guidance, psychosocial screening and referral, developmental and behavioral surveillance, screening, and guidance at each WCC visit. The coach is supported by parent-focused previsit screening and visit prioritization, a brief, problem-focused clinician encounter for a physical examination and any concerns that require a clinician’s attention, and an automated text message parent reminder and education service for periodic, age-specific messages to reinforce key health-related information recommended by Bright Futures national guidelines. We will examine parent-reported quality of care (receipt of nationally recommended WCC services, family-centeredness of care, and parental experiences of care), and health care use (WCC, urgent care, emergency department, and hospitalizations), conduct a cost analysis, and conduct a separate time-motion study of clinician time allocation to assess efficiency. We will also collect data on exploratory measures of parent-and parenting-focused outcomes. Our primary outcomes were receipt of anticipatory guidance and emergency department use.ResultsParticipant recruitment began in March 2019. After recruitment, 6- and 12-month follow-up surveys will be completed. As of August 30, 2021, we enrolled a total of 916 participants.ConclusionsThis large pragmatic trial of PARENT in partnership with federally qualified health centers will assess its utility as an evidence-based and financially sustainable model for the delivery of preventive care services to children in low-income communities.Trial RegistrationClinicalTrials.gov: NCT03797898; https://clinicaltrials.gov/ct2/show/NCT03797898International Registered Report Identifier (IRRID)DERR1-10.2196/27054

Estimated impact of COVID-19 on preventive care service delivery: an observational cohort study

BackgroundCOVID-19 has caused significant healthcare service disruptions. Surgical backlogs have been estimated but not for other healthcare services. This study aims to estimate the backlog of preventive care services caused by COVID-19.MethodsThis observational study assessed preventive care screening rates at three primary care clinics in Ottawa, Ontario from March to November 2020 using data from 22,685 electronic medical records. The change in cervical cancer, colorectal cancer, and type 2 diabetes screening rates were crudely estimated using 2016 census data, estimating the volume of key services delayed by COVID-19 across Ontario and Canada.ResultsThe mean percentage of patients appropriately screened for cervical cancer decreased by 7.5% (− 0.3% to − 14.7%; 95% CI), colorectal cancer decreased by 8.1% (− 0.3% to − 15.8%; 95% CI), and type 2 diabetes decreased by 4.5% (− 0.2% to − 8.7%; 95% CI). Crude estimates imply 288,000 cervical cancer (11,000 to 565,000; 95% CI), 326,000 colorectal cancer (13,000 to 638,000; 95% CI), and 274,000 type 2 diabetes screenings (13,000 to 535,000; 95% CI) may be overdue in Ontario. Nationally the deficits may be tripled these numbers. Re-opening measures have not reversed these trends.InterpretationCOVID-19 decreased the delivery of preventive care services, which may cause delayed diagnoses, increased mortality, and increased health care costs. Virtual care and reopening measures have not restored the provision of preventive care services. Electronic medical record data could be leveraged to improve screening via panel management. Additional, system-wide primary care and laboratory capacity will be needed to restore pre-COVID-19 screening rates.

Information Engineering and Workflow Design in a Clinical Decision Support System for Colorectal Cancer Screening in Iran.

Colorectal cancer is a major cause of morbidity and mortality throughout the world. Colorectal cancer screening is an optimal way for reducing of morbidity and mortality and a clinical decision support system (CDSS) plays an important role in predicting success of screening processes. DSS is a computer-based information system that improves the delivery of preventive care services. The aim of this article was to detail engineering of information requirements and work flow design of CDSS for a colorectal cancer screening program. In the first stage a screening minimum data set was determined. Developed and developing countries were analyzed for identifying this data set. Then information deficiencies and gaps were determined by check list. The second stage was a qualitative survey with a semi-structured interview as the study tool. A total of 15 users and stakeholders' perspectives about workflow of CDSS were studied. Finally workflow of DSS of control program was designed by standard clinical practice guidelines and perspectives. Screening minimum data set of national colorectal cancer screening program was defined in five sections, including colonoscopy data set, surgery, pathology, genetics and pedigree data set. Deficiencies and information gaps were analyzed. Then we designed a work process standard of screening. Finally workflow of DSS and entry stage were determined. A CDSS facilitates complex decision making for screening and has key roles in designing optimal interactions between colonoscopy, pathology and laboratory departments. Also workflow analysis is useful to identify data reconciliation strategies to address documentation gaps. Following recommendations of CDSS should improve quality of colorectal cancer screening.

