IV. Findings (continued)

2.7. Barriers to the Adoption, Integration, and Delivery of the USPSTF Recommendations

Health plans faced a number of common barriers with regard to adopting, integrating, and delivering the USPSTF recommendations and recommendations for clinical preventive services, more generally. These challenges are not due to fundamental issues with the USPSTF recommendations, but rather the result of larger systems-level challenges that health plans face with respect to adopting and integrating clinical preventive services recommendations. To study these challenges and barriers, we asked respondents to draw upon their experiences with the USPSTF recommendations, specifically asking them three key questions:

• "What barriers do you face to adopting the Task Force recommendations at the systems-level?"
• "Are there fundamental issues with the recommendations themselves—such as the topics or populations that the recommendations address—that prevent adoption and implementation at your system?"
• "Are certain types of Task Force recommendations easier to adopt and integrate than others?"

Health plan staff provided a candid overview of the barriers that are unique to their plans, health care settings, and patient populations. Barriers cited ranged from provider time constraints and staffing challenges to issues related to the integration and delivery of specific Task Force recommendations. Many of these barriers were not unique to one particular health plan, but were recognized by respondents across plans. This section provides a global discussion of the key barriers cited by health plan respondents, supported by specific examples from the plans.

Time Constraints. Health plan providers and staff face significant time constraints which may impede the delivery of the Task Force recommendations. Clinical Advisors from the hybrid plan told us that time pressures are serious for clinicians that deliver clinical preventive services: "Just the sheer scope [of the recommendations]. It's a lot for any one individual in any one exam room to sift their way through." Another Clinical Advisor respondent commented that the Institute of Medicine reported that only half of the recommended CPS recommendations are presented to patients at any one time: "I think that [the IOM report findings are] very true because of the time pressures." A Clinical Advisor from the closed-panel plan indicated that "if you actually took the time to do all of the CPS with every patient and have all of the necessary conversations and address all of the concerns necessary, you would be working 18 hours a day."^f

A Medical Director for the governmental plan indicated that one of the greatest challenges is the time associated with delivering all of the necessary CPS recommendations to the plan's patient population. This respondent cited that providers for the governmental plan have to address 30 different points during each patient visit, which can be a daunting task, especially with only a limited amount of face-to-face time with patients. This respondent expressed frustration with the number of recommendations, questioning how providers would find the time necessary to deliver more clinical preventive services recommendations.

From a quality improvement perspective, one respondent from the governmental plan told us that there are too many recommendations, given the limited amount of time that a provider has with each patient. Another Director of Quality Improvement from the closed-panel plan indicated that providers have a "full plate and [CPS recommendations] are just one more thing for them to do." While periodically the Quality Improvement Department at the closed-panel plan does receive concerns from providers about the time constraints they face in light of CPS recommendations, the Director of Quality Improvement indicated that most clinicians "are willing to implement [CPS recommendations]" because it is the "right thing to do" for the plan's patients.

Patient Resistance. Patient resistance to preventive care services during routine medical appointments was described as a barrier. Respondents remarked that patients typically have their own agendas and priorities when they enter the exam room, and it is difficult to turn the discussion to preventive health. One Clinical Advisor from the hybrid plan told us that "[clinical preventive you're trying to work [the recommendations] into the 12 minutes that you have."

Another Clinical Advisor from the open-panel plan told us that, from a provider's perspective, it is difficult to deliver all of the necessary recommendations due to patient resistance. For example, the respondent recently recommended a screening for retinology to a patient and was met by extreme resistance. The patient had only made the appointment to have the clinician complete "missed work papers" for an extended absence related to a minor injury, and subsequently, was not interested in learning about any other necessary screenings. The same Clinical Advisor respondent also cited diabetic patients as a very difficult population to deliver CPS recommendations: "We have a lot of resistance, especially with diabetics, as people do not want to take more pills... It's difficult to overcome patient resistance."

