V. Thematic Overviews (continued)

Systems-Level Changes to Encourage the Delivery of the USPSTF Recommendations

Overview. Researchers have highlighted a need for systems-level changes that will support the delivery of clinical preventive services. Little research has targeted change at the health plan level. We identify systems-level changes to encourage the delivery of the USPSTF recommendations in health plans. Key findings include: Health plan staff members described several important systems-level changes that have encouraged the delivery of the USPSTF recommendations in their plans. Future research should examine and measure the effects of systems-level strategies on the delivery of the USPSTF recommendations over the long-term.

Despite a growing body of evidence on the efficacy of clinical preventive services in improving overall health, delivery rates remain low in primary care practice settings.^1-2 As a result, researchers have highlighted a need for systems-level changes that will support the delivery of clinical preventive services.^3-4 Systems-level changes may include but are not limited to changes in staff roles, responsibilities, flow of activities, performance measurement, and tools for the delivery of clinical preventive services.^5-6 Much of the literature has focused on physician behavioral change, specifically through reminder systems that prompt the delivery of clinical preventive services,^7-8 the use of continuing medical education,⁹ and audit and feedback.¹⁰

Studies have also explored system changes at the practice-level, specifically focusing on family medicine. Crabtree et al. (2005) analyzed the delivery of clinical preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) ¹¹ in Midwestern family medicine offices, identifying important organizational features of the practices that supported the delivery of the recommendations.¹² Key findings include that practices with higher rates of clinical preventive service delivery had one or more physician champions who made prevention a priority in their practices. High delivery sites also reduced practice volume to enable physicians to spend more time with individual patients, and hired health educators and nurse practitioners to enhance delivery of services in busy offices. These findings may inform new systems-level changes to encourage the delivery of preventive services in family medicine offices. Limited research exists on systems-level changes that encourage the delivery of clinical preventive services recommended by the USPSTF at the health plan level.¹³

As part of a larger evaluation of the USPSTF recommendations for clinical preventive services, NORC at the University Chicago studied the integration and delivery of the USPSTF recommendations in four different types of health plans: a closed-panel health plan, open-panel health plan, hybrid health plan having both open and closed-panel characteristics, and governmental health plan. Structured interviews were conducted with over 40 health plan staff members, including Medical Directors, Directors of Quality Improvement and Health Information Technology (IT), Quality Improvement and Health IT staff, and Clinical Advisors (health care providers). This overview synthesizes their perspectives and identifies several systems-level changes that may encourage the delivery of the USPSTF recommendations in health plans.

Systems-Level Changes Focused on Health Plan Staff

Health plan staff respondents described that staff changes are necessary to improve the integration and delivery of the USPSTF recommendations. Respondents described the need for additional staff members focused on prevention and health IT to facilitate the delivery of the recommendations. First, respondents described the importance of having staff that are knowledgeable about recommendations for clinical preventive services. The governmental plan's Director of Quality Improvement indicated that the plan would benefit from additional prevention staff: "I have a clinical practice guidelines coordinator who puts different process action teams together. It would very much help if there was more than one person, at least in a back-up role, to work on these types of prevention activities.

"I have a clinical practice guidelines coordinator who puts different process action teams together. It would very much help if there was more than one person, at least in a back-up role, to work on these types of prevention activities." —Director of Quality Improvement, Governmental Plan

Second, respondents indicated that health plans need additional health IT staff to integrate the IT and clinical components of the plan for optimal delivery of the USPSTF recommendations. Specifically, a Clinical Advisor commented that "to ensure the delivery of clinical preventive services recommendations from a development, implementation, and usability perspective, IT resources must be supported directly by clinical resources." A Director of Quality Improvement also said that the plan would benefit from having more health IT staff to integrate the recommendations electronically.

Third, respondents from the hybrid plan noted that utilizing nursing staff to deliver counseling recommendations for tobacco cessation encourages the delivery of counseling recommendations in busy clinical practices. A Clinical Advisor noted that the plan recently 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 hybrid plan's positive experience with the nurse-led program highlights an opportunity for plans to incorporate nurses' expertise into the delivery of certain clinical preventive services. Additionally, this plan's experience suggests the need for new clinical decision support tools for use by nurses.

"I don't think we have changed staff as much as we have reorganized the thinking amongst existing staff. We are moving the organization to think in terms of performance and quality." —Medical Director, Open-Panel Plan

While the governmental and hybrid plans emphasized the need for new staff to facilitate the delivery of the recommendations, the closed-panel and open-panel plans discussed the need to reorganize their current staff. A Clinical Advisor from the closed-panel plan noted that "it's less about what new staff are needed and more about how to make the best use of the staff we have." Similarly, a Medical Director from the open-panel plan stated: "I don't think we have changed staff as much as we have reorganized the thinking amongst existing staff. We are moving the organization to think in terms of performance and quality."