Trends and Characteristics of Preventive Care Visits among Commercially Insured Adolescents, 2003-2010

To examine preventive care visit patterns among commercially insured adolescents during 2003-2010. In 2005-2007, the Advisory Committee on Immunization Practices (ACIP) recommended 3 vaccines targeted at adolescents. We also investigate the relationship between preventive care visits and immunization. Data were drawn from the MarketScan database. Adolescents aged 11-21 continuously enrolled in the same insurance plan during the calendar year were included. We calculated the annual proportion of adolescents with at least 1 preventive and 1 vaccination-related visit. Longitudinal analyses were conducted by following the 1992 birth cohort for 8 consecutive years. The proportion of adolescents making at least 1 preventive visit increased from 24.6%-41.1% during 2003-2010. The rate of vaccination-related visits increased from 12.9%-26.3%. The magnitude of the increase in preventive and vaccination-related visits was greater during the years in which ACIP issued recommendations. The rates of preventive and vaccination-related visits were considerably higher among female and early adolescents and adolescents in managed care plans. Longitudinal analyses indicated that only 2.4% of adolescents had an annual preventive visit during the 8 years. Yearly improvements in preventive care visits by adolescents were substantial. ACIP recommendations may be associated with this improvement. However, ongoing efforts are needed to improve the use and delivery of preventive care services.

Capsule Commentary on Yoong et al., A Cross-sectional Study Examining Australian General Practitioners’ Identification of Overweight and Obese Patients

Globally, the prevalence of obesity and overweight has reached epidemic proportions, leading to substantial morbidity/mortality and becoming a significant public health issue.1 Primary care physicians and general practitioners are well positioned to make a difference in the battle against obesity through early recognition and intervention in the at-risk patient population. This study by Yoong et al.,2 conducted in several practice sites in urban Australian cities, examined the accuracy of general practitioners (GPs) in identifying overweight and obese patients using as reference self-reported weight and height by patients. Yoong et al. also looked into GPs and patient characteristics associated with non-detection of overweight and obesity. They found GPs’ estimation of overweight and obesity to be 7 % and 8 % lower, respectively, than estimates based on patients’ self-report; the sensitivity of GP assessment was only 63 %, whereas specificity was 89 %. College-educated, male, non-diabetic, normotensive patients had higher odds of non-detection. There was no significant GP characteristic identified. The authors cited factors that may account for these observations, and recommended that strategies to help GPs improve identification of obese and overweight be initiated. The subjects in this study electronically entered height and weight from which body mass index (BMI) was calculated, but the GPs had no access to this data; instead, they were asked to complete a hard copy questionnaire answering “Yes or “No” to a list of patient’s health risk conditions, such as alcohol consumption, obesity, smoking, and overweight. This was done to minimize reporting bias if GPs were only queried on obesity and overweight. Yet, having data such as BMI available to primary care providers (PCPs) and GPs through electronic clinical support tools and reminders may be effective strategies that can improve clinician recognition and early intervention. Their use has been shown to improve practitioner outcomes in chronic disease management and delivery of preventive care services.3–5 Tapping into new information and communication technologies can help busy practitioners stay ahead in the race to decrease the burden of chronic diseases that obesity exemplifies. What impact providers can have on reducing or preventing obesity or what interventions are effective remain unknown and should be the focus of future research.

The patient centered medical home. A systematic review.

The patient-centered medical home (PCMH) describes mechanisms for organizing primary care to provide high quality care across the full range of individuals' health care needs.It is being widely implemented by provider organizations and third party payers. To describe approaches for PCMH implementation and summarize evidence for effects on patient and staff experiences,process of care, and clinical and economic outcomes. PubMed (through 6 December 2011), Cumulative Index to Nursing & Allied Health Literature, and the Cochrane Database of Systematic Reviews (through 29 June 2012). English-language trials and longitudinal observational studies that met criteria for the PCMH, as defined by the Agency for Healthcare Research and Quality, and included populations with multiple conditions. Information on study design, populations, interventions,comparators, financial models, implementation methods,outcomes, and risk of bias were abstracted by 1 investigator and verified by another. In 19 comparative studies, PCMH interventions had a small positive effect on patient experiences and small to moderate positive effects on the delivery of preventive care services(moderate strength of evidence). Staff experiences were also improved by a small to moderate degree (low strength of evidence).Evidence suggested a reduction in emergency department visits(risk ratio [RR], 0.81 [95% CI, 0.67 to 0.98]) but not in hospital admissions (RR, 0.96 [CI, 0.84 to 1.10]) in older adults (low strength of evidence). There was no evidence for overall cost savings. Systematic review is challenging because of a lack of consistent definitions and nomenclature for PCMH. The PCMH holds promise for improving the experiences of patients and staff and potentially for improving care processes,but current evidence is insufficient to determine effects on clinical and most economic outcomes

Early identification and preventive care for elevated cardiovascular disease risk within a remote Australian Aboriginal primary health care service

