- Email: [email protected]
Public Health Detailing of Primary Care Providers
Public Health Detailing of Primary Care Providers New York City’s Experience, 2003–2010 Michelle G. Dresser, MPH, Leslie Short, MPH, Laura Wedemeyer, BA, Victoria Lowerson Bredow, MPH, Rachel Sacks, MPH, Kelly Larson, MPH, Joslyn Levy, MPH, BSN, Lynn D. Silver, MD, MPH Background: Given evidence of widespread underuse of recommended clinical preventive services and chronic disease management, New York City developed the Public Health Detailing Program, a primary care provider outreach initiative to increase uptake of best practices on public health priorities.
Purpose: The goal of the study was to evaluate the effectiveness of the Public Health Detailing Program in helping primary care providers and their staff to improve patient care on public health challenges. Methods: An analysis was conducted of reported changes in clinical practice or behavior by examining providers’ retention and implementation of recommendations for campaigns.
Results: During each campaign, 170 to 443 providers and 136 to 221 sites were reached. Among providers who responded to questions on changes in their practice behavior, the following signifıcant increases occurred from baseline to follow-up. Screening for clinical preventive services increased, including routinely screening for intimate partner violence (14%– 42%). Clinical management increased, such as prescribing longer-lasting supplies of medicine (29%– 42%). Lifestyle modifıcation and behavior change, such as recommending increased physical activity to patients with high cholesterol levels, rose from 52% to 73%. Self-management goal-setting with patients increased, such as using a clinical checkbook to track hemoglobin HbA1c goals (28% to 43%). Conclusions: Data suggest that public health detailing can be effective for linking public health agencies and their recommendations to providers and influencing changes in clinical practice behavior. (Am J Prev Med 2012;42(6S2):S122–S134) © 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
T
he Public Health Detailing Program within the New York City Department of Health and Mental Hygiene (DOHMH) has worked closely with primary care providers and their staff since 2003 to improve patient care by addressing the leading, largely preventable, causes of illness, disability, and death. Drawing on evidence indicating that gaps in provider knowledge and the absence of offıce systems contribute to suboptimal care, the Public Health Detailing Program was designed From the Bureau of Chronic Disease Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York Address correspondence to: Michelle G. Dresser, MPH, Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene, 42-09 28 St, CN-46, Queens, NY 11101. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.03.014
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to address these and other issues of care delivery.1 Public health detailing focuses on neighborhoods facing the greatest health disparities and is part of New York City’s approach to reduce the disproportionate burden of poor health. Public health detailing initiatives center on clinical topics chosen for their anticipated effect on morbidity and mortality and other public health priorities. Although the focus is on managing chronic conditions, the program has “detailed” issues ranging from intimate partner violence screening to recruitment for the New York City Medical Reserve Corps, promoting the implementation and use of electronic health records, supporting exclusive breastfeeding, and improving medication adherence in patients with cardiovascular disease and diabetes. Public health detailing develops its campaigns
© 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Dresser et al / Am J Prev Med 2012;42(6S2):S122–S134
in collaboration with internal and external clinical experts. The program strives to improve primary care physician practice through one-on-one visits, or “detailing,” a well-known and successful strategy usually associated with the pharmaceutical industry.2,3 Whereas most public health interventions in the primary care setting focus on one condition or disease over time, public health detailing has developed a standard methodology for the delivery of a variety of public health messages. Highly trained health department representatives promote evidence-based, clinical preventive services and chronic disease management by delivering brief, targeted messages to the entire clinical care team of physicians, physician assistants, nurse practitioners, nurses, administrators, and other staff.2,4 Through its campaigns, public health detailing supports providers and their staff by (1) outlining and discussing evidence-based key recommendations tailored to specifıc clinical interventions, (2) providing information on new public health policies or practice guidelines, and (3) assessing readiness to adopt key recommendations and supporting clinical tools that best suit the practice.3 The Public Health Detailing Program’s “Action Kits” contain clinical tools, provider resources, and patient education materials to promote evidence-based bestpractices recommended by the DOHMH, which are the focus of discussion during offıce visits by representatives. The current paper outlines the results of evaluations from 20 different campaigns.
Methods Between October 2003 and 2010, the Public Health Detailing Program completed a total of 49 campaigns. Public Health Detailing used survey data of the leading health indicators by ZIP code to prioritize the geographic areas of East and Central Harlem, South Bronx, and North and Central Brooklyn as target areas for its campaigns, although some were expanded citywide. After working initially from a list of Medicaid providers, Public Health Detailing sought to identify and subsequently detail all primary care providers working in these geographic areas. Evidence showed that residents in these neighborhoods were more likely than other New Yorkers to have asthma, cancer, HIV/AIDS, diabetes, and heart disease and to be overweight or obese. These target neighborhoods are the primary geographic focus of many DOHMH programs.5 The Public Health Detailing Program uses highly trained Health Department representatives to deliver consistent and repeat messaging to providers.3 All representatives are expert communicators, and most have graduate degrees or experience in public health or are health professionals. Preceding each campaign, representatives undergo an intensive week-long training, with expert DOHMH faculty, to ensure profıciency in clinical content, communicating recommendations and materials, overcoming barriers and objections, and documentation for evaluation. Representatives usually visit providers three or four times a year with different June 2012
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campaigns, so they can develop relationships with them and their staff and are seen as a valuable resource from the DOHMH. This relationship-building fosters open communication channels and promotes the DOHMH and its resources to providers. No monetary incentives were offered for participation. Each representative is assigned between 35 and 45 primary care sites. A new campaign is implemented approximately every 3 to 4 months and typically lasts 10 to 14 weeks. Most campaigns focus on internal medicine and family practices; however, some have targeted others depending on the topic. For example, the Contraception campaign was expanded to include obstetricians, gynecologists, and pharmacists; the Identifying and Reporting Child Abuse and Neglect campaign was limited to family and pediatric practices. The core costs of personnel are covered by the Public Health Detailing Program, but many campaign expenditures are covered by grants or other DOHMH bureaus, which the program collaborates with to improve its sustainability. The Public Health Detailing Program’s communication strategy focuses on all staff in the practice—“the total offıce call”—a methodology shown to have a positive effect on chronic disease management, testing, and screening.2,3 Campaign messaging centers on key recommendations developed by DOHMH clinical experts and is usually limited to a maximum of three recommendations per campaign topic. Key recommendations provide the basis for assessment questions for evaluation. Representatives are trained to integrate the recommendations verbatim into their interactions with providers and staff at each visit. During visits, representatives promote the graphically appealing “Action Kits,” which contain printed clinical tools, provider resources, and patient education materials and are designed to have the look, feel, and quality of a commercially developed product so as to compete with private industry materials (Figure 1).2 The kit contents address the six components of the Chronic Care Model6 in support of informed clinical decision-making, enhanced patient self-management, improved delivery-system design, expanded use of clinical information systems, increased collaboration with community organizations, and heightened understanding of health system issues pertinent to the topic detailed. During each campaign, representatives visit providers and staff at their assigned sites at least two times.7,8 At these visits, representatives introduce and reinforce the key recommendations and campaign materials as well as answer any questions from the care team about the campaign. Representatives collect survey data by asking providers an identical short set of assessment questions at initial and follow-up visits. Responses help representatives tailor their presentation to align with providers’ interests and needs. In addition to the two standard visits, representatives often visit sites to deliver current and past campaign materials or fulfıll other requests, such as providing supplemental influenza and pneumococcal vaccines. Multiple visits to the entire offıce team are an integral part of the Public Health Detailing Model, providing opportunities to reinforce key recommendations, ensuring consistency of campaign messaging, and developing relationships with care teams. Of the 24 campaigns carried out in the priority underserved neighborhoods from 2003 to 2010, 20 were studied. Those excluded from the analysis were four Influenza and Pneumococcal Vaccination campaigns, which consisted of only one visit. Providers’ retention and implementation of key recommendations for
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Dresser et al / Am J Prev Med 2012;42(6S2):S122–S134 Help patients control hypertension, high cholesteroland diabetes
MEDICATION ADHERENC E A C T I O N K I T For Health Care Providers and Pharmacists
Figure 1. New York City Public Health Detailing Program Medication Adherence Action Kit cover Note: Reprinted with permission from the New York City Department of Health and Mental Hygiene (Copyright 2010).
