Delivering clinical preventive services is a systems problem

Solberg, Leif I.; Kottke, Thomas E.; Conn, Shirley A.; Brekke, Milo L.; Calomeni, Carolyn A.; Conboy, Kathleen

doi:10.1007/bf02892291

Cited by 75 publications

(44 citation statements)

References 50 publications

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“…Although some physicians may need to be reminded that preventive screening is "the examination of asymptomatic people to classify them as likely or unlikely to have the disease that is the object of screening," 33 it is more likely that systems need to be implemented that remind physicians and staff that screening is due. 34 Symptoms may prompt patients to see their physician and clinicians may feel patients are more likely to agree to be tested if symptoms are present. Authors and organizations reporting CRC testing rates should attempt to distinguish between diagnostic testing and asymptomatic screening rates.…”

Section: Discussionmentioning

confidence: 99%

Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Levy¹,

Nordin²,

Sinift³

et al. 2007

The Journal of the American Board of Family Medicine

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Background: Less than half of eligible Americans have been screened for colorectal cancer (CRC). The objective of this study was to describe physicians' reasons for screening or not screening specific patients for CRC and their approach to CRC testing discussions.Methods: This study used mixed-methods. Physicians described their reasons for screening or not screening 6 randomly chosen patients who were eligible for CRC screening (3 screened and 3 not screened) whose CRC testing status was ascertained by medical record review. Verbatim transcripts from physicians responding to structured interview questions were used to identify themes. Specific elements of discussion were examined for their association with each physician's screening rate. Fifteen randomly chosen Iowa family physicians from the Iowa Research Network stratified by privileges to perform colonoscopy, flexible sigmoidoscopy, or neither procedure dictated the reasons why 43 patients were screened and 40 patients were not screened.Results: Reasons patients were not up to date fell into 2 major categories: (1) no discussion by physician (50%) and (2) patient refusal (43%). Reasons for no discussion included lack of opportunity, assessment that cost would be prohibitive, distraction by other life issues/health problems, physician forgetfulness, and expected patient refusal. Patients declined because of cost, lack of interest, autonomy, other life issues, fear of screening, and lack of symptoms. Patients who were up to date received (1) diagnostic testing (for previous colon pathology or symptoms; 56%) or (2) asymptomatic screening (44%). Physicians who were more adamant about screening had higher screening rates (P < .05; Wilcoxon rank sum). Physicians framed their recommendations differently ("I recommend" vs "They recommend"), with lower screening rates among physicians who used "they recommend" (P ‫؍‬ .05; Wilcoxon rank sum).Conclusions: Reasons many patients remain unscreened for CRC include (1) factors related to the health care system, patient, and physician that impede or prevent discussion; (2)

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Section: Discussionmentioning

confidence: 99%

Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Levy¹,

Nordin²,

Sinift³

et al. 2007

The Journal of the American Board of Family Medicine

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“…There is now extensive evidence that those systems changes that emphasize care delegation and population approaches are important. 11,13,[33][34][35] It is also clear that those changes need to be combined with a focus on overcoming clinical inertia (defined by Berlowitz et al 36 -38 as failure to intensify treatment of a patient who is not at their evidence-based goal). Berlowitz et al also have developed a quality measure for clinical inertia in diabetes care that compares the total treatment a patient receives to the level of treatment expected as a result of their diabetes control.…”

Section: Discussionmentioning

confidence: 99%

Crossing the Quality Chasm for Diabetes Care: The Power of One Physician, His Team, and Systems Thinking