A Director of Quality Improvement for the closed-panel plan also described that family members and friends can affect whether a patient receives the recommended clinical preventive services: "Influences within a patient's social circle—namely family and friends—can create or exacerbate patient resistance." On a similar note, another Director of Quality Improvement respondent from the closed-panel plan indicated that popular media has an impact on the perception of clinical preventive services. For example, the respondent told us that "many of the UPSTF recommendations are more conservative than the lay press believes people need. Colorectal cancer screening for example. Katie Couric is on the radio and posters telling people "you've got to go get your colonoscopy." But, there may be less invasive options available." Interestingly, health plan respondents consider outside influences from family, friends—and even the media—to be significant barriers to ensuring that people receive the recommended clinical preventive services.

Staff Availability. Limited staff availability to complete the recommended clinical preventive services is a barrier in some health plans. There are not enough staff members to deliver all of the recommendations. A Director of Quality Improvement respondent from the governmental plan remarked that prioritization of CPS recommendations is crucial because of the staffing issue. The respondent told us that health care workers are oversaturated with clinical preventive services recommendations, making it difficult to ensure that all of the necessary CPS are actually being delivered: "We never give any of the [CPS recommendations] the justice they deserve because we don't have the staffing resources, or people reach a saturation point because they can only take in so much." There was a common theme that health care workers are oversaturated with every new clinical preventive service recommendation, making it difficult to give each recommendation proper consideration. Staffing availability was less of a problem for other plans, such as the closed-panel plan. According to a Clinical Advisor for the closed-panel plan, the plan's EMR has ameliorated the problem of staff availability. Specifically, the Clinical Advisor indicated that: "The power of the EMR—as well as the patient lists that are easily queried by specific topics such as when every diabetic last had an eye exam—we have so many tools available that the resource issue is less of an issue."

Delivery of Counseling Recommendations. A unanimous theme across all of the plans was that counseling recommendations are more difficult to adopt and integrate than screening recommendations. This issue was raised in response to two different questions. First, we asked respondents: "What barriers do you face to adopting the Task Force recommendations at the systems-level." Then, later we asked: "Are certain types of Task Force recommendations easier to adopt and integrate than others? For example, are screening recommendations easier to adopt and integrate than counseling recommendations, or vice-versa?" Counseling recommendations were cited as highly difficult to measure and monitor from a quality improvement perspective and difficult to deliver from a clinical perspective.

Respondents suggested that counseling recommendations are more difficult to adopt and integrate (than screening recommendations) because there are inherent challenges related to measuring and monitoring data from counseling recommendations. One Director of Quality Improvement from the open-panel plan indicated that, unlike screening recommendations, counseling recommendations may not have a distinct unit of measurement to indicate whether or not the recommendation was completed. Overall, respondents indicated that it is more difficult to assess whether a counseling recommendation has been delivered because the measure is somewhat subjective. Many respondents made the comparison between implementing a screening or lab test (e.g., hemoglobin A1c test) and delivering tobacco cessation counseling, citing the latter as more difficult to measure and monitor than the former. A Clinical Advisor from the closed-panel plan further described that it is easier to track and measure a recommendation that can be translated into a metric: "If it's a talking thing [counseling recommendation], you can say [the recommendation] but how do you know you've done it? You've got to have a metric." Quality improvement staff from the hybrid plan said: "We're kind of data driven... So if it is a counseling session—and we cannot get the data—it's a moot point for us to push it."

Clinical Advisor respondents indicated that counseling recommendations are difficult to adopt and integrate because of challenges related to staffing and patient resistance. A Clinical Advisor respondent at the governmental plan told us that screening recommendations are easier to integrate than counseling recommendations because the former requires less staff than the latter: "Counseling means you have to have the staff. [There are] a lot of recommendations. We may not be implementing everything or monitoring everything."