every campaign are evaluated through responses to the assessment questions. Changes in clinical practice or behavior are measured by providers’ self-reported status from initial to follow-up visit. At the beginning of each initial face-to-face visit, representatives recite assessment questions to providers. At follow-up visits, usually 4 to 6 weeks later, representatives attempt to conduct a second assessment with all providers initially visited. Questions are posed to only licensed prescribers (physicians, nurse practitioners, and physician assistants) because they are usually the decision-makers to implement key recommendations and system changes in the practice. On average, three or four assessment questions are designed for every campaign. The provider is not given a list of answer choices to select from; rather, he or she states to the representative his or her practice behavior, and answers are coded in predetermined categories, including “other,” so that all possible answers can be captured. Representatives receive training and practice to code and evaluate each visit before the campaign begins. Typically, the fırst assessment question examines the hoped-for effectiveness and uptake of individual campaigns by asking whether providers use specifıc guidelines for screening or how they implement recommended strategies for chronic disease management. A second question usually determines how providers identify specifıc populations for particular interventions, such as influenza and pneumococcal vaccination or screening all patients for intimate partner (domestic) violence. In many campaigns, a third assessment question explores providers’ choice of standard screen-
ing or testing tools related to the campaign content. Although this is the standard methodology used to develop the assessment questions, each campaign has its own unique needs. In addition to these questions, representatives ask providers their level of adoption or readiness to adopt the key recommendations by obtaining a commitment from the practitioners. Committing to one or more of the DOHMH evidence-based key recommendations is voluntary on the part of the medical provider and is gauged by self-report. Representatives record intended or adopted use of Public Health Detailing Program Action Kit clinical tools, provider resources, and patient education materials. They also rate the receptiveness of providers and staff to the key recommendations and materials on a 6-point scale ranging from “refusal to meet” to “adopted clinical tool(s)/key recommendations.” Representatives record visit data, including assessment question responses, material use, and rating scale, on a paper visit record and then enter them into an electronic database, allowing Public Health Detailing to analyze campaign data, track campaign reach and frequency, and gauges providers’ interest in the topic and materials. Statistical analysis of the assessment questions is conducted with SPSS 17.0. Chi-square tests are used to determine provider practice change between initial and follow-up visits. The visit data also include practice information, clinician and staff descriptions, and visit details. Representatives also record qualitative notes for each visit, observed best practices, and any other comments and suggestions for the Public Health Detailing Program. In addition to the detailing visit, Public Health Detailing Program staff collect order information from the DOHMH’s call center, which distributes agency-produced literature throughout New York City free of charge. With each campaign, select materials from the Action Kit are made available through the call center so that providers and their staff can call to replenish their supply as needed. Data are specifıcally collected on these materials to determine who is ordering them, which materials are being ordered, and the quantity and frequency of orders. These data help Public Health Detailing know which materials continue to be used by practices even after a campaign ends. A fınal campaign report containing all quantitative and relevant qualitative data is generated and distributed to key stakeholders throughout the DOHMH.
Results All 24 campaigns implemented between 2003 and 2010 in our high-risk neighborhoods and their associated key recommendations are outlined in Table 1. The 20 individual campaigns analyzed for this article reached between 136 and 221 clinical sites, and representatives “detailed” between 170 and 443 providers per campaign. In Table 2, the “All Provider Contacts” and “All Contacts (Providers and Staff)” columns indicate the total number of detailing visits (initial and follow-up visits) during the campaign with providers only and with providers and offıce staff together, respectively. Among all providers who received an initial campaign visit, on average 45% received a follow-up visit during the same campaign (2005–2007: 38% follow-up rate; 2008 –2010: 53% follow-up rate). www.ajpmonline.org
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Table 1. 2003–2010 public health detailing campaigns, key recommendations, and targeted providers: DOHMH Campaign Influenza Vaccination 2003
DOHMH key recommendations All people aged ⱖ50 years should receive an influenza vaccine every year.
Targeted providers Internal medicine
All healthy children aged 6–23 months should receive an influenza vaccine.
Family practice
All people aged ⱖ6 months (and their close contacts) who have a chronic medical condition should receive an influenza vaccine every year.
Pediatrics
All healthcare workers should be vaccinated early in the influenza season. The optimal time to receive influenza vaccine is during October and November, although vaccination should continue to March. Colon Cancer Screening 2004
Refer patients aged ⱖ50 years, or with a family history of colon cancer, for a colonoscopy.
Internal medicine
Colonoscopy is the New York City–recommended screening method.
Family practice
Smoking Cessation 2004
Assess smoking status and readiness to quit at every visit.
Internal medicine
Prescribe medications to assist patients in becoming tobacco-free.
Family practice
Any screening method is better than no screening method at all.
Provide brief counseling on cessation techniques. Asthma 2004
Influenza Vaccination 2004
Diabetes 2005
Assess each patient’s asthma severity at every visit and prescribe accordingly.
Internal medicine
Prescribe inhaled corticosteroids, the most effective treatment for most patients with persistent asthma.
Family practice
Partner with your patients; give them a written “Asthma Action Plan.”
Pediatrics
Only people at risk for serious illness or death from influenza should be vaccinated this year.
Internal medicine
People aged ⱖ65 years and children aged 6–23 months are at high risk.
Family practice
Most healthy people aged 2–64 years should not be vaccinated.
Pediatrics
A - Assess hemoglobin HbA1c level every 3–6 months; goal: ⬍7%.
Internal medicine
B - Measure blood pressure at every visit; goal: ⬍130/80 mm Hg.
Family practice
C - Monitor cholesterol (low-density lipoprotein) level annually; goal: ⬍100 mg/dL. S - Ask about smoking status at every visit; goal: help to quit and to establish a smokefree home. Contraception 2005
Influenza Vaccination 2005
Hypertension 2005
Take a brief sexual history of all patients.
Internal medicine
Encourage the appropriate use of contraception.
Family practice
Offer emergency contraception in advance and as needed.
Pediatrics
People aged ⱖ65 years and children aged 6–23 months should receive an annual influenza vaccine.
Internal medicine
All healthcare workers should receive an influenza vaccine to protect themselves, their families, and their patients.
Family practice
Physicians can implement strategies that increase influenza vaccine coverage in their practice.
Pediatrics
Encourage patients with hypertension and prehypertension to adopt healthy lifestyle changes.
Internal medicine
Prescribe thiazide diuretics as the initial drug of choice for most patients.
Family practice
Aim for target blood pressure of ⬍140/90 mm Hg for most patients with hypertension and ⬍130/80 mm Hg for those with diabetes or kidney disease. Depression Screening 2006
Primary care physicians can effectively detect and manage depression.
Internal medicine
Routinely screen for depression with a simple two-question tool (Patient Health Questionnaire-2).
Family practice
Depression can be treated. Medication and psychotherapy, alone or in combination, can help most patients. HIV Testing 2006
Offer HIV testing as a routine part of medical care to all people aged 18–64 years.
Internal medicine
Counseling requirements have been greatly reduced.
Family practice (continued on next page)
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Table 1. 2003–2010 public health detailing campaigns, key recommendations, and targeted providers: DOHMH (continued) Campaign Influenza and Pneumococcal Vaccination 2006
DOHMH key recommendations
Targeted providers
Vigorously recommend an influenza vaccine for all patients who need to receive one.
Internal medicine
Be sure you and your staff get influenza vaccines early in the season.
Family practice
Continue to vaccinate into the late winter and spring.
Pediatrics
Screen all patients to determine whether they need a pneumococcal vaccine. Cholesterol 2006
Counsel all patients on lifestyle modification, the cornerstone of cardiovascular disease prevention.
Internal medicine
Treat all patients with coronary or other atherosclerotic disease or diabetes to reach a low-density lipoprotein goal of ⬍100 mg/dL.
