1. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Using U.S. Preventive Services Task Force Recommendations and Resources to Improve Health Professions Education and Patient Care

2. Advancing Excellence in Health Care Acknowledgements This presentation is supported by the Agency for Healthcare Research and Quality (AHRQ) through a Knowledge Transfer contract with the Health Research and Educational Trust (HRET). HRET is a charitable and educational organization affiliated with the American Hospital Association organization affiliated with the American Hospital Association

3. Advancing Excellence in Health Care Session Faculty   David Schulke, Vice President, Research Programs, Health Research and Educational Trust (HRET); AHRQ Outreach Project Director   David Garr, MD, Associate Dean for Community Medicine and Professor of Family Medicine, Medical University of South Carolina; Executive Director of the SC AHEC

4. Advancing Excellence in Health Care Today’s Objectives 1. 1. Learn about the mission, methods, and contributions of the U.S. Preventive Services Task Force (USPSTF) 2. 2. Learn about resources that can be utilized in clinical and educational settings to assist with the provision of preventive services 3. 3. Learn how the interprofessional team can work together to increase patients’ adherence to prevention recommendations

5. Advancing Excellence in Health Care AHRQ has enlisted HRET to --   Enhance awareness among clinicians and health professions educators of the USPSTF’s evidence- based preventive care recommendations   Assist clinicians with implementing and health professions educators with teaching, the USPSTF preventive services recommendations   Document successful strategies for incorporating USPSTF recommendations into clinical practice Goals of the AHRQ Health Professions Outreach Project

6. Advancing Excellence in Health Care U.S. Preventive Services Task Force   Commissioned by Congress in 1984   Members include experts in disease prevention, health promotion, behavioral health, family medicine, internal medicine, nursing, obstetrics/gynecology, pediatrics, preventive medicine, research methods   Members are knowledgeable about clinical prevention, the critical appraisal of evidence and its application to clinical practice   Members are expert in counseling and behavioral interventions for primary care patients

7. Advancing Excellence in Health Care AHRQ and the USPSTF  USPSTF is supported by AHRQ  USPSTF is independent -- AHRQ has no control over recommendations  USPSTF has access to scientific support from AHRQ’s national network of Evidence-based Practice Centers (EPCs)

8. Advancing Excellence in Health Care Task Force Activities   Systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services   Age- and risk-factor specific when evidence is available   For routine use in primary care practice   Recommendations address:   Screening tests   Counseling   Preventive medications

9. Advancing Excellence in Health Care Keys to Understanding USPSTF Recommendations Preventive services recommendations are intended to apply to asymptomatic primary care patients Preventive services recommendations are intended to apply to asymptomatic primary care patients The cost of preventive services has no role or influence The cost of preventive services has no role or influence USPSTF balances the benefits and harms associated with preventive services in developing its recommendations USPSTF balances the benefits and harms associated with preventive services in developing its recommendations

10. Advancing Excellence in Health Care Keys to Understanding USPSTF Recommendations (cont’d) The recommendations often require some individualization and discussion between the clinician and patient The recommendations often require some individualization and discussion between the clinician and patient The USPSTF supports these discussions with evidence The USPSTF supports these discussions with evidence With some preparation, and help from health information technology, clinicians can ensure they’re delivering the best preventive services to our patients With some preparation, and help from health information technology, clinicians can ensure they’re delivering the best preventive services to our patients

11. Advancing Excellence in Health Care USPSTF Recommendations Updated regularly, most recommendations are updated at least every 5 years Most updates are published in major journals when released, and all recommendations and supporting information are always available at www.uspreventiveservicestaskforce.org with: www.uspreventiveservicestaskforce.org   Recommendation Statement   Supporting Article   Evidence Synthesis   Clinical Summary

12. Advancing Excellence in Health Care Grades of USPSTF Recommendations Certainty of Net Benefit Magnitude of Net Benefit SubstantialModerateSmallZero/ negative HighABCD ModerateBBCD LowI (Insufficient evidence) www.uspreventiveservicestaskforce.org/uspstf/grades.htm

13. Advancing Excellence in Health Care AHRQ’s USPSTF Web Site Offers Tools for Different Audiences Two ways for Clinicians to get USPSTF recommendations: 1. 1. Go to USPSTF website for all the information www.preventiveservices.ahrq.gov www.preventiveservices.ahrq.gov 2. 2. Install point of care prompts available via the electronic Preventive Services Selector (ePSS): www.epss.ahrq.govwww.epss.ahrq.gov   Install in an EMR (may require EMR vendor assistance), or   Install on a website or PC desktop (ePSS “widget”), or   Quickly download onto almost any handheld device User friendly Patient information at http://www.healthfinder.gov/http://www.healthfinder.gov/   Includes checklists to monitor individual preventive needs   For USPSTF A & B patient recommendations, see: http://healthfinder.gov/widgets http://healthfinder.gov/widgets

