Aren’t these the least ill patients?? “Studies indicate that most cardiovascular deaths occur in patients who were never diagnosed with vascular disease” National Post, February 24 2013 These are tomorrow’s seriously ill patients. “I wish we had caught this earlier.”
The ASaPOpportunity The ASaP Initiative is focused on supporting primary care providers ( physicians and nurse practitioners) and team members to offer a screening and prevention bundle to all their patients through enhanced opportunistic and planned outreach methods, targeting patients who do not present for screening care.
Maneuvers Menu for Adults ManeuverAge (years)Interval Blood Pressure18+Annual Weight18+Annual Height18+At least once Exercise Assessment18+Annual Tobacco Use Assessment18+Annual Alcohol Use Assessment18+Annual Influenza Vaccination/ Screen18+Annual Pap Test Females 21 – 69 3 years Plasma Lipid Profile Males 40 – 74 Females 50 – 74 3 years CV Risk Calculation Males 40 – 74 Females 50 – 74 3 years Diabetes Screen One of: - Fasting Glucose - Hgb A1c - Diabetes Risk Calculator 40+3 years Colorectal Cancer Screen One of: - FOBT/FIT - Flex Sigmoidoscopy - Colonoscopy 50 – 74 2 years 5 years 10 years MammographyFemales 50 - 69 (74)2 years The age and interval of given information is suitable for the general population. The need of individual patients will vary. For each maneuver, the physician/provider should offer as appropriate.
Practice Points ManeuverEvidence Based Practice Points Blood Pressure Use automated B/P cuffs when possible and complete more than one reading for accurate results The evidence does not define a testing interval and states at “every appropriate visit” Height & Weight Height & Weight are useful when using CV & Diabetes risk calculators & determining osteoporosis risk. If patient is obese, see ACFP Tools for Practice 2011. Is any diet better for weight loss or preventing negative health outcomes? http://www.acfp.ca/Portals/0/docs/TFP/20111028_101605.pdf http://www.acfp.ca/Portals/0/docs/TFP/20111028_101605.pdf Exercise Assessment Canadian Physical Activity Guideline 2011: Recommends 150+ minutes per week, with bouts of 10 minutes of vigorous activity. No upper age limit to stop assessing. Those over age 64 with poor mobility should perform physical activities to enhance balance and prevent falls. http://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheetsComplete-ENG.pdfhttp://www.csep.ca/CMFiles/Guidelines/CSEP-InfoSheetsComplete-ENG.pdf For evidence based intervention see ACFP Tools for Practice 2009. Motivating Patients to Move: A Light at the end of the Couch? http://www.acfp.ca/Portals/0/docs/TFP/20111028_111954.pdf http://www.acfp.ca/Portals/0/docs/TFP/20111028_111954.pdf Tobacco Use Assessment Tobacco use includes all forms including smokeless tobacco Evidence recommends that tobacco assessment commence at age 12 years & does not define an assessment interval Alcohol Use Assessment The Canadian College of Family Physicians recommends the use of the following approach http://www.sbir-diba.ca/http://www.sbir-diba.ca/ Evidence does not define an assessment interval Influenza Vaccination/ Screen Pneumococcal vaccination is recommended once for all adults 65+ years; can be administered at time of influenza vaccination. Influenza vaccine recommended annually for Albertans of all ages (free of charge) Pap Test Some new guidelines recommend pap testing starting at age 25 years Assess need based on reported sexual activity and start tests once sexually active Evidence recommends 3 negative tests in 5 years, then every 3 years Plasma Lipid Profile - Fasting Start males at age 40; females at age 50 or age 40 if post-menopausal Canadian Cardiovascular Society 2013: Recommends a 3-5 year interval for those with a Framingham risk score <5%, annual for those at higher risk. http://www.onlinecjc.ca/article/S0828-282X%2812%2901510-3/fulltext http://www.onlinecjc.ca/article/S0828-282X%2812%2901510-3/fulltext Cardiovascular Risk Calculation Highly recommended practice for determining CV risk using any accepted tool Framingham CV risk tool is embedded in all Alberta qualified EMRs Canadian Cardiovascular Society 2013: Recommends a cardiovascular risk assessment, using the 10-Year Risk provided by the Framingham model be completed every 3-5 year. Screen more frequently if at high risk. http://www.onlinecjc.ca/article/S0828- 282X%2812%2901510-3/fulltext http://www.onlinecjc.ca/article/S0828- 282X%2812%2901510-3/fulltext Diabetes Screen - Fasting Glucose OR - Hgb A1c OR - Diabetes Risk Calculator Recommended to use a Diabetes Risk Calculator (e.g. CANRISK, FINDRISC) Canadian Task Force on Preventive Health Care 2012: Does not recommend routine screening for Type 2 diabetes for adults at low to moderate risk of diabetes as determined with a validated risk calculator. http://www.cmaj.ca/content/184/15/1687http://www.cmaj.ca/content/184/15/1687 Colorectal Cancer Screen - FOBT/FIT OR - Flex Sigmoidoscopy OR - Colonoscopy FIT recommended screening for average risk adult. FIT available as of November 2013 Mammography New guidelines recommend mammography for women to age 74 years Clinical Breast Examination not indicated in conjunction with mammography
The Screening “Bundle” Providers will select 5 or more maneuvers for developing screening processes. For example: Cardiovascular Risk - ORTobacco Use Status - OPPAP - both Blood Pressure - OPHeight & Weight - OPMammography - both DiabetesExerciseColorectal - both LipidsFlu Vaccine Alcohol
Summary The 12 maneuvers selected for ASaP were selected based on supporting evidence and strong clinical importance Opportunistic screening focuses on adding screening during appointments for other reasons Outreach screening involves tracking patients who are due and inviting them to make a screening appointment These methods can be involve the provider, the clinic team and/or the primary care organization
Improvement Facilitator Training Improvement Facilitator – Building PCN Quality Improvement (QI) Knowledge and Capacity TOP Clinical Process Advisor Designated QI support specialist Quality Improvement Training in Cohort 2+1+1 = 4 days face- to-face Cohort Webinars Community of Learning Training Cohort Other Cohorts QI community building QI Knowledge Resources Institute for Healthcare Improvement (IHI): Open School Other resources Electronic Medical Record Knowledge Resources Screening and prevention