Family practice
Consider a low-density lipoprotein goal of ⬍70 mg/dL for very high-risk patients. Prescribe statins for most patients at increased risk to lower low-density lipoprotein and reduce cardiovascular events and mortality by ⱖ30%. Alcohol Screening and Brief Intervention 2007
Use a simple four-question screening tool (CAGE-AID) to ask every patient about alcohol.
Internal medicine
Provide clear, personalized advice, and set mutually acceptable goals.
Family practice
Offer information and treatment referrals. Electronic Health Records 2007
Adopt an electronic record that can improve the quality, safety, and efficiency of your primary care practice.
Internal medicine
Take all steps necessary to protect and secure electronic patient information.
Family practice Pediatrics Obstetrics/gynecology
Child Abuse and Neglect 2007
Report all suspected child abuse and neglect by calling the state central register.
Family practice
Do not assume someone else will report. You might be the only person to identify and report an abused or neglected child.
Pediatrics
Adult Obesity 2008
Assess BMI and weight history in all adult patients. If BMI is ⬎25, tell patient he or she is overweight, and address readiness to lose weight. If ready, help patient set a realistic, achievable goal and a plan to achieve that goal.
Internal medicine Family practice
Medical Reserve Corps 2008
Distribute antibiotics or vaccine during an emergency requiring mass prophylaxis. Assist with mass sheltering operations during a coastal storm.
All healthcare professionals
Increase medical surge capacity during an influenza pandemic. Colon Cancer Screening 2008
Intimate Partner Violence 2009
Breastfeeding 2009
Refer patients aged ⱖ50 years or patients aged ⱖ40 years with a family history of colon cancer for colonoscopy.
Internal medicine
Directly refer appropriate patients for colonoscopy rather than first sending patients to a gastrointestinal consultation.
Family practice
Screen all patients for intimate partner violence and encourage disclosure through routine inquiry and dialogue.
Internal medicine
Conduct a clinical assessment of all patients who disclose abuse or for whom abuse is suspected, and document findings thoroughly.
Family practice
If patients disclose intimate partner violence, promptly refer them to social and legal services.
Obstetrics/gynecology
Encourage and prescribe exclusive breastfeeding with no supplementation immediately following birth.
Family practice
Schedule a newborn visit 3–5 days after birth to assess and support breastfeeding.
Pediatrics
Routinely reinforce the importance of exclusive breastfeeding.
Obstetrics/gynecology
Remove formula manufacturers’ samples and educational materials from your office. Know the breastfeeding resources in your community and encourage your patients to use them. (continued on next page)
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Table 1. (continued) Campaign Influenza and Pneumococcal Vaccination 2009
DOHMH key recommendations
Targeted providers
Strongly recommend the appropriate influenza vaccine(s) for all at-risk patients.
Internal medicine
Screen all patients to determine whether they also need pneumococcal vaccination.
Family practice
Be sure you and your staff get vaccinated against both the seasonal and the novel H1N1 influenza as early as possible this fall.
Obstetrics/gynecology
Continue to vaccinate high-risk patients throughout the entire influenza season. Pneumococcal vaccine should be given to people aged ⱖ65 years and anyone with long-term health problems. Obesity in Children 2009
Assess all children and adolescents for overweight and obesity.
Family practice
Educate children, adolescents, and families about healthful eating and physical activity.
Pediatrics
Work with families to set realistic goals for healthy eating and exercise. Medication Adherence 2010
Assess adherence and discuss possible barriers to adherence at every patient visit.
Internal medicine
Reconcile your medication lists with the patient’s list, adjust doses, and eliminate unneeded medications.
Family practice
Prescribe once-daily formulations, less-expensive generics, and longer-lasting supplies of medicine whenever possible. Provide tools such as pill boxes and medication logs to help patients remember to take their medications. DOHMH, New York City Department of Health and Mental Hygiene
Table 3 illustrates changes in self-reported provider behavior documented during the individual campaigns. Campaigns worked to improve providers’ practice behavior to screen patients for clinical preventive services and chronic disease management, provide clinical management, and address lifestyle modifıcation and selfmanagement goal-setting with patients. In most campaigns, increases were seen among providers who positively changed their practice behavior from baseline to follow-up.
Screening for Clinical Preventive Services and Chronic Disease Management Several campaigns showed increases among providers who screened for clinical preventive services. The 2004 Colon Cancer campaign showed improvement in the proportion of providers who reported colonoscopy as their primary screening method for colon cancer, from 26% at baseline to 42% at follow-up (p⫽0.01). When repeated in 2008, an even greater proportion of providers stated that colonoscopy was their preferred screening method 82% to 93% of the time (p⫽0.01). The Depression campaign showed a marked increase in the percentage of providers who used the Patient Health Questionnaire-2,9 from 13% at baseline to 40% at follow-up (p⫽0.01). Greater uptake in the use of clinical tools to assess problem drinking was documented in the Alcohol Screening and Brief Intervention campaign. At baseline, 22% of the providers reported using the CAGE Questionnaire Adapted to Include Drugs (CAGE-AID)10 June 2012
tool to assess for problem drinking, and at follow-up, 42% of the providers reported adopting the CAGE-AID tool (p⫽0.01).10 Among providers visited for the Intimate Partner Violence campaign, those who reported screening all patients for intimate partner violence increased from 39% at baseline to 67% at follow-up (p⬍0.01), and those who reported making screening for intimate partner violence a part of routine inquiry and dialogue increased from 14% to 42% (p⬍0.01). During the Adult Obesity campaign, the number of providers who reported assessing BMI and weight at every visit rose from 25% at baseline to 47% at follow-up (p⫽0.01). The Obesity in Children campaign also showed an increase in providers who assessed BMI percentile-for-age at every visit from 59% at baseline to 73% at follow-up (p⬍|0.01). The proportion of providers addressing chronic disease management was shown in the Diabetes campaign. Providers who reported setting specifıc clinical management goals for patients to check their hemoglobin HbA1c levels at least every 6 months increased from 66% at baseline to 92% at follow-up (p⬍0.01), as well as those who indicated a target hemoglobin HbA1c level of 7 or less increased from 61% at baseline to 83% at follow-up (p⬍0.01).
Clinical Management Improvements seen in the provision of clinical management to patients include changes in prescribing practice. During the Contraception campaign, providers who re-
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Table 2. 2003–2010 public health detailing campaign reach: DOHMH Providers with initial and follow-up visits
All provider contacts
All contacts (providers and staff)
Campaign
Sites
Unique providers
Influenza Vaccination 2003
151
—
—
377
674
4
Colon Cancer Screening 2004
193
—
109
530
982
5
Smoking Cessation 2004
151
—
—
494
911
6
Asthma 2004
168
—
—
246
514
3
Influenza Vaccination 2004a
164
a
a
350
666
4
Diabetes 2005
176
—
—
339
1340
8
214
443
146
528
1732
8
Contraception 2005 a
Contacts per site
Influenza Vaccination 2005
204
129
a
129
255
1
Hypertension 2005
157
349
90
679
1294
8
Depression Screening 2006
198
352
127
366
1030
5
HIV Testing 2006
151
317
90
345
1170
8
116
256
2
Influenza and Pneumococcal Vaccination 2006a
143
116
a
Cholesterol 2006: high-risk patients only
136
279
113
405
1264
9
Alcohol Screening and Brief Intervention 2007
143
297
149
460
1688
12
Electronic Health Records 2007
221
216
109
339
1088
5
Child Abuse and Neglect 2007
154
240
119
345
1169
8
Adult Obesity 2008
199
410
166
588
2433
12
Medical Reserve Corps 2008
199
370
63
435
1742
6
Colon Cancer Screening 2008
189
279
133
413
1424
8
Intimate Partner Violence 2009
196
411
230
659
2234
11
Breastfeeding 2009
152
281
170
455
1452
10
175
684
4
Influenza and Pneumococcal Vaccination 2009a
157
170
a
Obesity in Children 2009
161
291
237
530
1588
10
Medication Adherence 2010
186
340
265
607
1727
9
a
No follow-up visits for 2004, 2005, 2006, and 2009 Influenza campaigns DOHMH, New York City Department of Health and Mental Hygiene
ported prescribing emergency contraception in advance increased from 7% at baseline to 17% at follow-up (p⫽0.01). During the Medication Adherence campaign, the percentage of providers who reported reconciling patients’ medication lists at every visit increased from 86% at baseline to 94% at follow-up (p⬍0.01). Additionally, the percentage of providers who reported prescribing combination pills increased from 26% at baseline to 43% at follow-up (p⬍0.01). Those prescribing generic or lower-cost branded drugs increased from 52% to 79% (p⬍0.01), and the percentage who prescribed longerlasting supplies (90 days vs 30 days), when appropriate, increased from 29% at baseline to 60% at follow-up (p⬍0.01).