14. Advancing Excellence in Health Care Introducing the electronic Preventive Services Selector (ePSS) Free, portable, decision support application to help clinicians and students quickly find age, gender, behavior-specific USPSTF recommendations for their patients. Downloadable to handhelds (e.g., iPhone; BlackBerry; Palm OS; Windows Mobile). Can be embedded in most EMRs and EHRs (may require vendor assistance). Download ePSS and Website Widget: http://epss.ahrq.gov

15. Advancing Excellence in Health Care Using the ePSS The following slides are based on a presentation by the Spanish Catholic Charities Center with funding from the D.C. Department of Health Can search all recommendations, or, for a targeted search based on age, sex and other factors, follow these steps:   Enter age.   Select sex by clicking Female or Male.   If Female is selected, indicate pregnancy status in the check box.   Indicate Tobacco User by clicking Yes or No.   Indicate Sexually Active by clicking Yes or No.   Click on Show Recommendations button to produce search results.   Click on Reset to clear search criteria and start a new search.

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17. Use the ePSS for Case Study One: 45 year-old male   Elbow pain - new tennis racket   No major chronic diseases   Hernia surgery 10 years ago   1 low-dose aspirin daily   Non-smoker   Occasional alcoholic beverage   TC and HDL-C normal 1 year ago   Married, monogamous   No STIs tested many years ago- no new exposures since   Not overweight; not hypertensive   Asked about prevention   No family history of heart disease or cancer

18. Advancing Excellence in Health Care Case Study One: 45 year-old male (continued) On the ePSS screen, enter 2 digits and 4 clicks--   For Age, enter “45”   For Sex, select “Male”   For Tobacco User, select “no”   For Sexually Active, select “yes”   Click on “Show Recommendations”

19. Advancing Excellence in Health Care Click Here

20. Advancing Excellence in Health Care ePSS View of USPSTF recommendations for 45 ePSS View of USPSTF recommendations for 45 yr old male, non-smoker, who is sexually active yr old male, non-smoker, who is sexually active ePSS View of USPSTF recommendations for 45 ePSS View of USPSTF recommendations for 45 yr old male, non-smoker, who is sexually active yr old male, non-smoker, who is sexually active

21. Advancing Excellence in Health Care Identifying Risk Information   With each patient, the clinician will need to take various additional factors into consideration before making specific recommendations.   The clinician can often find additional information on risk factors to be considered by clicking on the “Risk Info” box next to the recommendation.   For example, in the case of this patient, the first recommendation is to take “Aspirin to Prevent CVD: Men age 45 to 79 to prevent myocardial infarctions.”   Click on “Risk Info” as shown on next two slides.

22. Advancing Excellence in Health Care To drill down and seek underlying risk information in the ePSS click on “Risk Info” where it appears in the ePSS click on “Risk Info” where it appears To drill down and seek underlying risk information in the ePSS click on “Risk Info” where it appears in the ePSS click on “Risk Info” where it appears Click Here

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24. Tailoring the Recommendations for Your Patient   In addition to risk information that may be available, you can click on the “Details” column (with the magnifying glass icon) to get further information and guidance on implementing the recommendation and to help you discuss it with your patient.   A useful collection of patient counseling tools is available at http://epss.ahrq.gov/ePSS/Tools.dohttp://epss.ahrq.gov/ePSS/Tools.do   The next two slides show the content of the “Details” page for our case patient.

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27. Helping the Patient Assess Risk   If you are online via desktop or PDA, the arrow in the previous slide shows where to find a link that takes you to the Framingham risk assessment tool (http://hp2010.nhlbihin.net/atpiii/calculator.asp).   The handheld version of the ePSS requires you to click on the “Tools” tab for a drop down menu, then click again on “Tools” at the bottom of the menu to see the option to display the risk assessment tools.   Accessing the Framingham assessment tool the clinician can enter more data and show the patient their lifetime AMI risk (next slide)…

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29. Using the ePSS in a Clinical Setting Patients may be screened for applicable recommendations by a member of the health care team using the ePSS during initial portion of an encounter   A nurse typically takes vital signs and measures the patient’s height and weight. This provides an opportunity to complete a brief preventive medicine/wellness questionnaire and to consult the ePSS for relevant recommendations. Health care practitioner discusses selected USPSTF recommendations with the patient, recommending lifestyle modification or further screening   May download and print USPSTF recommendations for inclusion in the health record or save in the electronic record   Printed instructions at appropriate reading level provided to the patient for further reference and explanation of the health care team recommendations

