From “Bench to
Bedlam” Translating
Research into Primary
Care
Scott M. Strayer, MD, MPH
Associate Professor of Family Medicine and
Public Health Sciences
University of Virginia, Dept. of Family
Medicine, School of Public Health
Center for Information Mastery
ACS Volunteer Appreciation Presentation
“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.”
Preventive Service
Delivery
• Pneumococcal disease
− 10 to 14,000 deaths in 1997
− Only 43% aged 65 and > received Pneumovax
(U.S. Department of Health and Human Services, 2000)
• Tobacco, alcohol, diet, exercise
– 38% total deaths in 1990
– Preventable morbidity
– Health habit counseling < 10%
(Stange, KC etal. Preventive Medicine 2000; 31:167-176.)
• Colorectal Cancer Screening
- <50% of patients are screened as recommended
Some facts
• ¾ of population visit physician > 1
yearly
• > 25% outpt visits to FP
• Repeat visits & multiple opportunities
• Belief in importance of prevention
• Physicians over-estimate delivery of
preventive services
• Actual performance less than desired
New Ecology of Medical Care - 2000
1000 people
800 have symptoms
327 consider seeking
medical care
217 visit a physician’s
office
113 visit primary care
physician’s office
65 visit CAM provider
21 visit a hospital
outpatient clinic
14 receive home
health care
13 visit an emergency
department
8 are in a hospital
Green et al, NEJM 2001; 344: 2021-24.
<1 is in an academic
health center hospital
Barriers
• Physicians
– Competing demands
– Conflicting recommendations
– Lack of training
• Patients
– Lack of knowledge
– Fear of discomfort
– Cost
• Office
– Poor reimbursement
– Lack of systems
USPSTF Recommendations
• Screening
– BP, Pap, Mammo, CBE, Ht, Wt, Lipids, FOBT,
Flex sig, Etoh abuse, Rubella, Vision, Hearing
• Counseling
– Tobacco, Exercise, Seat belts, Helmets, Etoh
abuse, DUI, Diet, Calcium, STD,
Contraception, Fire safety, Guns, Dental care,
Falls, Hot water heater
• Immunizations
– Td, Rubella, Pneumovax, Influenza
• Chemoprophylaxis
– MVI, Folate, HRT discussion
Is there enough time for
prevention?
• Patient panel of 2500
• Age and sex distribution similar to US
pop.
• To fully satisfy the USPSTF recs, it
would take 1067 hours per year or 4.4
hours per working day of a physician’s
time
• If you include children and pregnant
women: 1621 hours per year / 6.8 hours
per day
Prioritizing clinical preventive
services
• Clinically preventable burden (CPB)
– Disease and injury prevented by CPS if
delivered 100% at recommended intervals
– Reflects both burden of disease and
effectiveness of service
– Quality adjusted life years saved (QALYs)
– Time frame for 1-year birth cohort
– Patient adherence (often estimated)
– Designed to capture CPS total value
Cost effectiveness
• Net cost of CPS / QALYs saved
• Net cost of CPS = costs of prevention –
costs averted
• For 13 of 30 CPS CE studies available
• 1995 dollars
• Panel on Cost Effectiveness in Health
and Medicine
• USPSTF
Priorities among recommended clinical preventive
services
Services
CPB
CE
Total
Childhood vaccinations
5
5
10
Adult tobacco cessation counseling *
Vision screening > 65 yrs *
Pap test, sexually active > 18 yrs
Colorectal cancer screening > 50 yrs *
5
4
5
5
4
5
3
3
9
9
8
8
Newborn metabolic screen
3
5
8
Hypertension screening
Influenza vaccine > 65 yrs
Lipid screening; men 35-65; women
45-65
5
4
5
3
4
2
8
8
7
Pneumovax >65 yrs *
2
5
7
Priorities among recommended clinical preventive
services
Services
CPB
CE
Total
Assess /counsel adolescents on
alcohol/drugs*
3
5
8*
Adolescent tobacco cessation
counseling *
Chlamydia screening women 15-24
yrs *
Problem drinking screening /
counseling *
Breast cancer screening 50 – 69 yrs
Rubella screening/vaccination in
women
Td boosters universal
4
4
8*
3
4
7*
4
3
7*
4
1
2
1
6
2
1
1
2
Coffield AB, Maciosek MV, etal. Am J Prev Med 2001;21(1):1-9.