Lifestyle Modification Increases in the proportion of providers who reported speaking with their patients about lifestyle modifıcation and behavior change—to aid in the management of certain chronic conditions—were seen throughout campaigns. During the Hypertension campaign, providers who discussed weight loss with their patients increased from 68% at baseline to 80% at follow-up (p⫽0.10), and those who discussed increasing physical activity with their patients rose from 88% to 94% (p⫽0.10). Similarly, during the Cholesterol campaign, at baseline, 52% of the providers reported recommending inwww.ajpmonline.org
Public Health Detailing of Primary Care Providers New York City’s Experience, 2003–2010 Michelle G. Dresser, MPH, Leslie Short, MPH, Laura Wedemeyer, BA, Victoria Lowerson Bredow, MPH, Rachel Sacks, MPH, Kelly Larson, MPH, Joslyn Levy, MPH, BSN, Lynn D. Silver, MD, MPH Background: Given evidence of widespread underuse of recommended clinical preventive services and chronic disease management, New York City developed the Public Health Detailing Program, a primary care provider outreach initiative to increase uptake of best practices on public health priorities.
Purpose: The goal of the study was to evaluate the effectiveness of the Public Health Detailing Program in helping primary care providers and their staff to improve patient care on public health challenges. Methods: An analysis was conducted of reported changes in clinical practice or behavior by examining providers’ retention and implementation of recommendations for campaigns.
Results: During each campaign, 170 to 443 providers and 136 to 221 sites were reached. Among providers who responded to questions on changes in their practice behavior, the following signifıcant increases occurred from baseline to follow-up. Screening for clinical preventive services increased, including routinely screening for intimate partner violence (14%– 42%). Clinical management increased, such as prescribing longer-lasting supplies of medicine (29%– 42%). Lifestyle modifıcation and behavior change, such as recommending increased physical activity to patients with high cholesterol levels, rose from 52% to 73%. Self-management goal-setting with patients increased, such as using a clinical checkbook to track hemoglobin HbA1c goals (28% to 43%). Conclusions: Data suggest that public health detailing can be effective for linking public health agencies and their recommendations to providers and influencing changes in clinical practice behavior. (Am J Prev Med 2012;42(6S2):S122–S134) © 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
T
he Public Health Detailing Program within the New York City Department of Health and Mental Hygiene (DOHMH) has worked closely with primary care providers and their staff since 2003 to improve patient care by addressing the leading, largely preventable, causes of illness, disability, and death. Drawing on evidence indicating that gaps in provider knowledge and the absence of offıce systems contribute to suboptimal care, the Public Health Detailing Program was designed From the Bureau of Chronic Disease Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York Address correspondence to: Michelle G. Dresser, MPH, Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene, 42-09 28 St, CN-46, Queens, NY 11101. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.03.014
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to address these and other issues of care delivery.1 Public health detailing focuses on neighborhoods facing the greatest health disparities and is part of New York City’s approach to reduce the disproportionate burden of poor health. Public health detailing initiatives center on clinical topics chosen for their anticipated effect on morbidity and mortality and other public health priorities. Although the focus is on managing chronic conditions, the program has “detailed” issues ranging from intimate partner violence screening to recruitment for the New York City Medical Reserve Corps, promoting the implementation and use of electronic health records, supporting exclusive breastfeeding, and improving medication adherence in patients with cardiovascular disease and diabetes. Public health detailing develops its campaigns
© 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
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Table 3. 2003–2010 public health detailing campaigns: self-reported changes in clinical practice: DOHMH (continued) Baseline (Initial), %
Follow-up, %
39
44
0.45
13
20
0.19
64
76
0.05
Recommends increased physical activity
52
73
0.01
Recommends statins
54
51
0.01
62
73
0.1
35
59
⬍0.01
67
76
0.1
22
42
0.01
41
34
0.09
40
45
0.43
75
98
⬍0.01
39
40
0.79
25
47
0.01
25
91
0.01
78
96
0.01
57
100
⬍0.01
1
18
⬍0.01
51
0.31
Campaign HIV Testing 2006
Campaign assessment questions and responses
p
Who do you routinely offer HIV testing to within your practice? Offers routine testing to all patients (aged 18–64 years) What type of HIV testing do you perform in your office, if any? Uses rapid testing
Cholesterol 2006
For patients with high cholesterol, diabetes, and/or atherosclerotic disease, what interventions do you routinely recommend for their cholesterol? Recommends general diet change
For patients with diabetes and no other complication, what is your LDL goal for treatment? LDL treatment goals of ⬍100 mg/dL When you prescribe medications, do you regularly provide patients with supporting materials or tools to address adherence? If yes, what are some examples? Provides educational materials on medication(s) and/or medication log Alcohol Screening and Brief Intervention 2007
What types of patients do you generally assess for problem drinking? Screens all patients for problem drinking Do you use a standard screening tool to assess problem drinking? Assesses using the CAGE-AID
Electronic Health Records 2007
Are you considering adopting an electronic health record system for your practice?
Identifying & Reporting Child Abuse & Neglect 2007
Have you reported a case of child abuse and neglect within the last 2 years?
Yes
Yes How do/would you report suspected child abuse and neglect? Call the State Central Register Have you had any training on identifying child abuse and neglect other than the New York State training requirement? Yes
Adult Obesity 2008
How do you assess your patients for obesity? Assesses using BMI and weight history In the past week, have you used nutritional visuals or props when speaking with your patients about obesity? Uses nutritional visuals or props In the past week, have you done formal goal-setting with your patients to address obesity? Uses formal goal-setting with patients
Medical Reserve Corps 2008
Have you heard of New York City Medical Reserve Corps? Yes Are you currently a New York City Medical Reserve Corps volunteer? Yes Would you like become a New York City Medical Reserve Corps volunteer? Yes
44
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Table 3. (continued) Baseline (initial), %
Follow-up, %
93
82
0.01
9
16
0.09
39
67
⬍0.01
At every visit
27
28
0.75
Routine inquiry and dialogue
14
42
⬍0.01
Refer to domestic violence hotline
13
33
⬍0.01
Schedule a follow-up appointment
9
20
⬍0.01
51
50
0.96
32
33
0.76
20
26
0.13
77
88
⬍0.01
59
73
⬍0.01
67
85
⬍0.01
86
94
⬍0.01
Prescribe once-daily formulations, if possible
43
58
⬍0.01
Prescribe combination pills to decrease number of medications
26
43
⬍0.01
Prescribe generic or lower-cost branded drug
52
79
⬍0.01
Prescribe longer-lasting supplies
29
60
⬍0.01
Adjust dosages
52
66
0.04
Depends on Insurance
36
52
⬍0.01
36
41
0.02
Campaign Colon Cancer Screening 2008
Campaign assessment questions and responses
p
What test do you usually recommend for colon cancer screening? Colonoscopy When you refer patients for screening, what referral form do you use? DERS form
Intimate Partner Violence 2009
Whom do you screen for intimate partner violence? All patients How often do you screen for intimate partner violence?
What do you do when a patient discloses intimate partner violence?