Solberg¹,

Klevan²,

Asche³

2007

The Journal of the American Board of Family Medicine

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Objective: To demonstrate that one physician can dramatically improve care of diabetes patients by taking a systems approach and getting support from leaders and other team members Material and Methods: Pre-/postcomparison of quality measures for the diabetes patients of one primary care physician, compared with those of his entire large multi-specialty medical group. Working with a mentor and with clinic and medical group leaders, he established a clear goal, focused on a repeatable and important performance measure, and used repeated rapid cycle trials to make systems changes in care, with extensive task delegation to team members and emphasis on repeated testing and treatment intensification. The composite outcome measure requires that each diabetes patient meet all 5 of the following: LDL <100, HbA 1C <7, systolic blood pressure <130, regular aspirin use, and tobacco-free status.Results: Over a 24-month period, quarterly measures for this physician's patients rose from 5.7% to 42.9%, while the 7000 diabetes patients of the entire medical group only increased from 4.2% to 12.1%. The change for those patients who stayed under his care for the entire period was even more dramatic-from 2.3% to 46.5% (P ‫؍‬ <.0001). The largest improvements were for smoking documentation, aspirin use, and LDL control, with little change in HbA 1C levels. Diabetes is one of the most common and costly chronic conditions. Most patients with diabetes have multiple comorbidities, and the major source of the extensive morbidity and mortality is cardiovascular disease.1-3 Although there have been some improvements over the past 30 years, there is still much to do, with greater need to reduce cardiovascular risk factors than to improve glycemic control. 4 -7 It is now clear that the old model of education and exhortation will not be adequate to accomplish such broad-based and difficult improvements. Even the intermediate behavior change approaches demonstrated to have some effect in randomized trials, like measurement feedback, opinion leaders, disease management programs, and academic detailing, are unlikely to help very much. 8 -10 Instead, significant redesign of care that emphasizes team care, task delegation, a proactive population approach, facilitation of patient self-management, and extensive use of improved clinical information systems will be needed, similar to the components of the Chronic Care Model of Wagner and colleagues [11][12][13] Perlin and Pogach 14have urged physicians to a higher standard-to review data and care processes, identify goals and strategies, develop action plans, track results, and get feedback. However, clinicians tend to feel discouraged about their ability to improve diabetes care, often blaming patient nonadherence for low performance rates. 15,16 Other clinician barriers include lack of time, simple oversight, lack of payment incentives, other clinical priorities in diabetic patients, other competing projects and priorities, lack of skills in diabetes management, concerns about drug side effects a...

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“…The literature also shows, however, that because they establish the structural context for service delivery to patients, the three broader levels of the health care framework (care units, organizations, and environment) can do much to help reduce these barriers for patients. For example, compelling evidence suggests that systematic diffusion of guidelines, computerized reminder systems, and a system of auditing physician adherence to guidelines, along with providing routine feedback to physicians, improve the rates of recommended preventive care delivery in practices that have a clear policy supporting screening guidelines (52,100,116).…”

Section: Perspectives On the Benefits Of Cancer Screeningmentioning

confidence: 99%

TOWARD A SYSTEM OF CANCER SCREENING IN THE UNITED STATES: Trends and Opportunities

Breen

Meissner

2005

Annu. Rev. Public Health

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■ Abstract The hard work of public health officials, physicians, and disease advocacy groups to educate Americans about the importance of early detection has resulted in uptake of screening tests at levels equivalent to or higher than in countries with organized cancer screening programs. However, the societal costs of high screening rates are larger in the United States than in other countries, including higher prices for screening, more unnecessary testing, and inefficiencies in delivery, especially in small practices. Further, screening rates are not evenly distributed across population groups, and the national expenditure on clinical and community research to promote cancer screening among individuals has not been matched by research efforts that focus on policy or clinical systems to increase screening widely throughout the population. We identify opportunities for organizational change that improve access to use, improve quality, and promote cost effectiveness in cancer screening delivery.

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Delivering clinical preventive services is a systems problem

Cited by 75 publications

References 50 publications

Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Why Hasn't This Patient Been Screened for Colon Cancer? An Iowa Research Network Study

Crossing the Quality Chasm for Diabetes Care: The Power of One Physician, His Team, and Systems Thinking

TOWARD A SYSTEM OF CANCER SCREENING IN THE UNITED STATES: Trends and Opportunities

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