A Director of Quality Improvement for the governmental plan indicated that patients are not interested in certain types of clinical preventive services, especially related to counseling, making some more difficult to deliver than others. On the same point, a Quality Improvement Staff member told us that at the governmental plan, some counseling recommendations must be conducted at every patient visit. One example the respondent provided was tobacco cessation counseling. The Quality Improvement Staff person indicated that tobacco cessation counseling is conducted for some patients upon every provider visit. "We were mandated to do some [counseling recommendations] at every visit, so you just do it. But [patients] get tired of it and say "I know, I know" or "you told me this yesterday," and it becomes a joke." As a result, over the long run, patients become more resistant to certain recommendations.

Overall, respondents remarked that counseling recommendations were highly challenging to deliver. A Clinical Advisor respondent from the hybrid plan ranked a variety of recommendations according to ease of adoption and integration, citing lab tests as easy to adopt and lifestyle changes as most difficult to adopt: "It is easiest to adopt a recommendation for a lab test, second would be a procedure, and third would be a lifestyle change. Lifestyle changes – such as counseling to reduce your BMI – are more difficult [to adopt]."

Barriers to Integration of Certain Types of USPSTF Recommendations. Respondents indicated that certain types of recommendations are easier to adopt and integrate than others. Specifically, recommendations that are not associated with specific measures are more difficult to integrate and monitor in the plan's EMR. For example, the closed-panel plan has some difficulty capturing certain recommendations for depression in its EMR. A Director of Quality Improvement at the closed-panel described that three follow-up provider visits (within one year) are required for patients on antidepressant medications. (While this is an NCQA requirement, the respondent may have thought this was also a Task Force recommendation). Typically at the health plan, patients have follow-up visits with the ordering practitioner or another medical professional such as a registered nurse or physician's assistant. However, the measure is only associated with one code, which does not distinguish whether a patient had a follow-up appointment with a registered nurse or the ordering practitioner. According to this respondent, the barrier is not screening recommendations or counseling recommendations. Rather, the problem lies with measurement: "It's how you are going to measure it that becomes more of a barrier."

From a different perspective, a Clinical Advisor at the hybrid health plan indicated that Task Force recommendations that can be delivered by non-physician members of the staff are easy to adopt—and highly desirable. Recently, the hybrid plan implemented a nurse-driven tobacco cessation program that puts basic decision support tools in front of the nurse and prompts him/her to do tobacco cessation counseling. The Clinical Advisor found this program to be useful because "it's simple, short, and one less thing for the doctor." The tobacco cessation program is the only program of its kind at the plan to integrate the help of nurses, specifically.

Availability of Clinical Preventive Services in the System. Respondents discussed that the availability of the clinical preventive services in practice settings is a barrier. A Director of Quality Improvement from the closed-panel plan indicated that certain Task Force recommendations are difficult to implement for a large patient population. Recommendations that require widespread screenings test a plan's internal capacity to deliver the recommendations, but also have implications for the larger clinical community: For example, the respondent told us that Abdominal Aortic Aneurysm (AAA) Screening is difficult to implement in a population of half a million members because "it overwhelms the system. Not only internally because we do our own radiology, but in the community if you start referring out. No one [in the community] is prepared to do that many ultrasounds. You need to make sure that there is enough access in the community to actually be able to deliver [the CPS recommendation]." According to this respondent, the challenges to adopting the recommendations do not lie with the recommendations themselves—but rather with the system's capacity to implement the recommendations.

Another respondent from the governmental plan commented on the colorectal cancer recommendation, citing that availability of screening tests can be an issue: "There are not enough endoscopies to do the number of colonoscopies necessary in the state if we recommended that for everyone over age 50. Specialist availability even in the [governmental plan] is a factor." A Clinical Advisor respondent from the plan indicated the system is stretched to its maximum capacity:

"Another issue that has been problematic at our facility is waits and delays for colonoscopy. Leaders have taken some drastic measures, including referrals to the private sector. The direct cause is patients coming to [the plan] for care and, for example, without ever having had a colonoscopy in their life though they are over 50. Fecal occult blood tests are done routinely, and we offer colonoscopy also, which further inundates our backlog."

