Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital

Slide Presentation from the AHRQ 2009 Annual Conference

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On September 15, 2009, Alice Hm Chen, MD, MPH made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (6.7 MB) (Plugin Software Help).

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Slide 1

Improving Preventive Health Care Success Stories: USPSTF and ePSS
at San Francisco General Hospital

AHRQ 2009 Conference
Alice Hm Chen, MD, MPH

 

Slide 2

SFGH Acknowledgements

• Lisa Johnson, Medical Director for Quality Improvement Programs, Community Primary Care
• Fred Strauss, IS/Provider Liaison
• Winnie Tse, Analyst, Community Primary Care
• Flu-FOBT Project: Michael Potter, Professor of Clinical Family and Community Medicine and Albert Yu, Medical Director of Chinatown Public Health Center

 

Slide 3

Outline

• Background
• SFGH delivery system and EMR
• Case study: colorectal cancer screening
• Case study: breast cancer screening

 

Slide 4

Why focus on preventive care?

• Only 10% of female Medicare beneficiaries received all of 5 recommended preventive care measures (cervical, breast and colorectal cancer screening;  pneumovax and influenza vaccines).
• Significant disparities in receipt of preventive care services among racial/ethnic groups and poor.

General Accounting Office congressional testimony on 3/23/02, available at: www.gao.gov/cgi-bin/getrpt?GAO-02-777T.

 

Slide 5

Barriers to Screening in the Safety Net

• Financial barriers (lack of insurance, co-pays)
• System resource constraints, e.g.
  • Lack of ability to offer screening colonoscopies
  • Difficulty hiring mammographers
• Literacy, language, and cultural barriers
• Conflicting guidelines for PCPs
• 7.4 hours/day to provide all USPSTF “A” and “B” services

Yarnell KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: Is there enough time for prevention? American Journal of Public Health 2003; 635-641.

 

Slide 6

Whose guidelines should we be following, anyways?

• Proliferation of guidelines
• “Eminence” based versus evidence based
• Internal versus external
  • Ability to tailor to resources
  • Time consuming to develop
  • Need for ongoing updates

 

Slide 7

SFGH Approach

• Agreement on evidence-based guidelines (USPSTF), tailored to our system's resource constraints
• Harnessing information technology
  • Electronic medical record
  • AHRQ Electronic Preventive Services Selector (ePSS)
  • Patient registries
• Systems interventions
  • Standing orders
  • Panel management
  • Culturally and linguistically appropriate outreach

 

Slide 8

San Francisco Safety Net

Comprehensive Specialty Services Full-time Academic UCSF Faculty & Trainees
> 500,000 ambulatory visits annually 29% specialty care, 20% diagnostics.

 

Slide 9

Screenshot of Clinical Alerts page.

 

Slide 10

Screenshot of the Female Health Maintenance Screen.

 

Slide 11

Screenshot of the Treatment and Referral Guidelines.

 

Slide 12

Screenshot of the Health Maintenance screen.

 

Slide 13

Screenshot of the Health Maintenance screen continued.

 

Slide 14

Screenshot of the Health Maintenance screen continued.

 

Slide 15

Screenshot of the Browse Topic screen.

 

Slide 16

Screenshot of the Search for Recommendation screen.

 

Slide 17

Colorectal Cancer Screening "Success"

• Practice based on USPSTF guidelines, tailored to system resource constraints (no screening colonoscopy)

• SF DPH recommends annual home FOBT, with diagnostic colonoscopy for abnormals

• Systems intervention: Flu-FOBT program

• Culturally and linguistically appropriate outreach

 

Slide 18

Screenshot of search result of colorectal cancer screening.

 

Slide 19

Screenshot of Screening for Colorectal Cancer screen.

 

Slide 20

Screenshot of the Colon Cancer Screening and Surveillance Guidelines.

 

Slide 21

Flu-FOBT Program

• Strategy: offer FOBT in combination with flu shots

• Initial pilot results
  • Flu only: 52.9% à57.3% eligible completed FOBT
  • Flu + FOBT: 54.5% à 84.3% eligible completed FOBT
  • Difference of 25.4 points, p<0.001
    
    Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh J. Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates. Annals of Family Medicine 2009; 7:17-23.

• SF DPH program at Chinatown Public Health Center  led by Mike Potter and Albert Yu, funded by CDC Slide courtesy of Albert Yu and Mike Potter

 

Slide 22

Outreach Materials

Images of outreach materials in english and other language.

Slide courtesy of Albert Yu and Mike Potter

 

Slide 23

Designed at Request of CPHC Staff with Patient Input

Image of approved and non approved items.

Slide courtesy of Albert Yu and Mike Potter

 

Slide 24

CPHC Preliminary Results

Efficacy among 50-80 year olds who came in for primary care visit during flu shot season

	Got Flu Shot (n=1286)	Didn't Get Flu Shot (n=588)
Up to date 9-29-08	51.2%	60.2%
Up to date 3-31-09	75.2%	64.8%
Change	+25.0%	+4.6%

Slide courtesy of Albert Yu and Mike Potter

Slide 25

SF DPH Screening Rates

Graph showing percentages of patients aged 51-75 with completed colorectal cancer screening.

 

Slide 26

Breast Cancer Screening Challenges

• Primary care quality improvement committee uses USPSTF guidelines, but specialty society (radiology) recommendations different

• Difficulties hiring mammographers had led to significant wait times for both screening and diagnostic mammograms

• Conflicting information given to patients

• Low mammography rates due to CBE requirement

 

Slide 27

Search results for Breast Cancer Screening.

 

Slide 28

Screening for Breast Cancer screen.

 

Slide 29

CHN Guideline for Use of Mammography in Breast Cancer Screening screen.

 

Slide 30

Mammogram Referral screen.

 

Slide 31

Scanned image of a letter issued indicating the person had not had a mammogram in more than 1 year.

 

Slide 32

Breast Imaging Request Form, highlighting the date of last clinical breast exam.

 

Slide 33

SF DPH Mamography Rates

Graph showing the percentage of women ages 42-69 who have had a mammogram in the past 2 years. Excluding data "not indicated" but does not give credit for "declined."

 

Slide 34

Conclusions

• USPSTF guideline process (rigorous, evidence-based, ongoing) critical to reliability and credibility.

• AHRQ ePSS enables easy access to updated USPSTF guidelines, especially with linkages EMR.

• Challenges remain with systems barriers that can only be addressed on an institutional level.

 

Slide 35

Questions?

Alice Hm Chen, MD, MPH
Assistant Professor of Medicine, UCSF
Medical Director, Adult Medical Center, SFGH
achen@ medsfgh.ucsf.edu

Current as of December 2009

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Internet Citation:

Improving Preventive Health Care Success Stories: USPSTF and ePSS at San Francisco General Hospital. Slide Presentation from the AHRQ 2009 Annual Conference (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualconf09/chen.htm

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