Breastfeeding 2009
What infant feeding method do you recommend during prenatal visits? Exclusive breastfeeding For breastfeeding babies, how soon after birth do you schedule newborn visit? 3–5 days after birth What is your policy regarding hospital staff giving formula during admission and/or at discharge in the form of samples? Does not allow formula during hospital stay or in discharge packs
Obesity in Children 2009
How do you currently assess for overweight or obesity in children aged 2–18 years? BMI percentile-for-age How often do you assess for overweight or obesity in children aged 2–18 years? At every visit In the past month, whom have you counseled for healthy eating and physical activity? All patients and their parent/caregiver
Medication Adherence 2010
How often do you reconcile patient’s medication lists? At every visit What prescribing practices do you use to increase patients’ adherence to their medications?
How frequently do you write prescriptions of greater than a 30-day supply for patients on long-term maintenance medications? Often a
No data available CAGE-AID, CAGE Questionnaire Adapted to Include Drugs; DERS, Direct Endoscopic Referral System; DOHMH, New York City Department of Health and Mental Hygiene; LDL, low-density lipoprotein; PHQ, Patient Health Questionnaire.
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creased physical activity to patients with high cholesterol levels, whereas 73% reported doing so at follow-up (p⫽0.01). At baseline, 64% of the providers reported routinely recommending diet change to patients with high cholesterol value. At follow-up, this proportion increased to 76% (p⫽0.05). Additionally, during the Obesity in Children campaign, providers who reported counseling all pediatric patients and their caregivers for healthy eating and physical activity increased from 67% at baseline to 85% at follow-up (p⬍0.01).
Self-Management Goal-Setting In several campaigns, providers reported an increased use of self-management goal-setting with their patients. During the Diabetes campaign, the percentage of providers who reported using a “checkbook-style” diary with patients to track their hemoglobin HbA1c level increased from 28% at baseline to 43% at follow-up (p⬍0.01). Data from the Adult Obesity campaign showed that almost all providers used goal-setting strategies for weight loss with their patients: from 78% at baseline to 96% at follow-up (p⫽0.01). Those reporting use of nutritional visuals or props when speaking about obesity management increased from 25% at baseline to 91% at follow-up (p⫽0.01).
Discussion By establishing open channels of communication; providing valuable information, evidence-based tools, resources, and patient education materials; and building strong relationships with primary care team members in high-need neighborhoods, the Public Health Detailing Program has developed a successful strategy for communicating public health recommendations to clinical care teams. Results of the campaign evaluation indicate that representatives are highly skilled at facilitating conversations and gaining agreements to implement the DOHMH’s recommendations. In the early days of the program, occasionally providers would reject visits, at times confusing them with regulatory activities of other agencies, but by 2010, all practices in the target communities were routinely receiving visits. Evaluation data from individual public health detailing campaigns suggest potential effectiveness of this model, which involves repeat, personal visits to offıce teams, as well as the importance of clear, consistent messaging around key clinical recommendations. All of the responding providers indicated that the detailing visits have changed their practice in a positive way, and 73% of practices implemented clinical tools (including 15% who adopted an electronic health record into their practice), key recommendations, and patient education materials.
Care teams reported that they value these tools and resources to help reinforce key recommendations, initiate conversations, improve mutual understanding, and facilitate goal-setting with their patients during and after campaigns. Since the inception of the Public Health Detailing Program, providers have allotted more time to each visit. Initially, visits lasted an average of 12 minutes, but by 2010, visits increased to an average of 17 minutes, an indication of the providers’ interest in the topic and a reflection of the relationships representatives developed with the practices throughout the years. An essential ingredient is having highly trained, knowledgeable representatives consistently working directly with providers.11 Literature shows that this multifaceted approach is an effective strategy for influencing provider attitudes and behavior and is more effective than certain other types of educational outreach. “Academic detailing” linked with other educational strategies may be the most effective paired intervention, because print-only or mailing interventions generally have not been found to be effective in modifying physician behavior.12,13 Public health detailing serves as a bridge between the DOHMH and community providers, creating a twoway flow of information. The valuable qualitative and quantitative feedback from providers has been used by the DOHMH to guide clinical interventions and programmatic initiatives. Economic sustainability of public health programs, in times of recession, continues to pose a challenge. Public health detailing has an average cost in New York City of approximately $95 per contact, of which $40 is for staff. Similar programs ideally might be fınanced by organizations to which savings would accrue as a result of improved care, such as Medicaid or Medicare, which therefore have direct interest in their continuity. Because the Public Health Detailing Program is run by a local health department—focusing on population health—and is without the evident fınancial interests private insurers might have, this appears to be a source of credibility for the program’s recommendations.
Limitations As stated above, the Public Health Detailing Program’s reach varied among the different campaigns. Fluctuation in the program’s reach for number of sites visited and providers seen varied on several factors, including length of the campaign, size of the target group of providers, variation in staff size, and provider or staff receptivity to messaging. However, a general trend of an increasing number of contacts per site has continued since the Public Health Detailing Program implewww.ajpmonline.org
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mented its fırst campaigns. Sites’ increasing familiarity with the program and representatives’ improving communication skills over the last several years enhanced the reach at each site and reduced wait time to see key offıce staff and providers. Loss of follow-up visits with the same providers during the course of individual campaigns was another limitation of the Public Health Detailing Program. Providers and staff often work at multiple sites on certain days and hours of the week, so the number of providers reached at follow-up is always lower than the number reached during initial visits. Strategies were implemented to increase the percentage match of initial and follow-up visits, particularly with physicians, nurse practitioners, and physician assistants, to 80% or higher, a goal subsequently achieved with at least two campaigns. Changes in the data structure since the program began also limited the conclusions drawn from these results. Some of the early campaigns did not capture data in the same format, and data were unavailable for a few campaigns. Most important, this evaluation relied on provider self-reported practices. Self-report may fail to accurately reflect providers’ actual clinical behavior. Use of clinical data to verify changes in clinical practice would be an important complement to assess effectiveness of this program. The power of electronic medical records also could be used to assess the effect of campaigns on clinical practice. When the Public Health Detailing Program began, electronic medical records were not as widely used as today, and they should be used for evaluating this and other clinical systems improvement efforts. However, counseling and provider–patient conversations around a disease topic and self-management goal-setting are often not adequately captured in the patient record. Patient exit surveys or other mechanisms to evaluate the messages patients received during an offıce visit, as well as which ones they intend to act on, would be another possible evaluation approach for the program. Finally, the extent to which the assessed practices would have changed in the absence of the Public Health Detailing Program effort is unknown. Providers are regularly exposed to numerous opportunities that may influence the way they practice medicine, such as continuing education courses, medical journals, conferences, and other means by which evidence-based recommendations and materials can be acquired. These factors alone, or in conjunction with public health detailing, could have affected clinical practice and behavior.
Conclusion Overall, the Public Health Detailing Program has been received very positively by the medical community in the June 2012
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underserved communities prioritized by the program. Despite the limitations noted, evaluation data based on provider self-report suggest that public health detailing can be an effective strategy for linking public health agencies and their recommendations to medical providers and staff as well as assisting in the development of future program and policy initiatives. The professional relationships developed between the providers and their staff and the DOHMH permit a dialogue described by Avorn: These conversations enable a talented communicator to understand the physician’s current practices, beliefs, and attitudes, making it possible to tailor a behavior-change message specifıcally to that individual’s decision-making process.11
Other public health agencies may fınd this approach for promoting important clinical practices a useful strategy to assist in improving population health. Publication of this article was supported by the U.S. DHHS Health Resources and Services Administration (HRSA) and the NIH National Institute on Minority Health and Health Disparities. The authors thank Tamara Dumanovsky, PhD, for her expertise and feedback as the former Director of Research and Evaluation for the Bureau of Chronic Disease Prevention and Control at the New York City Department of Health and Mental Hygiene as well as the many Health Department representatives for their detailing throughout the years. Human participant protection was not required because this review of the literature did not involve human participants. No fınancial disclosures were reported by the authors of this paper.