According to a Director of Quality Improvement at the closed-panel plan, access to preventive services is an issue across the country. The respondent indicated that "for gastroenterology – colonoscopies – there is a national shortage, especially on the East Coast. People just don't have the availability to do these as recommended or indicated. It's more of a national thing, rather than just our region." Breast cancer screening was also mentioned as a clinical preventive service that is a challenge to deliver because of resource availability: "There's been some discussion about mammography. When do you stop doing mammography? Does an 80 year old woman need a mammography? What is the right thing to do? Because our resources are limited, what is the trade-off?"

Geographic Barriers to Care. Respondents from the hybrid plan discussed the barriers to clinical preventive services for the rural contingent of its patient population. A Director of Quality Improvement from the hybrid plan discussed that "we're in a rural area and access to care is one of our members' major issues." For patients living in the rural, outermost edges of the hybrid plan's service area, access to clinical preventive services is a serious barrier. Travel is required for many patients seeking specialized health care services. In some rural areas, immediate access to colonoscopies and mammograms is an issue as well. Quality improvement staff from the hybrid plan discussed that data collection for their rural population is a challenge: "If we have to collect data manually, we may have geographical challenges to go get data. We may drive three hours to get one chart. That is the nature of the beast I guess."

Information Technology Barriers. The Director of Quality Improvement for the hybrid plan indicated that "there are IT barriers" to delivering clinical preventive services. Namely, physicians would like to have regularly updated electronic lists of members who need clinical preventive services. However, regularly producing and distributing this information can be challenging because of IT-barriers. The respondent indicated that it is difficult for the plan to keep physicians up to date about their patients' current needs: "That's difficult to provide regularly because of all sorts of issues... claims-based information and having to wait for a claim to see if someone needs something or doesn't. There are always barriers as to whether physicians are up to date."

Process Barriers. Plans describe the process of adopting and integrating CPS recommendations as challenging. For the hybrid plan, controversy about recommendations from various organizations can make it difficult to seamlessly adopt and integrate clinical preventive services recommendations. One Quality Improvement staff member from the hybrid plan indicated that "the only time there is a barrier is if there is controversy between organizations, such as the American College of Obstetricians and Gynecologists compared to the Family Practice Association."

A few respondents raised the concern that the UPSTF recommendations are not always aligned with the recommendations from other organizations, creating more work for health plans during the process of adopting and integrating the recommendations. In cases where recommendations are not aligned across various organizations that the plan references, leadership at the health plan has a more difficult time deciding which recommendations to adopt and implement. Specifically, a Clinical Advisor respondent from the hybrid plan told us that the recommendations from the Task Force do not align directly with the recommendations from the American Academy of Family Physicians. As a result, gaining consensus across the health plan about which recommendations to adopt and implement is more challenging.

Lack of Local Control. A lack of local control over the recommendations was described as a key area of frustration for respondents in the governmental plan. According to a Clinical Advisor, control over the adoption of clinical preventive services remains at the plan's headquarters: "We're in a Federal system. The mandate has to come from [our headquarters] for us to implement [clinical preventive services recommendations]." As a result, staff at the regional-level of the governmental system have very little control over which recommendations are adopted and integrated.

Barriers Related to Delivery of Recommendations in Clinical Practice. Respondents expressed a number of barriers related to the delivery of recommendations in clinical practice. First, according to a Clinical Advisor at the closed-panel plan, physician shareholders have substantial autonomy over the delivery of CPS recommendations, creating additional barriers to delivery. Physicians with "shareholder" status become an elite part of the plan's medical group where they enjoy job security and additional benefits. One respondent disclosed that "the biggest problem at [the closed-panel plan] is with salaried physicians. You get paid for seeing your scheduled patients. If you have someone who says "I have 200 diabetic patients and I don't care if they get aspirin or statins," and they are already a shareholder, then I can't do anything about it. We haven't worked out an incentive and punishment system yet. We don't go and invade people's rooms." The respondent indicated that while the plan does send electronic clinical reminders to prompt physicians to deliver recommendations, shareholders still have substantial control over delivery.