Other Systems-Level Changes

Many respondents highlighted that each of their health plans have made a commitment to building a culture of prevention. Research supports that identifying a focus for preventive care within an organization is a key enabling factor to preventive service delivery.¹⁴ Each of the health plans have pursued a stronger organizational culture of prevention. For example, the Medical Directors and Directors of Health IT and Quality Improvement promote prevention and the delivery of the USPSTF recommendations through newsletters and quality improvement programs related to prevention. The governmental plan's leadership works directly with plan staff on issues related to clinical preventive service delivery. Training sessions and "hands on" continuing education activities are conducted to ensure that staff members have timely information about clinical preventive services recommendations and targets.

The closed-panel plan has implemented two effective systems-level strategies to encourage the delivery of the USPSTF recommendations: involving providers in the development of its clinical practice guidelines and enabling staff from various departments to participate in the delivery of clinical preventive services. A Director of Quality Improvement discussed that "depending on the recommendation, different people need to be involved in the implementation. We involve nursing staff, people who work on our electronic medical record, primary care staff, and people from internal medicine." According to respondents, making prevention an organizational focus and system-wide priority can improve the delivery of the USPSTF recommendations.

Finally, respondents across health plans discussed that clinical decision support tools such as clinical reminders and electronic medical records have facilitated the delivery of the USPSTF recommendations. Future systems-level strategies will likely focus on utilizing health IT tools and quality improvement interventions to increase the delivery of clinical preventive services recommendations.

Conclusions and Further Exploration

While research demonstrates the value of prevention, clinical preventive services delivery rates remain relatively low. Reflecting on the barriers associated with improving the delivery of preventive services in clinical practice, Pommerenke and Dietrich (1992) stated: "The status quo is difficult to change and medical practice is no exception. The importance of this problem cannot be over-emphasized."¹⁵ Changing the status quo, and increasing the delivery of clinical preventive services can be accomplished by systems-level changes. Respondents described several important systems-level changes that have encouraged the delivery of the USPSTF recommendations in their health plans. Respondents also highlighted current staffing needs, such as more staff with a solid understanding of the preventive health recommendations and additional health IT staff. The hybrid plan's experience with a nurse-driven tobacco cessation program exemplifies the changing role of nurses, and their potential to increase the delivery of certain USPSTF recommendations. Strong leadership at the health plan level that fosters a plan-wide culture of prevention is another enabling factor that encourages the delivery of the USPSTF recommendations.

Future research should explore the systems-level changes and strategies that health plans have employed to increase the delivery of the USPSTF recommendations. Specifically, what approaches are used by closed-panel versus open-panel plans? What systems-level changes have been implemented? Which changes have had the greatest impact on the delivery of clinical preventive services? Longitudinal studies could potentially be used to explore these research questions, and examine and measure the effects of systems-level strategies on the delivery of the USPSTF recommendations over the long-term.

References

^1. Kottke TE, Solberg LI, Brekke ML, Cabrera A, Marquez MA. Delivery rates for preventive services in 44 Midwestern clinics. Mayo Clinic Proceedings 1997;72:515-523.
^2. Stange KC, Flocke SA, Goodwin MA, Kelly RB, Zyzanski SJ. Direct observation of rates of preventive service delivery in community family practice. Preventive Medicine 2000;31:167-176.
^3. Crabtree BF, Miller WL, Tallia AF, Cohen DJ, DiCicco-Bloom B, McIlvain HE, Aita VA, Scott JG, Gregory PB, Stange KC, McDaniel RR. Delivery of clinical preventive services in family medicine offices. Annals of Family Medicine 2005; 3(5):430-435.
^4.Jackson PL. A systems approach to delivering clinical preventive services. Pediatric Nursing Journal 2002; 28(4):377-381.
^5. Agency for Healthcare Research and Quality. (2001, October). Put prevention into practice, a step-by-step guide to delivering clinical preventive services: A systems approach (AHRQ Publication No. APPIP01-0001). Rockville, MD: Author.
^6. Crabtree et al., 2005.
^7. Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ. A computerized reminder system to increase the use of preventive care for hospitalized patients. New England Journal of Medicine 2001;345(13):965-70.
^8. Ornstein SM, Garr DR, Jenkins RG, Rust PF, Arnon A. Computer-generated physician and patient reminders: tools to improve population adherence to selected preventive services. Journal of Family Practice 1991; 32(1):82-90.
^9. Davis D, O'Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? Journal of the American Medical Association 1999;282:867-874.
^10. Greco PJ, Eisenberg JM. Changing physicians' practices. New England Journal of Medicine 1993; 329:1271-1273.
^11. In 1984, the U.S. Public Health Service created the USPSTF as an independent panel of experts in primary care and prevention that systematically review the evidence of effectiveness and develop recommendations for clinical preventive services. The Agency for Healthcare Research and Quality (AHRQ) began sponsoring USPSTF activities in 1998 and includes the USPSTF recommendations as part of their diverse Prevention Portfolio. The USPSTF recommendations are developed by a team of clinicians and are based on a thorough review of evidence including individual studies such as randomized controlled trials, costs, the negotiations of benefits and harms, and the evidence as a whole.
^12. Crabtree et al., 2005.
^13. Thompson RS. What have HMOs learned about clinical preventive services? An examination of the experience at group health cooperative of Puget Sound. The Milbank Quarterly 1996; 74(4):469-509.
^14. Ibid, 478.
^15. Pommerenke FA and Dietrich A. Improving and maintaining preventive services. Part 1: applying the patient model. Journal of Family Practice 34:86-91.