BackgroundCardiovascular disease (CVD) is the single greatest contributor to the gap in life expectancy between Indigenous and non-Indigenous Australians. Our objective is to determine if holistic CVD risk assessment, introduced as part of the new Aboriginal and Torres Strait Islander Adult Health Check (AHC), results in better identification of elevated CVD risk, improved delivery of preventive care for CVD and improvements in the CVD risk profile for Aboriginal adults in a remote community.MethodsInterrupted time series study over six years in a remote primary health care (PHC) service involving Aboriginal adults identified with elevated CVD risk (N = 64). Several process and outcome measures were audited at 6 monthly intervals for three years prior to the AHC (the intervention) and three years following: (i) the proportion of guideline scheduled CVD preventive care services delivered, (ii) mean CVD medications prescribed and dispensed, (iii) mean PHC consultations, (iv) changes in participants' CVD risk factors and estimated absolute CVD risk and (v) mean number of CVD events and iatrogenic events.ResultsTwenty-five percent of AHC participants were identified as having elevated CVD risk. Of these, 84% had not been previously identified during routine care. Following the intervention, there were significant improvements in the recorded delivery of preventive care services for CVD (30% to 53%), and prescription of CVD related medications (28% to 89%) (P < 0.001). Amongst participants there was a 20% relative reduction in estimated absolute CVD risk (P = 0.004) following the intervention. However, there were no significant changes in the mean number of PHC consultations or mean number of CVD events or iatrogenic events.ConclusionsHolistic CVD risk assessment during an AHC can lead to better and earlier identification of elevated CVD risk, improvement in the recorded delivery of preventive care services for CVD, intensification of treatment for CVD, and improvements in participants' CVD risk profile. Further research is required on strategies to reorient and restructure PHC services to the care of chronic illness for Aboriginal peoples in remote areas for there to be substantial progress in decreasing excess CVD related mortality.

Practice-based continuing education combined with process improvement methods improves delivery of preventive services to children

Question Does continuing medical education in combination with process improvement methods to implement office systems, increase rates of delivery of preventive care to children? Study design Cluster randomised controlled trial. Main results Significantly more children enrolled in intervention practices received all four preventive services compared with control practices after 30 months (change in proportion of children receiving all four preventive services: 7% to 34% with intervention vs 9% to 10% with no intervention; 4.6-fold increase with intervention compared with control, 95% CI 1.6 to 13.2, see Table 1). Table 1 Mean percentage of children receiving preventive services at baseline and 30 months follow up. Baseline At 30 months follow-up Significance Preventive service Intervention 22 practices (%) Control 22 practices (%) Intervention 22 practices (%) Control 22 practices (%) Ratio of change in prevalence, intervention v control All 4 services 11 12 34 10 4.6, 95 CI 1.6 to 13.2 Immunisations 66 64 Data presented graphically, no absolute numbers given No significant difference between groups Tuberculosis screening 39 36 54 32 p<0.05 Anaemia screening 65 64 79 71 p<0.05 Lead screening 32 29 68 30 p<0.05 Authors’ conclusions Practice-based continuing medical education in combination with process improvement methods increases the rate of delivery of preventive care services to children.

Feasibility of a Tailored Intervention to Improve Preventive Care Use in Women

Background. Women age 50 years and older are in need of multiple preventive health care services. Despite recent improvements in rates of delivery of preventive care services, especially within managed care organizations, substantial numbers of women are still being underscreened. Efforts to improve delivery of preventive care services have often focused on one outstanding service despite the fact that patients often are in need of many services.Methods. A total of 893 women age 50 to 55 years were mailed a self-administered survey to identify outstanding preventive health care service needs. Patients in need of three or more outstanding preventive health care services were identified from survey respondents to participate in a feasibility study evaluating a tailored, customized intervention called Tic Tac Health.Results. Five-hundred ninety-one women returned the survey (67%). Four-hundred forty-eight (76%) women were in need of one or more preventive health services; 92 (16%) were in need of three or more. Twenty-two patients (24%) completed the Tic Tac Health card. The women who completed the card were similar to those who did not.Conclusions. Despite documented physician visits, presence of managed care health insurance, and a designated primary care provider, a significant number of women are still in need of multiple preventive health services. An intervention targeting multiple preventive health services was demonstrated to be both feasible and effective. Further evaluation via a randomized controlled trial should be conducted to determine if an intervention like Tic Tac Health would be an effective modality for improving rates of receipt of multiple preventive health care services.

Audit and feedback versus alternative strategies: effects on professional practice and health care outcomes.

Audit and feedback has been identified as having the potential to change the practice of health care professionals. To assess the effects of audit and feedback compared with other interventions in changing health professional practice and to assess whether the effectiveness of audit and feedback can be improved by modifying how it is done. We searched MEDLINE up to June 1997, the Research and Development Resource Base in Continuing Medical Education, and reference lists of related systematic reviews and articles. Randomised trials of audit and feedback (defined as any summary of clinical performance of health care over a specified period of time) compared with other interventions. The participants were health care providers responsible for patient care. Two reviewers independently extracted data and assessed study quality. Twelve studies were included involving more than 2194 physicians. Seven trials with direct comparisons were included. The targeted behaviours were the management of low haemoglobin, the delivery of preventive care services (two studies), the management of high cholesterol, the performance of cervical smears, and the ordering of diagnostic tests (two studies). From the results of four trials, there is little evidence of a measurable effect of adding a complementary intervention such as a local consensus process to audit and feedback compared to audit and feedback alone. Two of three trials that compared audit and feedback to reminders reported that reminders were more effective in improving the delivery of some preventive services. It is not possible to recommend a complementary intervention to enhance the effectiveness of audit and feedback. Reminders might be more effective than audit and feedback to improve the delivery of some preventive services but the results are not striking. Few trials have investigated the effect of varying different characteristics of the audit and feedback process. Consideration should be given to testing the effects of modifying important characteristics such as the content, source, timing, recipient and format.