References 1. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q. 1996;4(2):12–25. 2. Larson K, Levy J, Rome MG, Matte TD, Silver LD, Frieden TR. Public health detailing: a strategy to improve the delivery of clinical preventive services in New York City. Public Health Rep. 2006;121(3):228 –234. 3. Soumerai SB, Avorn J. Principles of educational outreach (‘academic detailing’) to improve clinical decision making. JAMA. 1990;263(4): 549 –556. 4. Shojania KG, Ranji SR, McDonald KM, et al. Effects of quality improvement strategies for type 2 diabetes on glycemic control: a metaregression analysis. JAMA. 2006;296(4):427– 440. 5. New York City Department of Health and Mental Hygiene. Community Health Profıles. 2006. www.nyc.gov/html/doh/html/data/data.shtml. 6. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288(14):1775–1779. 7. Sheinfeld Gorin S, Gemson D, Ashford A, et al. Cancer education among primary care physicians in an underserved community. Am J Prev Med. 2000;19(1):53–58. 8. Boom JA, Nelson CS, Laufman LE, Kohrt AE, Kozinetz CA. Improvement in provider immunization knowledge and behaviors
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following a peer education intervention. Clin Pediatr (Phila). 2007;46(8):706 –717. 9. Spitzer RL, Kroenke K, Williams JBW. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. PrimaryCare Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282(18):1737–1744. 10. Petit J, Sederer LI. Brief intervention for alcohol problems. New York City Department of Health and Mental Hygiene. City Health Information. 2006;25(10):71–78.
11. Avorn J. Transforming trial results into practice change: the fınal translational hurdle: comment on “Impact of the ALLHAT/JNC7 Dissemination Project on thiazide-type diuretic use”. Arch Intern Med. 2010;170(10):858 – 860. 12. Avorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach: a randomized controlled trial of academically based “detailing.” N Engl J Med. 1983;308(24):1457–1463. 13. Heffner JE. Altering physician behavior to improve clinical performance. Top Health Inf Manage. 2001;22(2):1–9.
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Purpose: The goal of the study was to evaluate the effectiveness of the Public Health Detailing Program in helping primary care providers and their staff to improve patient care on public health challenges. Methods: An analysis was conducted of reported changes in clinical practice or behavior by examining providers’ retention and implementation of recommendations for campaigns.
Results: During each campaign, 170 to 443 providers and 136 to 221 sites were reached. Among providers who responded to questions on changes in their practice behavior, the following signifıcant increases occurred from baseline to follow-up. Screening for clinical preventive services increased, including routinely screening for intimate partner violence (14%– 42%). Clinical management increased, such as prescribing longer-lasting supplies of medicine (29%– 42%). Lifestyle modifıcation and behavior change, such as recommending increased physical activity to patients with high cholesterol levels, rose from 52% to 73%. Self-management goal-setting with patients increased, such as using a clinical checkbook to track hemoglobin HbA1c goals (28% to 43%). Conclusions: Data suggest that public health detailing can be effective for linking public health agencies and their recommendations to providers and influencing changes in clinical practice behavior. (Am J Prev Med 2012;42(6S2):S122–S134) © 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
T
he Public Health Detailing Program within the New York City Department of Health and Mental Hygiene (DOHMH) has worked closely with primary care providers and their staff since 2003 to improve patient care by addressing the leading, largely preventable, causes of illness, disability, and death. Drawing on evidence indicating that gaps in provider knowledge and the absence of offıce systems contribute to suboptimal care, the Public Health Detailing Program was designed From the Bureau of Chronic Disease Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York Address correspondence to: Michelle G. Dresser, MPH, Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene, 42-09 28 St, CN-46, Queens, NY 11101. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.03.014
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to address these and other issues of care delivery.1 Public health detailing focuses on neighborhoods facing the greatest health disparities and is part of New York City’s approach to reduce the disproportionate burden of poor health. Public health detailing initiatives center on clinical topics chosen for their anticipated effect on morbidity and mortality and other public health priorities. Although the focus is on managing chronic conditions, the program has “detailed” issues ranging from intimate partner violence screening to recruitment for the New York City Medical Reserve Corps, promoting the implementation and use of electronic health records, supporting exclusive breastfeeding, and improving medication adherence in patients with cardiovascular disease and diabetes. Public health detailing develops its campaigns
© 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
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in collaboration with internal and external clinical experts. The program strives to improve primary care physician practice through one-on-one visits, or “detailing,” a well-known and successful strategy usually associated with the pharmaceutical industry.2,3 Whereas most public health interventions in the primary care setting focus on one condition or disease over time, public health detailing has developed a standard methodology for the delivery of a variety of public health messages. Highly trained health department representatives promote evidence-based, clinical preventive services and chronic disease management by delivering brief, targeted messages to the entire clinical care team of physicians, physician assistants, nurse practitioners, nurses, administrators, and other staff.2,4 Through its campaigns, public health detailing supports providers and their staff by (1) outlining and discussing evidence-based key recommendations tailored to specifıc clinical interventions, (2) providing information on new public health policies or practice guidelines, and (3) assessing readiness to adopt key recommendations and supporting clinical tools that best suit the practice.3 The Public Health Detailing Program’s “Action Kits” contain clinical tools, provider resources, and patient education materials to promote evidence-based bestpractices recommended by the DOHMH, which are the focus of discussion during offıce visits by representatives. The current paper outlines the results of evaluations from 20 different campaigns.
Methods Between October 2003 and 2010, the Public Health Detailing Program completed a total of 49 campaigns. Public Health Detailing used survey data of the leading health indicators by ZIP code to prioritize the geographic areas of East and Central Harlem, South Bronx, and North and Central Brooklyn as target areas for its campaigns, although some were expanded citywide. After working initially from a list of Medicaid providers, Public Health Detailing sought to identify and subsequently detail all primary care providers working in these geographic areas. Evidence showed that residents in these neighborhoods were more likely than other New Yorkers to have asthma, cancer, HIV/AIDS, diabetes, and heart disease and to be overweight or obese. These target neighborhoods are the primary geographic focus of many DOHMH programs.5 The Public Health Detailing Program uses highly trained Health Department representatives to deliver consistent and repeat messaging to providers.3 All representatives are expert communicators, and most have graduate degrees or experience in public health or are health professionals. Preceding each campaign, representatives undergo an intensive week-long training, with expert DOHMH faculty, to ensure profıciency in clinical content, communicating recommendations and materials, overcoming barriers and objections, and documentation for evaluation. Representatives usually visit providers three or four times a year with different June 2012
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campaigns, so they can develop relationships with them and their staff and are seen as a valuable resource from the DOHMH. This relationship-building fosters open communication channels and promotes the DOHMH and its resources to providers. No monetary incentives were offered for participation. Each representative is assigned between 35 and 45 primary care sites. A new campaign is implemented approximately every 3 to 4 months and typically lasts 10 to 14 weeks. Most campaigns focus on internal medicine and family practices; however, some have targeted others depending on the topic. For example, the Contraception campaign was expanded to include obstetricians, gynecologists, and pharmacists; the Identifying and Reporting Child Abuse and Neglect campaign was limited to family and pediatric practices. The core costs of personnel are covered by the Public Health Detailing Program, but many campaign expenditures are covered by grants or other DOHMH bureaus, which the program collaborates with to improve its sustainability. The Public Health Detailing Program’s communication strategy focuses on all staff in the practice—“the total offıce call”—a methodology shown to have a positive effect on chronic disease management, testing, and screening.2,3 Campaign messaging centers on key recommendations developed by DOHMH clinical experts and is usually limited to a maximum of three recommendations per campaign topic. Key recommendations provide the basis for assessment questions for evaluation. Representatives are trained to integrate the recommendations verbatim into their interactions with providers and staff at each visit. During visits, representatives promote the graphically appealing “Action Kits,” which contain printed clinical tools, provider resources, and patient education materials and are designed to have the look, feel, and quality of a commercially developed product so as to compete with private industry materials (Figure 1).2 The kit contents address the six components of the Chronic Care Model6 in support of informed clinical decision-making, enhanced patient self-management, improved delivery-system design, expanded use of clinical information systems, increased collaboration with community organizations, and heightened understanding of health system issues pertinent to the topic detailed. During each campaign, representatives visit providers and staff at their assigned sites at least two times.7,8 At these visits, representatives introduce and reinforce the key recommendations and campaign materials as well as answer any questions from the care team about the campaign. Representatives collect survey data by asking providers an identical short set of assessment questions at initial and follow-up visits. Responses help representatives tailor their presentation to align with providers’ interests and needs. In addition to the two standard visits, representatives often visit sites to deliver current and past campaign materials or fulfıll other requests, such as providing supplemental influenza and pneumococcal vaccines. Multiple visits to the entire offıce team are an integral part of the Public Health Detailing Model, providing opportunities to reinforce key recommendations, ensuring consistency of campaign messaging, and developing relationships with care teams. Of the 24 campaigns carried out in the priority underserved neighborhoods from 2003 to 2010, 20 were studied. Those excluded from the analysis were four Influenza and Pneumococcal Vaccination campaigns, which consisted of only one visit. Providers’ retention and implementation of key recommendations for
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MEDICATION ADHERENC E A C T I O N K I T For Health Care Providers and Pharmacists
Figure 1. New York City Public Health Detailing Program Medication Adherence Action Kit cover Note: Reprinted with permission from the New York City Department of Health and Mental Hygiene (Copyright 2010).