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Delivering the USPSTF Recommendations in a Rural Health Care Setting

Overview. Rural populations are less likely to receive the recommended clinical preventive health services. We explore the challenges that one health plan faces in delivering the USPSTF recommendations to its rural patient population. Key findings include: Rural members face barriers to accessing preventive services, such as transportation and limited service availability in rural areas. Information exchange about preventive service delivery is more difficult in rural areas. Despite barriers, the stability of the rural population presents unique opportunities for delivering the USPSTF recommendations. Future research should explore the delivery of the USPSTF recommendations in rural communities on a wider scale.

Research suggests that rural populations may have lower access to and utilization of preventive health services than urban populations.^1-6 In a study assessing the utilization of preventive health care services by rural women and men, Casey et al. (2001) found that rural residents are significantly less likely than urban residents to obtain certain preventive health services and are further behind in meeting the Healthy People 2010

objectives. Evidence also suggests that certain subpopulations, such as rural women, are at a particular disadvantage for receiving the recommended clinical preventive services.^7-8 Additionally, differences in the utilization of preventive services between rural and urban residents may also vary by type of service.⁹

Access and utilization disparities between rural and urban populations may be a result of cultural barriers to the use of preventive health services, lack of primary health care providers in rural communities, and rural-urban differences in out-of-pocket costs for preventive services. Other factors may also exacerbate these disparities. For example, rural populations typically have to travel longer distances to access preventive health care services, impacting utilization.¹⁰ Differential access to preventive services is a key public policy issue, as research suggests that reduced access is associated with an increased risk for mortality or the disabling effects of various health conditions.¹¹

Few studies have explored rural populations' access to and utilization of clinical preventive services specifically recommended by the U.S. Preventive Task Force (USPSTF).¹² Furthermore, no studies have explored the barriers that rural health plans face in delivering the USPSTF recommendations to a rural patient population.

As part of a larger evaluation of the USPSTF recommendations for clinical preventive services, we studied the challenges associated with delivering the USPSTF recommendations in four different types of health plans, including a hybrid health plan (where some providers are plan-affiliated employees and others are independent contractors to the plan) that serves a large rural population. Given that few plans today can be characterized as purely open-panel (where physicians are independent contractors of the health plan) or closed-panel (where physicians are plan-affiliated employees), it is particularly informative to examine the integration of the USPSTF recommendations in a hybrid plan, which encompasses characteristics from both models. The mixed-model nature of the hybrid plan presents a unique opportunity to compare key health plan variables of open- and closed-panel health plans within a rural setting.

Structured interviews were conducted with nine health plan staff members at the rural plan, including a Director of Quality Improvement, Directors of Health Information Technology (IT), Quality Improvement and Health IT staff, and Clinical Advisors (health care providers who also serve in a leadership or broader prevention role at the plan). This overview presents these informants' perspectives on the challenges that the plan faces in delivering the USPSTF recommendations to a rural patient population.

Barriers to Delivering the USPSTF Recommendations

"Just having immediate access to colonoscopies and mammograms is an issue for members in rural areas." —Clinical Advisor

Foremost among the challenges associated with delivering the USPSTF recommendations to a rural patient population was the lack of local providers of certain clinical preventive services and the long travel distances often required to reach the nearest service provider. According to a Clinical Advisor, "just having immediate access to colonoscopies and mammograms is an issue for members in rural areas." In addition, respondents noted that rural members often have to travel longer distances to receive the recommended clinical preventive services than their urban counterparts: "We have counties that don't have a gastroenterologist. And they're rural. [People] don't want to travel."

