1 Finding a BETTER Way Donna Manca, Carolina Aguilar, Kami Kandola, Kris Aubrey-Bassler, Denise Campbell-Scherer, Nicolette Sopcak, Christopher Meaney, Julia Baxter, Melanie Heatherington, and Eva Grunfeld CPHA Conference Toronto - May 27, 2014 A Program to Facilitate Chronic Disease Prevention and Screening in Primary Care

2 Acknowledgements & Disclaimer Production of this presentation has been made possible through a financial contribution from Health Canada, through the Canadian Partnership Against Cancer. The views expressed herein represent the views of the BETTER 2 Coalition and do not necessarily represent the views of the project funders.

3 Background Primary care is an ideal setting for most chronic disease prevention and screening (CDPS) activities Evidence-based tools and strategies are inconsistently applied It would take an additional 7.4 hours/day to address prevention 1 Plethora of guidelines - many lack rigor, 2 conflicting guidelines confuse primary care providers Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) - informed by the Chronic Disease Framework – developed and tested effective approach to CDPS 1.Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: is there enough time for prevention? American journal of public health 2003;93: Graham ID, Beardall S, Carter AO, et al. What is the quality of drug therapy clinical practice guidelines in Canada? CMAJ 2001;165:

4 The BETTER Trial Setting - 8 Primary Care Teams (PCTs) Two interventions Patient Level Intervention: Prevention Practitioner (PP), 1 per PCT Prevention visits with individual patients, prepare prevention prescription tailored to each patient Practice Level Intervention: Practice Facilitator (PF), 1 per 4 PCTs Enable EMR (invitation letters, audit and feedback, decision support), “prevention prescriptions” tailored to the circumstances of each PCT Patient level (PP) intervention - most effective  BETTER 2 Program (expansion & deepen impact)

5 The BETTER Trial Results Grunfeld E, Manca D, Moineddin R, Thorpe KE, Hoch JS, Campbell-Scherer D, Meaney C, Rogers J, Beca J, Krueger P et al: Improving chronic disease prevention and screening in primary care: results of the BETTER pragmatic cluster randomized controlled trial. BMC family practice 2013, 14(1):175.

6 Objectives of the BETTER Program Overall Objective of the BETTER: Improve CDPS in the primary care team setting for: heart disease, diabetes, & cancers including their associated lifestyle risk factors Integrated knowledge translation - research, practice & policy Desired long-term goals of the BETTER: Improved clinical outcomes Reduced burden of chronic disease Improved sustainability of the health care system through improved CDPS in primary care

7 BETTER 2 Program Target Audiences Patients at risk for chronic disease: adults aged 40 – 65, a population eligible for most CDPS maneuvers Increased knowledge, self-management & access to CDPS resources Primary care providers, researchers and policy makers: To improve CDPS in adults aged Develop comprehensive source of tools and transform practice through a patient-level intervention using practice facilitation via a patient level intervention by a health care professional within the practice (PP) Primary Care Groups and Organizations: Facilitate change by dedicating resources (e.g. PPs) to CDPS

8 The Prevention Practitioner – A New Role Targets both at risk populations & individual patients Manca DP, Greiver M, Carroll JC, et al: Finding a BETTER way: A qualitative study exploring the prevention practitioner intervention to improve chronic disease prevention and screening in family practice. BMC family practice 2014, 15(1):66.

9 Guideline Harmonization through Integrated Knowledge Translation Clinicians, Researchers & Policy Working Together Campbell-Scherer D, Rogers J, Manca D, Lang-Robertson K, Bell S, Salvalaggio G, Greiver M, Korownyk C, Klein D, Carroll JC et al: Guideline harmonization and implementation plan for the BETTER trial: Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice. CMAJ Open 2014, 2(1):E1-E10.

10 Spaghetti Diagram BETTER Developed Tools to Address the Modifiable Risk Factors Haydon E, Roerecke M, Giesbrecht N, Rehm J, Kobus-Matthews M. (2006, March). Chronic disease i Ontario and Canada: Determinants, risk factors and prevention priorities: Summary of full report. Prepared for the Ontario Chronic Disease Prevention Alliance & the Ontario Public Health Association. Available from:

11 Preparing for a Prevention Visit The Health Survey is filled in by patients before the visit and includes tools to capture a detailed prevention and screening history including risks such as Smoking Exercise Diet Alcohol Family History An assessment of Readiness to change

12 Prevention Visit Form Extracts information from the patients’ surveys, health record and physical measures to determine eligible CDPS maneuvers & develop an approach informed by the individuals’ risks (lifestyle, family history, etc.)

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14 Algorithm

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16 Prevention Prescription

17 Program Evaluation RE-AIM Evaluation of Effectiveness & Sustainability: REACH Representativeness & proportion participating EFFECTIVENESS Impact on outcomes including a composite index of met/eligible outcomes ADOPTION in different settings IMPLEMENTATION Adaptations and how the intervention was delivered MAINTAIN the approach How BETTER is adapted and maintained in different settings Time and cost of the intervention will be captured

18 Questions?

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21 BETTER 2 Logic model

22 BETTER Tools