David Haggstrom Slides from AHRQ Kick-Off Event
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Transcript of David Haggstrom Slides from AHRQ Kick-Off Event
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Colorectal cancer screening:overview & background
January 8,2007
David A. Haggstrom, MD, MAS
LEADERS SYMPOSIUM“Strategic Planning to Inform a Funded Project onhow to Achieve Workflow Integration in Developing and Implementing CDS for CRC Screening”
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Outline
I. CRC screening practice guidelines
II. Competing clinical demands for CRC screening
III. Applied research for screeningA. Clinical decision support
A. Facilitators & barriers
B. Practice-based interventions
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Colorectal cancer screeningClinical practice guidelines Target population: men & women 50 years of
age & older at average risk for colorectal cancer
Caveat (VA/DoD): providers should discuss screening with patients ages 80 & older, taking into account estimated life expectancy & presence of co-morbid disease
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Colorectal cancer screeningClinical practice guidelines (USPSTF)Test Interval
Fecal occult blood testing (FOBT)3 cards done at home
Annually
Flexible sigmoidoscopy Every 5 years
Colonoscopy Every 10 years
Double-contrast barium enema Every 5 years
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Competing clinical demands Most clinical practice guidelines (CPGs) did not
address their applicability for older patients with
multiple comorbidities Most didn’t discuss
burden, short- & long-term goals give guidance for incorporating patient preferences into
treatment plans (Boyd, Wu, JAMA, 2005)
To fully satisfy all USPSTF recommendations 7.4 hrs/working day is needed for the provision of
preventive services by physicians
(Yarnall et al., AJPH, 2003)
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Computer reminders – Regenstrief InstituteClinical focus: FOBT, mammography, & Pap testing
Study design: 6-mo. RCTPopulation: 31 GIM faculty & 145 residents at Indiana UniversityIntervention: “directed reminders” vs. routine reminders
1) done/order today 3) patient refused2) NA to patient 4) next visit
Primary outcome: compliance with reminder “directed reminders” overall (46% vs. 38%, p = 0.002) FOBT (61% vs. 49%, p = 0.0007)
Secondary outcomes: 21% of time: NA to patient - due to inadequate data in pt’s EMR 10% of time: patient refused
Conclusions:• Requiring MDs to respond to computer-generated reminders
improved their compliance• However, 100% compliance with cancer screening reminders will
be unattainable due to clinical appropriateness & patient refusal
(Litzelman, Tierney, JGIM, 1993)
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Electronic health record – Partners HealthCareBarriers to use 24% of physicians “never/sometimes” used
any EHR functionality during patient visit Barriers to EHR use:
Loss of eye contact with patients (62%) Falling behind schedule (52%) Computers being too slow (49%) Inability to type quickly enough (32%) Using computer in front of patient is rude (31%) Preferring to write long prose notes (28%)
(Linder, AMIA Annu Symp Proc, 2006)
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Computer reminders - VAFacilitators to adherence
In VA, overall adherence rate to 15 CRs: 86% (67% - 97%) Variation by clinic, individual clinician, & individual CR
Positive influence upon reminder completion rate: full utilization of support staff in completion process receiving frequent individual feedback on completion
No influence: provider demographics provider attitudes towards reminders
(Mayo-Smith, Abha Agrawal, 2004 & 2006)
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Computer reminders - VABarriers to reminders
HIV clinical reminders Design: ethnographic observations & semi-
structured interviews Barriers to effective use:
Workload Time to remove inapplicable reminders False alarms Reduced eye contact Use of paper forms rather than software
(Patterson, Doebbeling, Asch et al., J Biomed Inform, 2005)
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Colorectal cancer screeningPrimary care-based interventions
• Practice-individualized facilitation of implementation of tools:• Group randomized clinical trial• 77 community family practices
• Intervention:• 1-day practice assessment - nurse facilitator observed practice MDs & staff• 1.5 hour meeting with practice day after• frequent visits thereafter (unknown dose effect)
• Outcomes at 12 months• Summary scores of preventive service delivery rates:
• Intervention: 42% vs. 31%• Control: 37% vs. 35% (p=0.015)
• Screening services, (p=0.048), not immunization services• Sustained after 24 months
(STEP-UP - Study to Enhance Prevention by Understanding Practice)
(Stange, Goodwin, Am J Prev Med, 2001 & 2003)
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CRC screening in primary care practices Most CRC screening interventions focus on either
patients or individual clinicians without examining the office context
Methods: chart review (795 pts eligible for CRC screening) practice surveys (22 family medicine practices)
Factors associated with higher CRC screening: Using nursing or health educator staff to provide
behavioral counseling Reminder system use
(Hudson & Crabtree, Can Det Prev, 2007)
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Conclusions1. Generally positive, but sometimes mixed, results
for clinical, computer reminders Direct observation & qualitative methods provide
opportunity to understand potential pathways for effectiveness of clinical reminders
2. Computer reminders Need not only to incorporate evidence base, but address
patient preferences & comorbidities
3. Prior positive experience with practice change Computer reminder often key component Team-based approach also important, particularly to
help address competing time demands
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Questions or comments?
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Systems engineering framework1. Identify system of interest
2. Choose appropriate performance measure
3. Select best modeling tool
4. Study model properties & behavior under variety of scenarios
5. Make design & operation decisions for implementation
previous applications in hemodialysis, radiation therapy, & patient flow modeling
(Kopach-Konrad, Doebbeling et al., JGIM, 2007)