1. VA National Center for Health Promotion and Disease Prevention Using USPSTF Recommendations in VHA Clinical Practice Linda Kinsinger, MD, MPH Chief Consultant for Preventive Medicine Office of Patient Care Services

2. Veterans Health Administration US’s largest integrated health care system –Facilities in all 50 states –153 medical centers, 745 out-patient clinics 5.5 million active patients Unique population –Older (half over age 65) –Poorer (~70% with annual incomes <$26,000) –Sicker (more physical and mental health diagnoses) –Mostly men (5% women now but % increasing)

3. System Features that Support Delivery of Preventive Services Computerized patient record system Clinical practice guidelines –Cover ~ 20 clinical topics –Address both prevention and treatment Clinical reminders Performance measures

4. Performance Measures Process measures, based on evidence-based guidelines Prevention-related measures based on USPSTF recommendations: –Cancer screening Breast Cervical Colorectal –Tobacco use screening and counseling –Alcohol use screening and counseling

5. Prevention-Related Performance Measures Other prevention-related measures: –Cardiovascular Hypertension control, LDL in ischemic heart disease –Diabetes Hypertension control Foot sensory exam HbA1c control LDL control Retinal exam –Infectious Diseases Influenza immunization Pneumococcal immunization

6. Delivery of Clinical Preventive Services 20002004 TestVANon-VAVANon-VA CRC screening65517957 Breast cancer screening74809277 Cervical cancer screening98909990 Cholesterol screening95839687 Regular aspirin use86799082 Smoking cessation coun.78467555 Influenza vaccination62547253 Pneumococcal vacc.71628163 Ross et al. Arch Intern Med. 2008;168:950-8

7. VA National Center for Health Promotion and Disease Prevention Field-based program office of the Office of Patient Care Services, VHA Located in Durham, NC 20 staff (physicians, nurses, psychologists, health educators, dietitian, physical therapist, program analysts, administrative staff)

8. NCP Program Areas Clinical Prevention Policy and Practice MOVE! Weight Management Program HealthierUS Veterans Initiative Health Promotion/Employee Wellness Veterans Health Education and Information Evaluation and Research

10. Clinical Prevention Policy and Practice: USPSTF Cardiovascular Recommendations Inter-agency agreement with AHRQ to develop patient and provider resources on USPSTF cardiovascular preventive services recommendations: –General CVD Recommendations (HTN, Lipids) (patient only) –Screening for Abdominal Aortic Aneurysm –Aspirin for Primary Prevention of CVD –Screening for Peripheral Arterial Disease and Carotid Artery Stenosis –Screening for Coronary Heart Disease

11. Patient Brochures Picture of patient resources

12. Patient Brochure for Screening for AAA

14. Provider Fact Sheets

15. Provider Fact Sheet on Screening for AAA

17. VHA Adaption of UPSPTF Recommendation for Screening for AAA Adaptations for VHA implementation: –Ultrasound preferred but CT or MRI acceptable –Guidelines on re-screening intervals –No screening needed if had negative study between ages 60 and 65 –Large number of patients in target population – no deadline set for accomplishing screening of currently eligible patients –Sample clinical reminder developed –Patient education brochure being developed

18. Clinical Prevention Policy and Practice: USPSTF Cardiovascular Recommendations Evaluation plans –Pilot-testing of resources with small group of patient health educators and providers –Outside facilitator to gather feedback –Final edits, then production of materials and wide dissemination to VHA staff –Survey of providers about 6 months after dissemination Dissemination by AHRQ for broad use

19. Clinical Prevention Policy and Practice: Comprehensive Clinical Preventive Services Policy No one VHA policy or set of guidelines addressing all recommended clinical preventive services NCP developing a dynamic website with: –VHA recommendations (most based on USPSTF recommendations) –Information about implementation in VHA –Patient education materials –Provider information/resources

20. Clinical Prevention Policy and Practice: Comprehensive Clinical Preventive Services Policy

22. MOVE! Weight Management Program Comprehensive weight management program for veterans (www.move.va.gov)www.move.va.gov Available in every VA facility Based on NIH and USPSTF guidelines for screening and treatment of obesity –USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults (B rating).

23. Conclusion VA endorses and supports USPSTF recommendations in many clinical areas. We look forward to on-going collaboration with AHRQ and the USPSTF.