30. Advancing Excellence in Health Care The Role of the Interprofessional Team   Prevention greatly benefits from a team approach   Using motivational interviewing is important   No one person in the office should be responsible for addressing the patient’s prevention needs

31. Advancing Excellence in Health Care The Benefit of Interprofessional Care   Sharing responsibility for the patient’s preventive care and outcomes increases team members’ involvement and contributions   Job satisfaction can increase when people believe they are important contributors to the patient’s preventive care and outcomes   The members of the team can be prepared with consistent messages, praise and celebrate patients’ successes

32. Advancing Excellence in Health Care Healthy People 2020 Education for Health Framework Riegelman R. & Garr./Am J Prev Med 2011;40(2):203-206

33. Advancing Excellence in Health Care Healthy People 2020 Education for Health Objectives   ECBP-3: Increase the proportion of elementary, middle, and senior high schools that have health education goals or objectives that address the knowledge and skills articulated in the National Health Education Standards (high school, middle, elementary)   PHI-6: Increase the proportion of 2-year colleges that offer public health or related associate degrees and/or certificate programs

34. Advancing Excellence in Health Care Healthy People 2020 Education for Health Objectives   PHI-4: Increase the proportion of 4-year colleges and universities that offer public health or related majors and/or minors   ECBP-12 – 16: Increase the inclusion of core clinical prevention and population health content in health professions education

35. Advancing Excellence in Health Care Evidence-Based Resources for Healthy People 2020   USPSTF Clinical Preventive Services   Guide to Community Preventive Services   Healthfinder.gov’s Quick Guide to Healthy Living Information for Consumers

36. Advancing Excellence in Health Care Using the ePSS in Education   During clinical rotations, preceptors can help students use the USPSTF recommendations in practice, and vice versa   Clinical rotation directors can set expectation for preceptors that students will use the ePSS to assess patient needs and risks during their rotation   Ask students to download the ePSS   Ask students to select a USPSTF recommendation and present a patient case to peers or to the preceptor   Free resources listed on the next slide can be used in pre-clinical and clinical education of health professions students

37. Advancing Excellence in Health Care   AHRQ’s USPSTF website (http://www.preventiveservices.ahrq.gov) has downloadable electronic Preventive Services Selector (ePSS) app   Information for clinicians and printable patient counseling information is available at http://epss.ahrq.gov/ePSS/Tools.dohttp://epss.ahrq.gov/ePSS/Tools.do   Technical Assistance paper with patient cases for health professions education http://www.ahrq.gov/qual/kt/tfmethods/impuspstf.htmhttp://www.ahrq.gov/qual/kt/tfmethods/impuspstf.htm   PowerPoint slide deck for educators and clinicians: “Understanding the Methods Used by the USPSTF in Developing Recommendations” http://www.ahrq.gov/qual/kt/tfmethods/tfmethods.htm http://www.ahrq.gov/qual/kt/tfmethods/tfmethods.htm   C oming soon:   AACOM PowerPoint slide deck for educators and clinicians: “Putting Prevention into Practice”   Training video for interviewing and motivating patients   Prevention OSCE (Objective Standardized Clinical Examination) AHRQ-supported Resources to Facilitate Teaching about USPSTF Recommendations

38. Advancing Excellence in Health Care   Draft developed by faculty at the Indiana University School of Medicine.   Objectives: Assess the student's ability to – 1. 1. Identify evidence-based preventive care recommendations for a patient based on his/her risk factors in an unbiased yet culturally competent way 2. 2. Assess health risks in a non-judgmental manner, demonstrating culturally sensitive skills   Case Scenario: 38 yr AA Female presents to PCP today for a routine check-up, losing health insurance at the end of the month and hasn’t had an annual exam or complete physical for 5 years. Life has been stressful during the past few months. She wants to be tested for everything that is recommended by her physician. Example of an Objective Standardized Clinical Exam (OSCE) on Preventive Services

39. Advancing Excellence in Health Care Group Discussion   What is going well with prevention in your program?   How are you using/might you use USPSTF resources (e.g. ePSS) in your program?   What might you want to do differently in your program to incorporate the use of USPSTF recommendations?   What more could AHRQ do through this project to help you, your students and patients?

40. Advancing Excellence in Health Care Thank you!