Prioritizing clinical preventive
services
• Attempt to provide relative values
• Top ranking services with low delivery
rates may be higher priority
• Tailor to local realities
• Does not account for resources needed to
increase delivery rates
• Focus on high CPB ?
• How to define the “greatest good” ?
• Individual in the context of a population
What do patients actually
want?
•
•
•
•
•
•
Advice / counseling
Personalized plan
Scheduling additional appt for follow-up
Referrals to experts (e.g. nutritionist)
Informational materials (e.g. brochures)
Telephone or email follow-up
Massett HA, Wolff LS. Barriers and opportunities to promoting prevention in the
primary care setting. Presented September 12, 2003. RWJF P4H Annual
Meeting.
How well do physicians
address smoking cessation?
– Smoking cessation only occurs at 23 to
46% of primary care visits
– Only 35% of physicians assist with
smoking cessation attempts
– Less than 10% arrange follow-up for
smoking patients
•Thorndike AN, Rigotti NA, Stafford RS, Singer DE. National patterns in the treatment of smokers by
physicians. JAMA 1998; 279:604-608
•Lewis CE, Clancy C, Leake B, Schwartz JS. The counseling practices of internists. Ann Intern Med
1991; 114:54-58.
•Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking
cessation counseling practices. Prev Med 1998; 27:720-729.
What We Know…
Leveraging 1 Minute for
Prevention
1 minute is the realistic average amount
of time that primary care providers can
devote to prevention during a typical
office visit
Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The
power of leveraging to fulfill the promise of health behavior counseling.
Am J Prev Med, 2002; 22:320-323.
Opportunities for Intervention
• Most people visit a primary care doctor about
three times per year.
• Even 2-3 minute interventions are effective,
especially when followed up with telephone,
e-mail, nurse calls, referrals, 1-800 numbers,
etc.
• Many primary care providers provide 2-3
minute health promotion/behavior
interventions at every outpatient visit.
Stange, KC, Woolf, SH, Gjeltema K. One minute for prevention: The power of
leveraging to fulfill the promise of health behavior counseling. Am J Prev Med,
2002; 22:320-323.
Behavioral Change Theories
• 5 A’s
• Stages of Change----assess patient’s
readiness to change and then deliver
stage-appropriate interventions
• Motivational Interviewing---a nonconfrontational technique for helping
patients change their health behavior
Integrating the Behavioral
Theories
Not
Stage-dependent
• Ask
• Advise
Smoking and BMI as
Vital signs
• Assess
Stages of Change
Motivational Interviewing
• Assist
• Arrange
Use Motivational
Interviewing
Stage-based interventions
Motivational Interviewing
Local and national
resources
Development of the MLIT
•
•
•
•
•
•
•
Operationalize the Stages of Change
Identify stage based interventions
Scripted motivational interviewing
Risk calculators
Pharmacotherapy info
Local and national resources
Modular design
What we found with seasoned
clinicians
• More likely to advise patients to stop smoking
(p = 0.049)
• Increased overall use of the "5 A's" during
patient encounters for both smoking
cessation (p = 0.031)
• Increased general counseling behaviors
– frequency of counseling, provision of behavior
specific information, and use of pharmacotherapy
and referrals for smoking cessation (p = 0.047)
More results
• Improved self-efficacy in counseling
patients regarding smoking cessation (p
= 0.006)
• Increased comfort in providing follow-up
to help patients sustain their efforts at
smoking cessation (p = 0.042)
QuitAdvisorMD
PDA-based clinical assessment and
smoking cessation tool
ACS Volunteer Appreciation Presentation
Content Development
• Adapted from Public Health Service
Guidelines (Fiore et al 2000), Stages of
Change (Prochaska and Diclemente) and
Motivational Interviewing (Miller and Rollnick)
for use at the Point-of-Care
• Iterative, collaborative process between UVa
& Silverchair
• Much consideration of “scripting” versus
“guiding”
• Result: 1) Algorithm and 2) Clinician’s
Reference
Technology Development
• Silverchair’s staff adapted our platforms to create an IT
Ecosystem:
Technology Development
Technology Development
Technology Development
Product Demonstration
• Simulated Patient
Encounter
• Point-of-Care
Assessment
and Interview
Usability Testing
5 physician volunteers each in a 45minute observed session
• Self-familiarization with the prototype,
simulated patient interview,
performance of three directed tasks, exit
questions and solicited user feedback
• Resulted in 2 navigation modifications
(Global Nav, preparation script), 1
content change (Action script)
Stages of Change Assessment
• Stage of Change process used by all
– All evaluated smoking history before stages of change
– Accessed and used by 3 of 4 physicians without help
– 2 used tool immediately; 2 initiated on own first
• Future improvements based on observations:
– MAXIMIZE USE OF STAGE OF CHANGE TOOL
• Add smoking history script to engage physicians immediately
• Increase prominence of the Stage of Change Tool
– EMPHASIZE PRECISE WORDING AND FOLLOWUP
• Encourage precise use of script wording
• Add follow-up questions about confidence to fully engage
patient
– RECOMMEND SUMMARY STATEMENTS
• Strengthen the use of summary statements/reflection for
connecting with patient, demonstrating empathy, and guiding
process.