On a similar note, a Director of Quality Improvement from the closed-plan indicated that it is difficult to ensure the delivery of new CPS recommendations. According to this respondent, even with the capabilities of the plan's EMR and associated technologies, it is difficult to ensure that new recommendations or changes to existing recommendations are being incorporated into practice: "If you decide to make a change [to a CPS recommendation], how do you get that into the individual practitioner's brain? We can get it into their hands, into email, but how do you get that into practice?"

Another Director of Quality Improvement from the closed-panel plan discussed that practice patterns and personal beliefs can often interfere with the appropriate delivery of the USPSTF recommendations. The respondent described that even when the recommendation for a certain clinical preventive service changes, physicians' practice patterns and techniques do not necessarily change in accordance. For example, if a recommendation has been in circulation for many years, and then suddenly there is a change in one particular aspect of the recommendation, it is more difficult to integrate the change into practice. One interesting example cited was for cervical cancer screening.

In 1999, the recommendation for cervical cancer screening at the closed-panel plan was to screen eligible women every three years after three normal Papanincolaou tests. However, plan providers were still performing the screenings every year in practice, namely because a few people believed that it was necessary to do the screenings on a yearly basis. Recently, the recommendation at the plan was reevaluated, though not changed. Interestingly, only after the second review have practice patterns finally started to align with the recommendation.

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^f. Yarnall (2003) estimated that it would take approximately 7.8 hours per day for a primary care physician to deliver all of the preventive services recommended by the USPSTF.

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III. Improving Dissemination of the USPSTF Recommendations in Health Plans

3.1. Improving the Utility of the USPSTF Recommendations

Over the course of the semi-structured interviews, respondents suggested a variety of ways to improve the utility of the USPSTF recommendations. Suggestions for improving the utility of the recommendations ranged from improving the packaging of the recommendations to developing new prevention tools specifically designed for nurses delivering counseling recommendations. This section explores a few of the key suggestions.

• Standardizing coding and measurement. A Medical Director respondent at the open-panel plan suggested that AHRQ could create procedure codes or performance measures that coincide with the clinical preventive services recommendations in order to ease the process of integration: "AHRQ could come up with a standardized template for establishing measures to show performance. That would be valuable. They have one out there, and it's a little too complex." Standardizing measurements and procedures codes was an important issue at the hybrid plan as well. Health IT Staff respondents at the hybrid plan indicated that AHRQ should develop procedure codes for the Task Force recommendations. The codes would be similar to HEDIS specification codes: "You can say that everybody needs to have a mammogram and that's all fine and good, but there are subtle differences in the codes. In a way, if you can make them as specific as possible—like a HEDIS spec—that makes it easier."
• Cost information. A Director of Quality Improvement at the open-panel plan highlighted that it would be an improvement to have cost information about preventive services and programs: "It would help if we had some cost information about preventive programs. If we had some type of cost analysis information of the adoption of preventive [recommendations], that would help us here at the plans." A Clinical Advisor from the hybrid plan also indicated that it would be helpful for plans to have a better understanding of the cost and reimbursement implications of clinical preventive services: "Reimbursement is important. If you develop a screening for abdominal aortic aneurysm, but Medicare doesn't pay for it until 2007, then it would help to know, in terms of implementation, that there is a reimbursement issue."
• Adequacy of the recommendations. A Director of Health IT from the closed-panel plan requested for the USPSTF to provide an analysis of how decision-making should occur for people who are slightly outside of the recommendation's age limit, or for individuals with multiple chronic conditions:

  "The level of detail that I don't think is routinely there is "for whom these are not appropriate recommendations." At an even deeper level—and this is unfortunately not something I think is easily provided—but how should decision-making occur for people who are outside of the recommendation? Recommendations are typically recommendations for healthy people. There is a creep into people with chronic diseases for whom the recommendations are often inappropriate and there's a lot of wasted energy for that."