every campaign are evaluated through responses to the assessment questions. Changes in clinical practice or behavior are measured by providers’ self-reported status from initial to follow-up visit. At the beginning of each initial face-to-face visit, representatives recite assessment questions to providers. At follow-up visits, usually 4 to 6 weeks later, representatives attempt to conduct a second assessment with all providers initially visited. Questions are posed to only licensed prescribers (physicians, nurse practitioners, and physician assistants) because they are usually the decision-makers to implement key recommendations and system changes in the practice. On average, three or four assessment questions are designed for every campaign. The provider is not given a list of answer choices to select from; rather, he or she states to the representative his or her practice behavior, and answers are coded in predetermined categories, including “other,” so that all possible answers can be captured. Representatives receive training and practice to code and evaluate each visit before the campaign begins. Typically, the fırst assessment question examines the hoped-for effectiveness and uptake of individual campaigns by asking whether providers use specifıc guidelines for screening or how they implement recommended strategies for chronic disease management. A second question usually determines how providers identify specifıc populations for particular interventions, such as influenza and pneumococcal vaccination or screening all patients for intimate partner (domestic) violence. In many campaigns, a third assessment question explores providers’ choice of standard screen-
ing or testing tools related to the campaign content. Although this is the standard methodology used to develop the assessment questions, each campaign has its own unique needs. In addition to these questions, representatives ask providers their level of adoption or readiness to adopt the key recommendations by obtaining a commitment from the practitioners. Committing to one or more of the DOHMH evidence-based key recommendations is voluntary on the part of the medical provider and is gauged by self-report. Representatives record intended or adopted use of Public Health Detailing Program Action Kit clinical tools, provider resources, and patient education materials. They also rate the receptiveness of providers and staff to the key recommendations and materials on a 6-point scale ranging from “refusal to meet” to “adopted clinical tool(s)/key recommendations.” Representatives record visit data, including assessment question responses, material use, and rating scale, on a paper visit record and then enter them into an electronic database, allowing Public Health Detailing to analyze campaign data, track campaign reach and frequency, and gauges providers’ interest in the topic and materials. Statistical analysis of the assessment questions is conducted with SPSS 17.0. Chi-square tests are used to determine provider practice change between initial and follow-up visits. The visit data also include practice information, clinician and staff descriptions, and visit details. Representatives also record qualitative notes for each visit, observed best practices, and any other comments and suggestions for the Public Health Detailing Program. In addition to the detailing visit, Public Health Detailing Program staff collect order information from the DOHMH’s call center, which distributes agency-produced literature throughout New York City free of charge. With each campaign, select materials from the Action Kit are made available through the call center so that providers and their staff can call to replenish their supply as needed. Data are specifıcally collected on these materials to determine who is ordering them, which materials are being ordered, and the quantity and frequency of orders. These data help Public Health Detailing know which materials continue to be used by practices even after a campaign ends. A fınal campaign report containing all quantitative and relevant qualitative data is generated and distributed to key stakeholders throughout the DOHMH.
Results All 24 campaigns implemented between 2003 and 2010 in our high-risk neighborhoods and their associated key recommendations are outlined in Table 1. The 20 individual campaigns analyzed for this article reached between 136 and 221 clinical sites, and representatives “detailed” between 170 and 443 providers per campaign. In Table 2, the “All Provider Contacts” and “All Contacts (Providers and Staff)” columns indicate the total number of detailing visits (initial and follow-up visits) during the campaign with providers only and with providers and offıce staff together, respectively. Among all providers who received an initial campaign visit, on average 45% received a follow-up visit during the same campaign (2005–2007: 38% follow-up rate; 2008 –2010: 53% follow-up rate). www.ajpmonline.org
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Table 1. 2003–2010 public health detailing campaigns, key recommendations, and targeted providers: DOHMH Campaign Influenza Vaccination 2003
DOHMH key recommendations All people aged ⱖ50 years should receive an influenza vaccine every year.
Targeted providers Internal medicine
All healthy children aged 6–23 months should receive an influenza vaccine.
Family practice
All people aged ⱖ6 months (and their close contacts) who have a chronic medical condition should receive an influenza vaccine every year.
Pediatrics
All healthcare workers should be vaccinated early in the influenza season. The optimal time to receive influenza vaccine is during October and November, although vaccination should continue to March. Colon Cancer Screening 2004
Refer patients aged ⱖ50 years, or with a family history of colon cancer, for a colonoscopy.
Internal medicine
Colonoscopy is the New York City–recommended screening method.
Family practice
Smoking Cessation 2004
Assess smoking status and readiness to quit at every visit.
Internal medicine
Prescribe medications to assist patients in becoming tobacco-free.
Family practice
Any screening method is better than no screening method at all.
Provide brief counseling on cessation techniques. Asthma 2004
Influenza Vaccination 2004
Diabetes 2005
Assess each patient’s asthma severity at every visit and prescribe accordingly.
Internal medicine
Prescribe inhaled corticosteroids, the most effective treatment for most patients with persistent asthma.
Family practice
Partner with your patients; give them a written “Asthma Action Plan.”
Pediatrics
Only people at risk for serious illness or death from influenza should be vaccinated this year.
Internal medicine
People aged ⱖ65 years and children aged 6–23 months are at high risk.
Family practice
Most healthy people aged 2–64 years should not be vaccinated.
Pediatrics
A - Assess hemoglobin HbA1c level every 3–6 months; goal: ⬍7%.
Internal medicine
B - Measure blood pressure at every visit; goal: ⬍130/80 mm Hg.
Family practice
C - Monitor cholesterol (low-density lipoprotein) level annually; goal: ⬍100 mg/dL. S - Ask about smoking status at every visit; goal: help to quit and to establish a smokefree home. Contraception 2005
Influenza Vaccination 2005
Hypertension 2005
Take a brief sexual history of all patients.
Internal medicine
Encourage the appropriate use of contraception.
Family practice
Offer emergency contraception in advance and as needed.
Pediatrics
People aged ⱖ65 years and children aged 6–23 months should receive an annual influenza vaccine.
Internal medicine
All healthcare workers should receive an influenza vaccine to protect themselves, their families, and their patients.
Family practice
Physicians can implement strategies that increase influenza vaccine coverage in their practice.
Pediatrics
Encourage patients with hypertension and prehypertension to adopt healthy lifestyle changes.
Internal medicine
Prescribe thiazide diuretics as the initial drug of choice for most patients.
Family practice
Aim for target blood pressure of ⬍140/90 mm Hg for most patients with hypertension and ⬍130/80 mm Hg for those with diabetes or kidney disease. Depression Screening 2006
Primary care physicians can effectively detect and manage depression.
Internal medicine
Routinely screen for depression with a simple two-question tool (Patient Health Questionnaire-2).
Family practice
Depression can be treated. Medication and psychotherapy, alone or in combination, can help most patients. HIV Testing 2006
Offer HIV testing as a routine part of medical care to all people aged 18–64 years.