Motivational Interviewing
• All participants used approach and scripts for at
least a portion of the interview
• Participants in some cases reverted to
paraphrasing (sometimes incorrectly) and own
scripts.
– Non-tool scripts were often too directive or jumped
stages
• Future improvements based on observations:
– USE PROMPTS TO AID TRANSITIONS
• Assist physicians when transitioning between conversations
(including integration of more summary and reflective
statements)
– FACILITATE EASY PROGRESSION
• Add links to other question alternatives and links to ease
appropriate progression to other stages (especially preparation)
• Provide further guidance for closing remarks
Use of QuitAdvisorMD
• Approaches to using the tool in practice
– All physicians would review tool before using clinically
– Most imagine reviewing the tool prior to each clinical
visit
– Many describe using the tool as a guide during the visit
– Some physicians would introduce the tool to patients
• Importance of training
– All physicians noted the need for training and practice
for use of the tool at the point of care.
– Many difficulties in first use observations would likely
be avoided once physicians were more familiar with the
tool.
Feasibility Testing
• 6 week ‘in practice’ trial of
QuitAdvisorMD
– Pre and Post Knowledge Assessment
– Mid-study feedback
• Added a patient role-play for physicians with
limited use of tool clinically at study mid-point
– Satisfaction and Feedback assessed post
study
– 7 physicians enrolled
Feasibility Testing
• Usage data:
– Total Syncs: 19
– Total Sessions: 42
– Average Syncs/User: 3.2
– Average Sessions/Sync: 2.1
– Average Sessions/User: 7
– Average Pages per Session: 8.3
Feasibility Results
•
Our primary indicators for success were
– >50% of physician users would be
satisfied or mostly satisfied with the tool,
and
– >50% would use the prototype if
modified according to suggestions
• 5/5 of physicians who responded were
satisfied or mostly satisfied with the tool.
• 100% of physicians stated they would use
the tool if modified according to feedback
Challenges & Barriers
• Content Development – guide or script?
– Iterative development among content group
– Usability Testing
– Further Examination Possible
• IRB Approval – Human subject exception
– Caused Project Delays (3 months)
• Prototype Technology – log data capture
– Revised server based code
• Enrollment levels – VaPSRN physicians sensitized
– Widened study to additional UVa departments and area
practices
• Usage Levels
– Conducted Midpoint “role play” training
Phase II Research Directions
1.
2.
3.
4.
5.
Extend the tool’s capability to run on additional
hardware platforms (e.g., smart phones, laptops, PC’s,
Tablet PC’s, and PDAs); upgrade data logging and
capture
Enable QuitAdvisorMD to accept updates that are
“pushed” out automatically through Internet connectivity,
ensuring that the user has access to the most up to date
guidelines and resources at all times
Link to tailored patient support materials to help extend
the intervention’s effect past the initial interview
Integrate CME and Reimbursement Capture to foster
usage
Evaluate the efficacy and acceptance of the revised
QuitAdvisorMD prototype in a large, randomized,
controlled study comparing QuitAdvisorMD to usual
care