  Thus, according to this respondent, more specific information is needed to inform providers about how and when to recommend clinical preventive services to complex patient populations.
• Packaging of the recommendations. While the USPSTF recommendations are available on AHRQ's Web site, some respondents indicated that it would be helpful to receive full paper copies of the recommendations. A Clinical Advisor at the governmental plan described that "anyone can access [the recommendations] with the Internet, but it takes time. Accessing them at hand would be easier. I'm not sure if we have anything in our library; I haven't tried to look for it." Quality Improvement Staff members of the governmental plan described that it would be helpful if the USPSTF recommendations could be distributed by the central office to the facility-level with the plan's Technical Manual: "If we had the recommendations along with [our plan's] Manual, which comes out every year, we could sit down and take the time to read it. If [the Task Force recommendations] could come out with the Manual, we could look at it."
• New prevention tools. According to a Clinical Advisor from the hybrid plan, there is a need for new tools, and in particular, "anything that is provided at the patient level that is useful right out of the package to activate and motivate patients." Another respondent indicated that it would be helpful for AHRQ to develop clinical decisions support tools for nurses related to Task Force recommendations. Recently the hybrid plan implemented a nurse-driven tobacco cessation program, but did not have access to any clinical decision support tools specifically designed for nurses. Clinical Advisors told us that "unfortunately, we ended up growing our own [clinical decision support tools for nurses]."

3.2. AHRQ's Role in Improving the Dissemination of the USPSTF Recommendations

Respondents indicated that AHRQ could play a key role in improving the dissemination of the USPSTF recommendations, particularly by launching new dissemination strategies to put the recommendations into the hands of health plan leadership and staff in various positions. Our conversations with respondents suggested that many people are unfamiliar with the USPSTF recommendations, including Directors of Quality Improvement and Quality Improvement Staff. However, a number of respondents would like to receive more information from AHRQ. Health IT Directors and Staff, the group that was least knowledgeable about the Task Force recommendations overall, indicated that it would be useful to know more about the USPSTF recommendations. One Health IT Staff respondent from the closed-panel plan told us that "I think the more people know about [the Task Force recommendations] the better. The Quality Improvement people are very busy. If I know what's coming down the pipeline [in terms of clinical preventive services recommendations], I don't think it hurts."

Respondents also indicated that AHRQ and the USPSTF should disseminate more information about the methodology for selecting and prioritizing the recommendations. Directors of Quality Improvement from the open-panel plan and the hybrid plan both indicated that it would be helpful if the Task Force did more to disseminate information about the process used because this would help to "validate" the recommendations. A Director of Health IT from the open-panel plan indicated that from an information technology perspective, it would be useful if the Task Force targeted information about the process to Health IT Staff. A Director of Health IT from the hybrid plan cited that more process-related information would be useful: "If [plan leadership] said that they're going to take Task Force recommendations and follow them, and they explained it to me, it would help me to do my job."

A Clinical Advisor respondent indicated that it would be useful for AHRQ to improve the visibility of the USPSTF recommendations by participating in professional meetings for providers especially when the agenda focused on preventive health. One suggestion was for AHRQ to attend these meetings and potentially present on a few of the Task Force recommendations. Another suggestion from a Director of Quality Improvement was to mobilize a thought-leader group or professional symposium that discussed the Task Force recommendations in practice. Attendees would represent various health plans across the country that utilize the Task Force recommendations: "AHRQ could have meetings—some thought-leader kind of symposium that gets people like me together with other people like me, and creates a dialogue among [Task Force recommendation] users. A users' group, so to speak."

Thus, in sum, respondents believed that AHRQ can play a key role in improving the dissemination of the USPSTF recommendations. Dissemination efforts should target health plan leadership and staff—especially Directors of Quality Improvement, Directors of Health Information Technology, and providers—and also focus on improving the visibility of the USPSTF recommendations overall.

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