An Overview of the Alberta Screening & Prevention Initiative

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

The “Gap” in Screening

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 Origins of ASaP

P

The ASaP Partnerships

The ASaP Opportunity

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 AdultsManeuver Age (years) Interval

Blood Pressure 18+ Annual Weight 18+ AnnualHeight 18+ At least onceExercise Assessment 18+ AnnualTobacco Use Assessment 18+ AnnualAlcohol Use Assessment 18+ AnnualInfluenza Vaccination/ Screen 18+ AnnualPap Test Females 21 – 69 3 years

Plasma Lipid ProfileMales 40 – 74

Females 50 – 74 3 years

CV Risk CalculationMales 40 – 74

Females 50 – 74 3 years

Diabetes ScreenOne of:- Fasting Glucose- Hgb A1c- Diabetes Risk Calculator

40+ 3 years

Colorectal Cancer ScreenOne of:- FOBT/FIT- Flex Sigmoidoscopy- Colonoscopy

50 – 74

  2 years5 years10 years

Mammography Females 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 PointsManeuver Evidence Based Practice PointsBlood 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

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.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

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/ 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

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

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/184/15/1687

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 - OR Tobacco Use Status - OP PAP - both

Blood Pressure - OP Height & Weight - OP Mammography - both

Diabetes Exercise Colorectal - both

Lipids Flu 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

ASaP Questions

Questions ?