Put Prevention Into Practice
http://www.ahrq.gov/clinic/ppipix.htm

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. For example, although pneumococcal disease caused 10,000 - 14,000 deaths in 1997, only 43 percent of persons aged 65 and older received a pneumococcal vaccine (U.S. Department of Health and Human Services, 2000).

Barriers to making preventive services a routine part of patient care exist among clinicians, patients, and within the clinical setting. Clinicians report they do not have enough time to provide these services because most of their time is spent responding to patients' need for treatment (Frame, 1992; Kottke et al., 1993). Clinicians also cite competing demands, uncertainty about conflicting recommendations, and lack of training in prevention as barriers to providing clinical preventive services (Jaén et al., 1994).

Patients often do not ask their health care providers about preventive services because they are unaware of the benefits or availability of these services, are not motivated to seek them out, are deterred by what they perceive as the inconvenience and expense of preventive care (which their health plans may not routinely cover), and are worried about the discomfort they think preventive care may entail. In the clinical setting, barriers to providing preventive services include inadequate reimbursement for these services, patient mobility, and the lack of a system for integrating preventive services into regular patient care (Frame, 1992; Kottke et al., 1993; Stange, 1996; McPhee et al., 1989; Jaén et al., 1994; Solberg et al., 1997; Stange et al., 1998).

There is increasing evidence that many of these barriers can be overcome through a formal system for delivering clinical preventive services (Kottke et al. 1993). The Agency for Healthcare Research and Quality's (AHRQ's) Put Prevention Into Practice (PPIP) program presents such a system in this publication, A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach. The Guide describes easy-to-follow, logical steps to take you through the process. It is designed to be used by various audiences—physicians, nurses, health educators, and office staff—in public health clinics, community health centers, private practices, and other settings.

Effectiveness of Systems for Delivering Clinical Preventive Services

What Is a System?

A system is a process that integrates staff roles, responsibilities, and tools for the routine delivery of preventive care. In a system, individual responsibilities are defined, the flow of activities is specified, and performance is measured. A system must have an "owner" or champion: someone who will take responsibility for its implementation and monitoring (Frame, 2000).

Evidence That Systems Work

Several studies provide evidence that implementing a formal system for delivering preventive services increases their delivery in the clinical setting.

The effect of implementing a system to deliver preventive services on the delivery rates of specific services was evaluated in two community health centers and three family practice residency programs at five Texas sites between September 1993 and February 1994 (Gottlieb et al., 2001). The new system included pre-auditing charts with reminder notices, using communication flow sheets, having patients use personal health guides for education and record keeping, and having clinicians use the Clinician's Handbook of Preventive Services (see Chapter 6) to establish a preventive care protocol. With this system, 372 charts were selected for pre-auditing at baseline and 376 charts were selected for auditing 33-39 months after the new system was implemented.

Compared with baseline:

• Documentation of timely cholesterol screening increased from 70 to 84 percent.
• Smoking assessment increased from 56 to 80 percent.
• Up-to-date Pap smears increased from 70 to 81 percent.
• Yearly mammograms for women aged 51 and older increased from 30 to 48 percent.

Documented tetanus-diphtheria vaccinations increased from 19 to 59 percent. For adults aged 66 and older, documentation of pneumococcal vaccination increased from 22 to 48 percent and influenza vaccination increased from 45 to 49 percent (not statistically significant).

Another study found statistically significant improvement in the documentation of patient education (assessment of risk plus appropriate counseling) delivered in five areas between 1994 and 1997 (Smith, unpublished data, 1994-97). Specifically, documented delivery of:

• Tobacco education increased from 43 to 67 percent.
• Nutrition education increased from 9.4 to 41 percent.
• Physical activity education increased from 9.4 to 44 percent.
• Sexually transmitted disease/human immunodeficiency virus (STD/HIV) education increased from 5.3 to 51.6 percent.
• Alcohol use education increased from 46 to 72.6 percent.

Kottke et al. (1992) tested a clinic-wide teamwork approach to delivering preventive services in 10 clinics at 29 sites in Minnesota. Responsibility was spread among staff for identifying smokers, assessing their smoking habits, advising them to quit, negotiating action, and providing follow-up counseling. Of the 466 patients reporting from these sites, 40.5 percent said that they had been counseled about smoking, compared with 26.4 percent of the 507 patients at the sites that did not deliver preventive care.

The Physician-Based Assessment and Counseling for Exercise (PACE) program was implemented to improve the rate and quality of counseling for physical activity in the primary care setting. In a controlled trial conducted in 17 physician practices, sedentary patients who received 3-5 minutes of counseling about physical activity plus a booster telephone call 2 weeks later demonstrated significantly higher rates of increased physical activity than those who were not counseled (Calfas et al., 1996). Investigators observed that in offices where this counseling was delivered consistently, forms were kept in convenient places, office staff had clear responsibilities for handing out PACE forms, and completed protocols were consistently found in charts.

Other studies have demonstrated that implementing a systems approach to delivering clinical preventive services is effective in increasing the rates of delivery of cancer screening (Carney et al., 1992; Kohatsu et al., 1994) and general disease prevention services (Dietrich et al., 1994a, 1994b) in the clinical setting.

The components of such a delivery system have been used and are documented in several studies (Frame, 2000; Carney et al., 1992; Dickey and Kamerow, 1994; Crabtree et al., 1998), the Texas adaptation of PPIP (Goodson et al., 1999; Goodson, in press; Smith, 1999; Gottlieb et al., 2001), and business literature (Mink et al., 1991, 1993; Senge, 1990; Wheatley, 1994; Argyris, 1990). There is scientific evidence to support the effectiveness of using certain tools in a system to deliver preventive services—such as preventive care flow sheets (Prislin et al., 1986) and reminder notes on patient charts (Chang et al., 1995; Cohen et al., 1989; Briss et al., 2000), standing orders (Briss et al., 2000), assessment and feedback to providers (Briss et al., 2000), and patient reminders, including telephone calls, letters, or postcards (Briss et al., 2000). The steps described in this Guide are based on empirical evidence.