Fam Pract Manag. 1999;6(1):56-57
Preventive services are an important part of primary care. Few physicians would dispute that. But if someone were to ask you today how well your practice is performing in the area of preventive care, what would you say? Do you know for certain that your patients are getting the preventive services they need? What's more, do you have the data to substantiate it? Do you know how your performance compares to national or regional averages?
Our large group practice recently tackled a project to answer these questions. We wanted to gauge how well we were doing in three targeted areas: mammography screening, childhood immunizations and influenza vaccinations. We hoped that our findings would encourage greater adherence to screening recommendations and would ultimately improve the quality of patient care in our practice.
The assessment
The process we used to assess our prevention efforts is something nearly all physician practices can do, if they are committed to investing some time and effort. Using information from our group's central business office, we first identified patients who fit the demographics for each screening. For example, for influenza, we identified all patients age 65 or older. We then picked at random roughly 400 patients, or 10 per physician, from each of the three groupings: mammography screening, childhood immunizations and influenza vaccination. Several alternates were also picked, to be used if charts could not be located or if a patient had not been seen at least three times in the practice being studied.
Two physicians and a registered nurse who serves as the group's clinical coordinator then carried out manual chart reviews. Using a simple template to record their assessment, they looked to see whether the appropriate intervention was 1) performed and documented, 2) documented as having been done at another location or 3) suggested by the physician but not yet performed or documented. They also recorded the number of visits each patient had made to our office. (See “A sample template.”)
A sample template
The author's practice used a template like the one shown here to record the findings of its chart review for influenza vaccination. The template was modified to assess mammography screening and childhood immunizations as well.
| Patient ID # | DOB | Physician | How many visits has the patient had to the practice? | Patient received the vaccine in our practice. | Patient stated he/she received the vaccine in another facility. | MD documented informing patient of need for vaccine. | Other comments |
|---|---|---|---|---|---|---|---|
| 1 2 3 more | yes no | yes no | yes no | ||||
| 1 2 3 more | yes no | yes no | yes no | ||||
| 1 2 3 more | yes no | yes no | yes no | ||||
| 1 2 3 more | yes no | yes no | yes no | ||||
| 1 2 3 more | yes no | yes no | yes no |
We then analyzed the data and compared our findings to national and local standards (see “National benchmarks”). We assessed compliance of the group as a whole, by individual group practices and by individual physicians.
National benchmarks
There are a number of sources for national, regional and local benchmarks for preventive services. One common source is the National Committee for Quality Assurance (NCQA). NCQA uses its Health Plan Employer Data and Information Set (HEDIS) to measure the performance of HMOs nationwide. The data listed below represent the percentage of patients who received the designated intervention. All (except the influenza data) are the 1997 national averages for all HMOs that submitted data to NCQA. The percentage given for influenza vaccination is the 1995 national average provided by the CDC's Advisory Committee on Immunization Practices.
The three bolded items are those studied by the author's practice.
| Advising smokers to quit | 64.0% |
| Beta blockers for heart attack patients | 74.0% |
| Breast cancer screening | 71.3% |
| Cervical cancer screening | 71.3% |
| Cesarean sections | 20.7% |
| Childhood immunizations | 65.4% |
| Diabetic retinal exams | 39.0% |
| Prenatal care in the first trimester | 83.1% |
| Influenza vaccination for seniors | 58.0% |
Definitions:
Breast cancer screening rate: The percentage of women aged 52 to 69 who have had a mammogram within the last two years.
Childhood immunization rate: The percentage of children who by age two have received at least: four diphtheria/pertussis/tetanus immunizations AND three polio virus immunizations AND one mumps/measles/rubella immunization AND one Hemophilus influenza type B immunization and two hepatitis B vaccines.
Influenza vaccination rate: The percentage of persons aged 65 or older who received an influenza vaccination in the past year.
Recommendations
Overall our group did well when compared to national averages. We did, however, identify these action points, which other physicians may find useful in their own practices:
Increase physician education about current preventive care and screening guidelines. Sources such as the Guide to Clinical Preventive Services, published by the U.S. Preventive Services Task Force, are especially useful.
Consider every visit an opportunity for prevention. It takes just an extra moment at each visit to check the patient's chart or to ask whether he or she has had the appropriate preventive service.
Move away from annual physical exam visits to revolving health screening visits. Rather than going head to toe in one hour once a year, seasonal visits give you more opportunities to make timely interventions.
Increase patient education. Physicians can counter patient misinformation and education deficits with appropriate patient information in the form of handouts, even videos, that explain the importance of certain screenings and when they are recommended.
Improve your reminder systems. Reminder postcards, chart alerts and waiting-room posters are just a few ideas that may help. A computerized system that automatically generates reminders would be ideal.
Utilize nonphysician staff. Your staff can help you boost your preventive screening rates by encouraging or initiating screenings. Empower them to do so.
Consider group delivery of screening/intervention. For example, you could assign every Wednesday in October and November as flu shot day. It's efficient for your office and easy for patients.
Offer your patients incentives, perhaps even cost reductions, for staying current on preventive screenings. The incentives could be anything from a free flu shot to a “buy one, get one free” coupon from your local coffee shop. In other words, be creative.
As modern medicine evolves, so does the need to more efficiently manage the mass of information that comes with it. Manual chart reviews can be costly and labor intensive, but without collection, assessment and interpretation of information, no system can best serve its patients or physicians. Ultimately, our project has served us well and will aid us in our quest for high-quality patient care.