One population that faces severe barriers to receipt of clinical preventive services is the rural elderly. The rural plan is located in a state with a larger elderly population than the national average, and within the state, the rural population is disproportionately older than the non-rural population. As a result, a large portion of the plan's rural membership is elderly. A Clinical Advisor noted that utilization of preventive services by the elderly is inhibited by the rural geography: "There are travel and convenience issues. These issues are more important in [the elderly] population. Most times for specialized services, the question is: where is the nearest hospital?"

"Our rural population has a real obesity problem. [It's unclear] whether that's because of our rural nature or [the state] in general. But many of the lifestyle [clinical preventive services] recommendations are related to weight and diet, issues that are difficult for us in our rural population." —Clinical Advisor

Obesity, physical inactivity, and substance abuse are common issues in the plan's rural member population as well. This finding supports a body of evidence that suggests that rural populations are more affected by these health conditions than non-rural populations.^13-14 In order to care for this large subpopulation, Clinical Advisors noted that many of the plan's "lifestyle" preventive services recommendations are related to diet and weight management, as well as substance abuse: "Our rural population has a real obesity problem. [It's unclear] whether that's because of our rural nature or [the state] in general. But many of the lifestyle [clinical preventive services] recommendations are related to weight and diet, issues that are difficult for us in our rural population." Another respondent indicated that the plan "has no shortage of patients who smoke." The plan has responded by developing new quality improvement programs to increase the delivery of tobacco cessation counseling.

The health plan's large rural service area also poses some challenges for the dissemination of the USPSTF recommendations. Specifically, Clinical Advisors described the challenge of adequately communicating clinical preventive services recommendations from the USPSTF and other sources to rural providers across the plan's large service area. The respondent noted that "with over 40 provider sites across a large area, communication of programs and recommendations across all of our providers is a difficult thing."

From an operational standpoint, the plan also faces geographic challenges to collecting and monitoring data on the delivery of the USPSTF recommendations in its rural areas. Approximately half of the plan's providers are located in rural settings across a wide service area. Since most of these plan providers are not affiliated with the plan's parent health system, they do not have access to the system-wide electronic medical record (EMR) and other health IT tools. Quality Improvement Staff and Clinical Advisors described that this aspect creates challenges to monitoring whether patients in rural areas are receiving the recommended clinical preventive services: "For patients in the outer edges of our service area who get services outside of the health system, the results come back on paper. There is no clean loop of closure for those folks."

Quality Improvement Staff also indicated that, in order to track service delivery for rural members (whose providers often do not utilize an EMR), it is sometimes necessary for them to travel to remote provider locations to collect the data: "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." These examples illustrate the quality improvement and technological challenges associated with serving a large rural patient population where a significant proportion of providers are not plan-affiliated employees.

Are Certain Types of USPSTF Recommendations Easier to Deliver in Rural Settings?

We also asked respondents whether certain types of USPSTF recommendations are easier to integrate and deliver than others, given that the health plan serves a rural population in a rural setting. Several respondents indicated that certain recommendations are, in fact, easier to deliver than others because of the plan's rural nature.

"We don't struggle as much with delivering immunizations. The transient population that you deal with in the inner cities is not necessarily a problem here." —Clinical Advisor

A Clinical Advisor suggested that the plan finds it easier than its urban counterparts to deliver recommendations for immunizations, for example: "We don't struggle as much with delivering immunizations. The transient population that you deal with in the inner cities is not necessarily a problem here." Another respondent elaborated on the plan's stable patient population, saying "people stay forever." As described by another respondent, patient turnover is less of a problem for providers, making it easier to deliver clinical preventive services recommendations: "One of the things we have seen in our service area that is different than in cities is that people we care for tend to have roots in the area. There is less of a turnover of patients across our service area. There is some switch from provider to provider, but we have a more stable patient population."

With a highly stable patient population, the plan has an enhanced ability to track patient outcomes over the long-term—something that it hopes to do more of in the future. One Clinical Advisor described that "we probably have more longitudinal data on patients than [other plans]. It's easier to find people. We'd have the ability to follow the effects of an intervention over a decade." With more longitudinal data on its patients, the plan has the ability to explore the impact of quality improvement programs over time.

