An Overview of the Alberta Screening & Prevention Program

Why Screening? TOP Data Family physicians do a good job of screening patients – when patients book screening appointments! More than 1/3 of patients with physicians do not present for screening There is a significant group of patients who are not getting appropriate screening – those who don’t make appointments for an “annual check-up” or periodic health exam – greater than one third of Albertans. In rural areas, it has been estimated that the number may be as high as 50%. There is a “gap” that needs to be addressed.

The “Gap” in Screening The beige bars represent data from “Screening for Life” – AB Cancer Registry (considered to be the “best” population data we have for Alberta). These numbers a bit out of date - for pap – now 65%; for breast - now 55% They’re “not sure” for colorectal – they say “about 60%”. The numbers represent Alberta women who should be screened for breast and cervical cancer and HAVE been screened - regardless of whether they are attached to a provider, or not.) The green bars are from the EPICS project (Enhancing Participation in Cancer Screening), which looked at the evidence of the screening “offer” for age and gender appropriate patients at any visit. These results are from the “pre-intervention” chart reviews. The brown bars are from Health Screen in Action – the results are also from chart reviews (pre-intervention), but this project only looked at Periodic Health Exams – the “annual” appointment where screening is typically addressed. We can see that physicians are doing a good job of offering screening to those patients who come in for their “annual physical”. We saw that in EPICS as well – but we also noticed that patients who didn’t make that annual physical appointment didn’t get screened. Even those who were in the clinic very frequently with chronic problems. If it wasn’t a Periodic Health Exam, the odds of being offered screening were much lower.

These are the results from Health Screen in Action – the Program represented by the brown bars on the previous graph. (The one where we looked at offers of screening at the Periodic Health Exam.) You may have noticed that the reliability rates of offering screening for PAP and Mammography were already quite high pre-intervention (97% & 92%). Colorectal screening started off lower (62%), but with the inclusion of the checklist reminder, this number improved to 83%. In fact, every maneuver we looked at improved to some degree with the use of a checklist. So, we know that using reminder tools is helpful in improving screening offers, but there’s more to consider.

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.” (This slide is animated) One of the issues with focusing on screening is the reasoning that these are the “least ill” patients. Shouldn’t we focus our energy on those people who we know are seriously ill? Put question out to group. (CLICK) These results were summarized best (and most efficiently!) by the National Post. (Not who we would normally quote, but their reference fit on the slide!) When it comes to cardiovascular disease, so many deaths occur before a person has been diagnosed. Regular screening can prevent us from having to say, “I wish we had caught this earlier.”. This statement was really driven home for us at TOP. During the planning of ASaP, our Director (Doug Stich) received the call that his close friend and best man from his wedding had died suddenly of a massive heart attack at age 51.

The Origins of ASaP National Context Council of Federation Health Innovation Working Group http (://www.councilofthefederation.ca/pdfs/Communique_Task%20Force_Jan_17.pdf) Health Innovation Working Group composed of all provincial and territorial health ministers. While acknowledging that Canada’s provinces and territories are pursuing innovation in their own jurisdictions, Premiers recognize that more can be done together. One of the areas of innovation chosen was clinical practice guidelines that promote greater consistency in the delivery of evidence-informed care. The HIWG mandate aligned well with the vision of the National C- Change Program . It was recommended by HIWG that the C-Change Guidelines for cardiovascular disease be adopted across all provinces The C-CHANGE (Canadian Cardiovascular Harmonization of National Guidelines Endeavour) Program http://c-changeprogram.ca/ was established to harmonize clinical practice recommendations for cardiovascular disease prevention and treatment. C-CHANGE was founded by a number of key organizations. (Institute of Circulatory and Respiratory Health (ICRH) at the Canadian Institute of Health Research (CIHR), the Canadian Vascular Coalition (CVC) and the Public Health Agency of Canada (PHAC)). The C-CHANGE Program was initially undertaken to provide physicians with a simple and effective means to manage cardiovascular risk factors by harmonizing the multiple risk factor clinical practice guidelines into one coordinated, evidence based, clinical practice guideline for CVD management. In order to achieve this in AB it was recognized that a # of partners should be involved. Alberta Context Alberta Health extended invitation to participate to AHS and others including TOP . Currently a number of projects aligned in Alberta AHS Vascular Strategic Clinical Networks –Vascular Risk Reduction Project Integrated clinics project Pharmacy project Worksite project ASaP project

The ASaP Partnerships TOP worked together with a number of partners across Alberta These partners include: -Alberta Health -Alberta Health Services through the Strategic Clinical Networks and DIMR Alberta College of Family Physicians AMA – Primary Care Alliance - HQCA - AIM - Physician Learning Program This Program has been heavily driven by primary care and fully supported at every step.

The ASaP Opportunity The ASaP Program 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

Practice Points

The Screening “Bundle” Providers will select 5 or more maneuvers for developing screening processes. For example: Cardiovascular Risk - OR Tobacco Use Status - OP PAP - both Blood Pressure - OP Height & Weight - OP Mammography - both Diabetes Exercise Colorectal - both Lipids Flu Vaccine Providers will select which maneuvers they’d like to bundle and develop screening processes for. We ask that they select a minimum of 5 – this is primarily to ensure that there’s enough to constitute a “bundle”. As well, it’s likely that most providers are already routinely screening for at least 5 of this group of options already – but they’re likely addressing them individually.

Summary The 11 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 The Value of the PCN facilitator Studies have shown practice facilitation to be 2.76 times more effective at implementing evidence-based guidelines. http://www.annfammed.org/content/10/1/63.short This does not need to be doctor work Assist put the team processes in place ( who’s going to do what) TOP will offer Trained face to face with a cohort of facilitators to gain QI knowledge, skills and build a network in QI Four days total face to face training provided Engage in a Community of Learning to share lessons learned and leading practices throughout the Program Access to the Institute for Healthcare Improvement (IHI.org) Open School courses in Quality Improvement as well as other knowledge resources Support from a designated TOP Clinical Process Advisor, a QI specialist, to meet the unique needs of the facilitator Access through TOP to electronic medical record knowledge resources that support screening and prevention

ASaP Questions Questions ?