1. The Impact of Clinical Prompts on Prenatal Care at Two Family Medicine Teaching Clinics Maggie Riley, MD Academic Fellow University of Michigan Dept of Family Medicine

2. Goals of Research To determine how well FM physicians meet the standards for prenatal care To determine how well FM physicians meet the standards for prenatal care To assess whether a clinical intervention can improve compliance to prenatal care standards To assess whether a clinical intervention can improve compliance to prenatal care standards To improve prenatal care provided at our teaching clinics To improve prenatal care provided at our teaching clinics

3. Factors when considering a clinical intervention Impact on existing clinical system Impact on existing clinical system Ease of implementation Ease of implementation Ease of provider/staff use Ease of provider/staff use Cost of intervention Cost of intervention Long-term utility of intervention Long-term utility of intervention Effectiveness of intervention Effectiveness of intervention

4. Utility of Clinical Prompts Improve quality of patient care Improve quality of patient care Track chronic disease management Track chronic disease management Track health maintenance screening Track health maintenance screening Increase provider efficiency Increase provider efficiency Useful for pay-for-performance evaluations Useful for pay-for-performance evaluations

5. Clinical Prompts “The Utility of an Evidence-Based Lecture and Clinical Prompt as Methods to Improve Quality of Care in Colorectal Cancer Screening” Assessed screening rate at baseline, after evidence-based lecture, and after instituting point-of-care clinical prompt Assessed screening rate at baseline, after evidence-based lecture, and after instituting point-of-care clinical prompt Seres KA, et al. Am J of Gastroenterol 2007; 102:1-6

6. Colorectal Clinical Prompts Significantly improved attempts at screening as compared to baseline (39.6% vs. 67.6%, p<0.0001) Significantly improved attempts at screening as compared to baseline (39.6% vs. 67.6%, p<0.0001) Significantly increased ordering of colon imaging (24 vs. 46%, p<0.0001) Significantly increased ordering of colon imaging (24 vs. 46%, p<0.0001) Prompts are superior to lecture Prompts are superior to lecture Low cost intervention Low cost intervention

7. Clinical Prompts ClinfoTracker = Clinical Reminder System (CRS) ClinfoTracker = Clinical Reminder System (CRS) Provides up to date information regarding needed preventive and disease management services at the point of care Provides up to date information regarding needed preventive and disease management services at the point of care

8. Research Population Pregnant females of any age seen at University of MI Ypsilanti or Chelsea FM clinic for their prenatal care Pregnant females of any age seen at University of MI Ypsilanti or Chelsea FM clinic for their prenatal care Both sites are teaching clinics and have varying patient demographics Both sites are teaching clinics and have varying patient demographics

9. Research Methods Implement prompts through ClinfoTracker Implement prompts through ClinfoTracker Compare pre- to post-intervention percent adherence during a four month time period (Nov to March ‘06-07 and ‘07-08) Compare pre- to post-intervention percent adherence during a four month time period (Nov to March ‘06-07 and ‘07-08) Determine if study site or level of experience impact adherence to those standards Determine if study site or level of experience impact adherence to those standards

10. Prompts Generated Prenatal labs (RPR, rubella, HepBsAg, T&S, CBC, pap, GC/CT, HIV, urine culture) Prenatal labs (RPR, rubella, HepBsAg, T&S, CBC, pap, GC/CT, HIV, urine culture) Offer genetic testing (cystic fibrosis, Tay- Sachs, hemoglobinopathies) Offer genetic testing (cystic fibrosis, Tay- Sachs, hemoglobinopathies) First trimester screen (11 to 14 weeks) First trimester screen (11 to 14 weeks) Quad screen or MSAFP (15 to 20 6/7 weeks) Quad screen or MSAFP (15 to 20 6/7 weeks) Influenza vaccine (if pregnant during flu season) Influenza vaccine (if pregnant during flu season) Consider fetal survey Consider fetal survey

11. Prompts Generated One-hour glucose tolerance test One-hour glucose tolerance test 3rd Trimester Antibody Screen and RhoGam – Rh Negative patients ONLY 3rd Trimester Antibody Screen and RhoGam – Rh Negative patients ONLY 2nd/3rd trimester CBC 2nd/3rd trimester CBC Consider Repeat GC/CT Screen in High Risk Populations Consider Repeat GC/CT Screen in High Risk Populations GBS culture GBS culture Antenatal testing Antenatal testing

12. Compliance to Standard Result documented within EMR Result documented within EMR Patient declined test and decline documented Patient declined test and decline documented Test documented as ordered Test documented as ordered Patient not a candidate for the test Patient not a candidate for the test

13. Results Total number of patients: Total number of patients: –144 pre-intervention (53.5% followed by residents) –115 intervention (60% followed by residents) –161 Ypsilanti and 98 Chelsea patients Adherence to ALL prenatal care standards: Adherence to ALL prenatal care standards: –18.6% of baseline patients –57.1% of intervention patients –Statistically significant improvement (P<0.005)

14. Most Commonly Missed Services First trimester aneuploidy screening First trimester aneuploidy screening Genetic screening Genetic screening HIV testing HIV testing Repeat gonorrhea/Chlamydia screening for high risk patients at 28 weeks gestation Repeat gonorrhea/Chlamydia screening for high risk patients at 28 weeks gestation Influenza vaccination Influenza vaccination

15. Statistically Significant Results

16. Study Site and Experience Ypsilanti providers were significantly more likely to offer HIV and GC/Chl testing (P<0.05) Ypsilanti providers were significantly more likely to offer HIV and GC/Chl testing (P<0.05) Residents were significantly more likely than attending physicians to offer HIV testing regardless of site (P=0.009) Residents were significantly more likely than attending physicians to offer HIV testing regardless of site (P=0.009)

17. Conclusions Adherence to prenatal care standards by FM providers at baseline was low Adherence to prenatal care standards by FM providers at baseline was low Overall, level of experience and study site did not impact adherence to standards Overall, level of experience and study site did not impact adherence to standards Intervention significantly improved adherence to early screening for genetic abnormalities, STI screening, and influenza vaccination Intervention significantly improved adherence to early screening for genetic abnormalities, STI screening, and influenza vaccination

18. Conclusions Results support the use of automated prenatal care reminders as an effective way to aid FM physicians in meeting prenatal care standards Results support the use of automated prenatal care reminders as an effective way to aid FM physicians in meeting prenatal care standards Further research should assess the effect of prenatal reminders on efficiency, cost, and perinatal outcomes Further research should assess the effect of prenatal reminders on efficiency, cost, and perinatal outcomes

19. References 1) Seres KA, Kirkpatrick AC, Tierney WM. The Utility of an Evidence-Based Lecture and Clinical Prompt as Methods to Improve Quality of Care in Colorectal Cancer Screening. Am J of Gastroenterol 2007; 102:1-6. 1) Seres KA, Kirkpatrick AC, Tierney WM. The Utility of an Evidence-Based Lecture and Clinical Prompt as Methods to Improve Quality of Care in Colorectal Cancer Screening. Am J of Gastroenterol 2007; 102:1-6. 2) Zoschnick LB, Brackbill EL, Green LA, Van Harrison R, Shumacher RE. University of Michigan Prenatal Care Guideline. Updated 6/2006. Available at: http://www.med.umich.edu/1info/fhp/practicegu ides/newpnc/pnc2006.pdf 2) Zoschnick LB, Brackbill EL, Green LA, Van Harrison R, Shumacher RE. University of Michigan Prenatal Care Guideline. Updated 6/2006. Available at: http://www.med.umich.edu/1info/fhp/practicegu ides/newpnc/pnc2006.pdf