Conclusions and Further Exploration

This overview suggests that rural health plans face additional barriers to delivering the USPSTF recommendations for clinical preventive services than their non-rural counterparts, as well as some advantages. According to respondents from the rural health plan, rural populations face barriers such as transportation and limited service availability in some areas. The plan also has difficulty communicating the recommendations to all of its providers across the rural landscape. While access to a common EMR is helpful for plan providers that are affiliated with the plan's parent health system, information exchange is lacking for the 50 percent of providers that are not directly employed by the system. The fact that the majority of these providers are located in rural areas at a distance from the plan's headquarters further inhibits the plan's ability to track and monitor the data on provision of services, and execute quality improvement interventions. Despite these challenges, the rural environment does present some unique opportunities for delivering the USPSTF recommendations. Since the member population is more stable, certain recommendations such as immunizations, are easier to deliver and track. In addition, the plan has more longitudinal data on its patients, which is useful in assessing the long-term value of quality improvement interventions.

Future research should explore the delivery of the USPSTF recommendations in rural communities on a wider scale. Do providers in rural communities deliver the USPSTF recommendations in a systematically different way than providers in urban communities? For example, do providers in rural communities rely on their own judgment rather than the USPSTF recommendations because they treat the same patients for decades, and perhaps feel they know what is best for them? From a systems perspective, as health plans develop advanced health IT solutions, will providers have an improved ability to deliver the USPSTF recommendations in rural communities? On a similar note, will health IT help rural health plans to track service delivery and patient outcomes over time? Studies should explore these research questions in order to improve the delivery of the USPSTF recommendations in rural communities.

As these research questions are explored in greater detail, we recommend that research on hybrid health plans be a key component of analyzing the impact of plan structure on the delivery of clinical preventive services. Given their open- and closed-panel features, further research on hybrid health plans provides a unique opportunity to understand the impact of plan structure on the delivery of clinical preventive services in rural settings.

References

^1. Casey MM, Call KT, Klingner JM. Are rural residents less likely to obtain recommended preventive healthcare services? American Journal of Preventive Medicine 2001:21(3).
^2. Ricketts TC, Johnson-Webb KD, Randolph RK. Populations and places in rural America. In Ricketts (Ed.), T. C. Rural health in the United States. 1999. New York: Oxford University Press.
^3. Amery CH, Miller MK, Albrecht SL. The role of race and residence in determining stage at diagnosis of breast cancer. Journal of Rural Health 1997; 13(2):99-108.
^4. Higginbotham JC, Moulder J, Currier M. Rural v. urban aspects of cancer: First-year data from the Mississippi Central Cancer Registry. Family and Community Health 2001; 24(2):1-9.
^5. Larson SL, Fleishman JA. Rural-urban differences in usual source of care and ambulatory service use: Analyses of national data using Urban Influence Codes. Medical Care 2003; 41(Suppl. 7):III65-III74.
^6. Mayne L, Earp J. Initial and repeat mammography screening: Different behaviors/different predictors. Journal of Rural Health 2003; 19(1):63-71.
^7. Hughes Gaston M. 100% access and 0 health disparities: Changing the health paradigm for rural women in the 21st century. Women's Health Issues 2001; 11(1):7-16.
^8. Carr WP, Maldonado G, Leonard PR, Halberg JU, Church TR, Mandel JH, Dowd B, Mandel JS. Mammogram utilization among farm women. Journal of Rural Health 1996; 12(4 Suppl):278-290.
^9. Zhang P, Tao G, Irwin KL. Utilization of preventive medical services in the United States: a comparison between rural and urban populations. Journal of Rural Health 2000; 16(4):349-356.
^10. Schur CL, Franco SJ. Access to health care. In T. C. Ricketts (Ed.), Rural health in the United States. 1999. New York: Oxford University Press.
^11. Ibid.
^12. In 1984, the U.S. Public Health Service created the USPSTF as an independent panel of experts in primary care and prevention that systematically review the evidence of effectiveness and develop recommendations for clinical preventive services. The Agency for Healthcare Research and Quality (AHRQ) began sponsoring USPSTF activities in 1998 and includes the USPSTF recommendations as part of their diverse Prevention Portfolio. The USPSTF recommendations are developed by a team of clinicians and are based on a thorough review of evidence including individual studies such as randomized controlled trials, costs, the negotiations of benefits and harms, and the evidence as a whole.
^13. Patterson PD, Moore CG, Probst JC, Shinogle JA. Obesity and physical inactivity in rural America. Journal of Rural Health 2004; 20(2):151-159.
^14. Van Gundy K. Substance abuse in rural and small town America. Carsey Institute 2006; 1(2):1-38.

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