PPRNet: An AHRQ funded Research Center in Primary Care Practice Based Research and Learning (P30)

PPRNet: An AHRQ funded Research Center in Primary Care Practice Based Research and Learning (P30)

To present recent (2013 14) USPSTF recommendations for adults To review PS and the ACA To present new PPRNet PS report format To review PPRNet learning about how to improve preventive services delivery

An independent panel of non federal experts in prevention and evidence based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, OB GYN, nurses, and health behavior specialists). http://www.uspreventiveservicestaskforce.org/uspsto pics.htm

A B C D I The USPSTF recommends the service. There is high certainty that the net benefit is substantial. The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small. The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. The USPSTF concludes that current evidence is insufficient to assess the balance of benefits & harms of the service.

Service BRCA risk assessment and genetic counseling/testing HIV infection (all 15 to 65 y.o, pregnant women, others at high risk) Alcohol misuse: screening and behavioral counseling Intimate partner violence (women of childbearing age) HCV one time for those born between 1945 1964 Lung cancer screening CT (adults 55 80 with 30 pack year history and currently smoke or have quit within past 15 years) Screening for gestational diabetes in pregnant women >24 weeks gestation Grade B A B B B B B

B recommendation Screening for women who have 1 or more family members with breast, ovarian, tubal or peritoneal cancer using a screening tool (http://www.uspreventiveservicestaskforce.org/uspstf12/brcatest/brcate stfinalrstab.htm#tab2) or (https://www.breastcancergenescreen.org/default.aspx) Women with positive screen should receive genetic counseling and BRCA testing if indicated D recommendation USPSTF recommends against routine testing for women without FH

15 to 65 year olds and pregnant women One time screen is reasonable, with repeated screening for those at increased risk

Adults 18 or older Single question screening: How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day? Can also use AUDIT, AUDIT C Brief multicontact behavioral counseling seems to have the best evidence of effectiveness

Recommended for women of childbearing age HITS instrument 4 questions, self or clinician administered (http://www.orchd.com/violence/documents/ HITS_eng.pdf)

Persons at high risk for infection (past or current IV drug use, HD, blood tx before 1992, incarceration, intranasal drug use, unregulated tattoos, percutaneous exposures) One time screening for adults born btwn 1945 1965

Annual screening with low dose CT in adults age 55 89 w/ 30 pack year history and currently smoke or quit within past 15 years Screening should be discontinued once person has not smoked for 15 years Most evidence comes from RCTs done in large academic medical centers with expertise in diagnosing abnormal lung lesions

Recently changed from I to B recommendation 2 strategies 2 step approach 50 g OGC, if threshold not met > 100 g 3 hr OGTT 1 step approach 75 g 2 hour test

Service Breast cancer preventive medications for women at increased risk for breast cancer Grade B

B recommendation Clinicians engage in shared decision making with women at increased risk for breast ca about medications to reduce risk Risk can be calculated using tool (http://www.cancer.gov/bcrisktool/) USPSTF concludes that many women with an estimated 5 year breast cancer risk of 3% or greater may benefit Women at increased risk for breast ca and at low risk for adverse medications should be offered risk reducing medication (tamoxifen, raloxifene)

Service Oral cancer Elderly or vulnerable adults for abuse or neglect Peripheral artery disease screening with ABI Routine screening for dementia in older adults Screening for open angle glaucoma in adults Grade I I I I I

Service Estrogen and progestin for the prevention of chronic conditions in women postmenopausal/hysterectomy Vitamin supplementation to prevent cardiovascular disease or cancer Vit D and calcium for fracture prevention in pre or postmenopausal women Grade D D beta carotene, vit E I MVI, other vitamins I premenopausal I postmenopausal with >400IU vit D and >1000 mg calcium D postmenopausal with 400 IU vit D and 1000 mg calcium

http://epss.ahrq.gov/pda/index.js

Covers A and B USPSTF PS and ACIP immunizations at no cost sharing to patients Applies to people enrolled in policies created after March 2010. Grandfathered plans not required to comply with all provisions Covered PS through an in network provider Plans are not required to cover newly endorsed screening until one year after the date of the recommendation Medicare has more discretion over covering recommendations; National Coverage Determination process for new screening tests (can take between 6 months and 2 years)

G0442 Annual alcohol misuse screening (15 min) G0443 Brief face to face behavioral counseling for alcohol misuse (15 min) G0444 Annual depression screening (15 min, allowed only with G0439 AWV) G0445 High intensity behavioral counseling to prevent sexually transmitted infections, face to face, individual, performed semi annually, includes: education, skills training, and guidance on how to change sexual behavior (30 min) G0446 Annual, face to face intensive behavioral therapy for cardiovascular disease, individual (15 min) G0447 Face to face behavioral counseling for obesity (15 min) http://www.cms.gov/medicare/prevention/prevntiongeninfo/downloads/mps_ QuickReferenceChart_1.pdf

BRCA screening and counseling Breast cancer preventive medication Fall prevention in older adults Folic acid supplementation in women capable of pregnancy GC screening in women at increased risk HIV screening Hep C screening (adults born 1945 1965) Intensive behavioral dietary counseling for hyperlipidemia/ other risk factors for CVD and diet related chronic disease Intimate partner violence screening Lung cancer screening Obesity screening and counseling for those >=6 years Skin cancer behavioral counseling STI counseling for all adolescents and adults at high risk Syphilis screening adults at high risk

Maintain UTD HM templates, train all on use Practice policies/procedures, clear communication/expectations re: team care, staff training and education, leadership f/u Flexible entry to HM: direct or via template Patient activation via EHR generated update sheet, clear/consistent messages Nemeth et al : J Am Board Fam Med September October 2012 vol. 25 no. 5 594 604