Developing clinical decision tools to implement chronic disease prevention and screening in primary care: the BETTER 2 program (building on existing tools to improve chronic disease prevention and screening in primary care)

Abstract

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial demonstrated the effectiveness of an approach to chronic disease prevention and screening (CDPS) through a new skilled role of a ‘prevention practitioner’(PP). The PP has appointments with patients 40–65 years of age that focus on primary prevention activities and screening of cancer (breast, colorectal, cervical), diabetes and cardiovascular disease and associated lifestyle factors. There are numerous and occasionally conflicting evidence-based guidelines for CDPS, and the majority of these guidelines are focused on specific diseases or conditions; however, primary care providers often attend to patients with multiple conditions. To ensure that high-level evidence guidelines were used, existing clinical practice guidelines and tools were reviewed and integrated into blended BETTER tool kits. Building on the results of the BETTER trial, the BETTER tools were updated for implementation of the BETTER 2 program into participating urban, rural and remote communities across Canada.MethodsA clinical working group consisting of PPs, clinicians and researchers with support from the Centre for Effective Practice reviewed the literature to update, revise and adapt the integrated evidence algorithms and tool kits used in the BETTER trial. These resources are nuanced, based on individual patient risk, values and preferences and are designed to facilitate decision-making between providers across the target diseases and lifestyle factors included in the BETTER 2 program. Using the updated BETTER 2 toolkit, clinicians 1) determine which CDPS actions patients are eligible to receive and 2) develop individualized ‘prevention prescriptions’ with patients through shared decision-making and motivational interviewing.ResultsThe tools identify the patients’ risks and eligible primary CDPS activities: the patient survey captures the patient’s health history; the prevention visit form and integrated CDPS care map identify eligible CDPS activities and facilitate decisions when certain conditions are met; and the ‘bubble diagram’ and ‘prevention prescription’ promote shared decision-making.ConclusionThe integrated clinical decision-making tools of BETTER 2 provide resources for clinicians and policymakers that address patients’ complex care needs beyond single disease approaches and can be adapted to facilitate CDPS in the urban, rural and remote clinical setting.Trial registrationThe registration number of the original RCT BETTER trial was ISRCTN07170460.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0299-9) contains supplementary material, which is available to authorized users.

Hidden care: Revelations of a case‐note audit of physical health care in a community mental health service

“…There are many examples and models available to guide this work (Manca et al . ; World Health Organization (WHO) ; Jacobs et al . ; Hughes ), most notably those informed by the Chronic Care Model (Wagner et al .…”

Implementation of the BETTER 2 program: a qualitative study exploring barriers and facilitators of a novel way to improve chronic disease prevention and screening in primary care

“…Although the role is new, the person who takes on the PP role is typically a health care provider who is already an integral part of a primary care team, such as a nurse, licensed practical nurse, or a dietician who gains specialized skills in CDPS. PPs use tools specifically developed for BETTER that are based on an extensive review and synthesis of high-level evidence for CDPS activities, which has been previously described [3, 4]. Before their prevention visit with the PP, patient participants completed the BETTER health survey, an instrument that captured a detailed prevention and screening history including risk factors such as smoking, physical activity, diet, alcohol, and family history.…”

“…The quantitative results of the implementation of BETTER 2, which include descriptive statistics of the clinical settings, are currently under review for publication at a different journal (Aubrey-Bassler et al, Achievement of chronic disease prevention and screening maneuvers at six-month follow-up: An implementation study of the BETTER 2 Program, manuscript submitted). The protocol for BETTER 2 [8], the knowledge synthesis and the integration process used [4] have been previously published. This paper describes the findings of the qualitative component of the program evaluation, focusing on understanding facilitators and barriers, benefits, and disadvantages of the BETTER approach in different settings in Newfoundland and Labrador, Canada.…”

Would you like to add a weight after this blood pressure, doctor? Discovery of potentially actionable associations between the provision of multiple screens in primary care

“…Recommendations applicable to almost all patients age 45 or older and responsible for the largest effect on health included recording tobacco use, alcohol use, diet, exercise, fasting blood glucose or haemoglobin A1c (A1c), lipid profile including low‐density lipoprotein (LDL), body mass index (BMI), waist circumference (WC), and blood pressure (BP) . While there is some controversy about the frequency with which these data elements should be recorded, frequently proposed intervals and standards for most patients are at least every 2 years for vital signs (BP, WC, and BMI) and at least every 3 years for laboratory tests (fasting blood glucose/A1c and LDL), recorded information about lifestyle risk factors in a summary health profile …”

“…8 While there is some controversy about the frequency with which these data elements should be recorded, frequently proposed intervals and standards for most patients are at least every 2 years for vital signs (BP, WC, and BMI) and at least every 3 years for laboratory tests (fasting blood glucose/A1c and LDL), recorded information about lifestyle risk factors in a summary health profile. 10 However, physicians do not screen their patients consistently. For example, recording tobacco use in primary care electronic medical records (EMRs) has been found to be inconsistent and may vary by patient factors or physician characteristics.…”