VA National Center for Health Promotion and Disease Prevention

Using USPSTF Recommendations

in VHA Clinical Practice

Linda Kinsinger, MD, MPHChief Consultant for Preventive Medicine

Office of Patient Care Services

Veterans Health Administration

• US’s largest integrated health care system– Facilities in all 50 states– 153 medical centers, 745 out-patient clinics

• 5.5 million active patients• Unique population

– Older (half over age 65)– Poorer (~70% with annual incomes <$26,000)– Sicker (more physical and mental health diagnoses)– Mostly men (5% women now but % increasing)

System Features that Support Delivery of Preventive Services

• Computerized patient record system

• Clinical practice guidelines– Cover ~ 20 clinical topics– Address both prevention and treatment

• Clinical reminders

• Performance measures

Performance Measures

• Process measures, based on evidence-based guidelines

• Prevention-related measures based on USPSTF recommendations:– Cancer screening

• Breast • Cervical • Colorectal

– Tobacco use screening and counseling

– Alcohol use screening and counseling

Prevention-Related Performance Measures

• Other prevention-related measures:– Cardiovascular

• Hypertension control, LDL in ischemic heart disease – Diabetes

• Hypertension control• Foot sensory exam• HbA1c control• LDL control• Retinal exam

– Infectious Diseases• Influenza immunization• Pneumococcal immunization

Delivery of Clinical Preventive Services

2000 2004

Test VA Non-VA VA Non-VA

CRC screening 65 51 79 57

Breast cancer screening 74 80 92 77

Cervical cancer screening

98 90 99 90

Cholesterol screening 95 83 96 87

Regular aspirin use 86 79 90 82

Smoking cessation coun. 78 46 75 55

Influenza vaccination 62 54 72 53

Pneumococcal vacc. 71 62 81 63

Ross et al. Arch Intern Med. 2008;168:950-8

VA National Center for Health Promotion and Disease Prevention

• Field-based program office of the Office of Patient Care Services, VHA

• Located in Durham, NC

• 20 staff (physicians, nurses, psychologists, health educators, dietitian, physical therapist, program analysts, administrative staff)

NCP Program Areas

• Clinical Prevention Policy and Practice

• MOVE! Weight Management Program

• HealthierUS Veterans Initiative

• Health Promotion/Employee Wellness

• Veterans Health Education and Information

• Evaluation and Research

Clinical Prevention Policy and Practice:USPSTF Cardiovascular Recommendations

• Inter-agency agreement with AHRQ to develop patient and provider resources on USPSTF cardiovascular preventive services recommendations:– General CVD Recommendations (HTN, Lipids)

(patient only)– Screening for Abdominal Aortic Aneurysm– Aspirin for Primary Prevention of CVD – Screening for Peripheral Arterial Disease and Carotid

Artery Stenosis– Screening for Coronary Heart Disease

Patient Brochures

• Picture of patient resources

Patient Brochure for Screening for AAA

Patient Brochure for Screening for AAA

Provider Fact Sheets

Provider Fact Sheet on Screening for AAA

Provider Fact Sheet on Screening for AAA

VHA Adaption of UPSPTF Recommendation for Screening for AAA

• Adaptations for VHA implementation:– Ultrasound preferred but CT or MRI acceptable– Guidelines on re-screening intervals– No screening needed if had negative study

between ages 60 and 65– Large number of patients in target population –

no deadline set for accomplishing screening of currently eligible patients

– Sample clinical reminder developed– Patient education brochure being developed

Clinical Prevention Policy and Practice:USPSTF Cardiovascular Recommendations

• Evaluation plans– Pilot-testing of resources with small group of

patient health educators and providers– Outside facilitator to gather feedback– Final edits, then production of materials and

wide dissemination to VHA staff– Survey of providers about 6 months after

dissemination

• Dissemination by AHRQ for broad use

Clinical Prevention Policy and Practice:Comprehensive Clinical Preventive Services Policy

• No one VHA policy or set of guidelines addressing all recommended clinical preventive services

• NCP developing a dynamic website with: – VHA recommendations (most based on

USPSTF recommendations)– Information about implementation in VHA– Patient education materials– Provider information/resources

Clinical Prevention Policy and Practice:Comprehensive Clinical Preventive Services Policy

Clinical Prevention Policy and Practice:Comprehensive Clinical Preventive Services Policy

MOVE! Weight Management Program

• Comprehensive weight management program for veterans (www.move.va.gov)

• Available in every VA facility• Based on NIH and USPSTF guidelines for

screening and treatment of obesity– USPSTF recommends that clinicians screen

all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults (B rating).

Conclusion

• VA endorses and supports USPSTF recommendations in many clinical areas.

• We look forward to on-going collaboration with AHRQ and the USPSTF.