Internal medicine
Counseling requirements have been greatly reduced.
Family practice (continued on next page)
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Table 1. 2003–2010 public health detailing campaigns, key recommendations, and targeted providers: DOHMH (continued) Campaign Influenza and Pneumococcal Vaccination 2006
DOHMH key recommendations
Targeted providers
Vigorously recommend an influenza vaccine for all patients who need to receive one.
Internal medicine
Be sure you and your staff get influenza vaccines early in the season.
Family practice
Continue to vaccinate into the late winter and spring.
Pediatrics
Screen all patients to determine whether they need a pneumococcal vaccine. Cholesterol 2006
Counsel all patients on lifestyle modification, the cornerstone of cardiovascular disease prevention.
Internal medicine
Treat all patients with coronary or other atherosclerotic disease or diabetes to reach a low-density lipoprotein goal of ⬍100 mg/dL.
Family practice
Consider a low-density lipoprotein goal of ⬍70 mg/dL for very high-risk patients. Prescribe statins for most patients at increased risk to lower low-density lipoprotein and reduce cardiovascular events and mortality by ⱖ30%. Alcohol Screening and Brief Intervention 2007
Use a simple four-question screening tool (CAGE-AID) to ask every patient about alcohol.
Internal medicine
Provide clear, personalized advice, and set mutually acceptable goals.
Family practice
Offer information and treatment referrals. Electronic Health Records 2007
Adopt an electronic record that can improve the quality, safety, and efficiency of your primary care practice.
Internal medicine
Take all steps necessary to protect and secure electronic patient information.
Family practice Pediatrics Obstetrics/gynecology
Child Abuse and Neglect 2007
Report all suspected child abuse and neglect by calling the state central register.
Family practice
Do not assume someone else will report. You might be the only person to identify and report an abused or neglected child.
Pediatrics
Adult Obesity 2008
Assess BMI and weight history in all adult patients. If BMI is ⬎25, tell patient he or she is overweight, and address readiness to lose weight. If ready, help patient set a realistic, achievable goal and a plan to achieve that goal.
Internal medicine Family practice
Medical Reserve Corps 2008
Distribute antibiotics or vaccine during an emergency requiring mass prophylaxis. Assist with mass sheltering operations during a coastal storm.
All healthcare professionals
Increase medical surge capacity during an influenza pandemic. Colon Cancer Screening 2008
Intimate Partner Violence 2009
Breastfeeding 2009
Refer patients aged ⱖ50 years or patients aged ⱖ40 years with a family history of colon cancer for colonoscopy.
Internal medicine
Directly refer appropriate patients for colonoscopy rather than first sending patients to a gastrointestinal consultation.
Family practice
Screen all patients for intimate partner violence and encourage disclosure through routine inquiry and dialogue.
Internal medicine
Conduct a clinical assessment of all patients who disclose abuse or for whom abuse is suspected, and document findings thoroughly.
Family practice
If patients disclose intimate partner violence, promptly refer them to social and legal services.
Obstetrics/gynecology
Encourage and prescribe exclusive breastfeeding with no supplementation immediately following birth.
Family practice
Schedule a newborn visit 3–5 days after birth to assess and support breastfeeding.
Pediatrics
Routinely reinforce the importance of exclusive breastfeeding.
Obstetrics/gynecology
Remove formula manufacturers’ samples and educational materials from your office. Know the breastfeeding resources in your community and encourage your patients to use them. (continued on next page)
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Table 1. (continued) Campaign Influenza and Pneumococcal Vaccination 2009
DOHMH key recommendations
Targeted providers
Strongly recommend the appropriate influenza vaccine(s) for all at-risk patients.
Internal medicine
Screen all patients to determine whether they also need pneumococcal vaccination.
Family practice
Be sure you and your staff get vaccinated against both the seasonal and the novel H1N1 influenza as early as possible this fall.
Obstetrics/gynecology
Continue to vaccinate high-risk patients throughout the entire influenza season. Pneumococcal vaccine should be given to people aged ⱖ65 years and anyone with long-term health problems. Obesity in Children 2009
Assess all children and adolescents for overweight and obesity.
Family practice
Educate children, adolescents, and families about healthful eating and physical activity.
Pediatrics
Work with families to set realistic goals for healthy eating and exercise. Medication Adherence 2010
Assess adherence and discuss possible barriers to adherence at every patient visit.
Internal medicine
Reconcile your medication lists with the patient’s list, adjust doses, and eliminate unneeded medications.
Family practice
Prescribe once-daily formulations, less-expensive generics, and longer-lasting supplies of medicine whenever possible. Provide tools such as pill boxes and medication logs to help patients remember to take their medications. DOHMH, New York City Department of Health and Mental Hygiene
Table 3 illustrates changes in self-reported provider behavior documented during the individual campaigns. Campaigns worked to improve providers’ practice behavior to screen patients for clinical preventive services and chronic disease management, provide clinical management, and address lifestyle modifıcation and selfmanagement goal-setting with patients. In most campaigns, increases were seen among providers who positively changed their practice behavior from baseline to follow-up.
Screening for Clinical Preventive Services and Chronic Disease Management Several campaigns showed increases among providers who screened for clinical preventive services. The 2004 Colon Cancer campaign showed improvement in the proportion of providers who reported colonoscopy as their primary screening method for colon cancer, from 26% at baseline to 42% at follow-up (p⫽0.01). When repeated in 2008, an even greater proportion of providers stated that colonoscopy was their preferred screening method 82% to 93% of the time (p⫽0.01). The Depression campaign showed a marked increase in the percentage of providers who used the Patient Health Questionnaire-2,9 from 13% at baseline to 40% at follow-up (p⫽0.01). Greater uptake in the use of clinical tools to assess problem drinking was documented in the Alcohol Screening and Brief Intervention campaign. At baseline, 22% of the providers reported using the CAGE Questionnaire Adapted to Include Drugs (CAGE-AID)10 June 2012
tool to assess for problem drinking, and at follow-up, 42% of the providers reported adopting the CAGE-AID tool (p⫽0.01).10 Among providers visited for the Intimate Partner Violence campaign, those who reported screening all patients for intimate partner violence increased from 39% at baseline to 67% at follow-up (p⬍0.01), and those who reported making screening for intimate partner violence a part of routine inquiry and dialogue increased from 14% to 42% (p⬍0.01). During the Adult Obesity campaign, the number of providers who reported assessing BMI and weight at every visit rose from 25% at baseline to 47% at follow-up (p⫽0.01). The Obesity in Children campaign also showed an increase in providers who assessed BMI percentile-for-age at every visit from 59% at baseline to 73% at follow-up (p⬍|0.01). The proportion of providers addressing chronic disease management was shown in the Diabetes campaign. Providers who reported setting specifıc clinical management goals for patients to check their hemoglobin HbA1c levels at least every 6 months increased from 66% at baseline to 92% at follow-up (p⬍0.01), as well as those who indicated a target hemoglobin HbA1c level of 7 or less increased from 61% at baseline to 83% at follow-up (p⬍0.01).
Clinical Management Improvements seen in the provision of clinical management to patients include changes in prescribing practice. During the Contraception campaign, providers who re-
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Table 2. 2003–2010 public health detailing campaign reach: DOHMH Providers with initial and follow-up visits
All provider contacts
All contacts (providers and staff)
Campaign
Sites
Unique providers
Influenza Vaccination 2003
151
—
—
377
674
4
Colon Cancer Screening 2004
193
—
109
530
982
5
Smoking Cessation 2004
151
—
—
494
911
6
Asthma 2004
168
—
—
246
514
3
Influenza Vaccination 2004a
164
a
a
350
666
4
Diabetes 2005
176
—
—
339
1340
8
214
443
146
528
1732
8
Contraception 2005 a
Contacts per site
Influenza Vaccination 2005
204
129
a
129
255
1
Hypertension 2005
157
349
90
679
1294
8
Depression Screening 2006
198
352
127
366
1030
5
HIV Testing 2006
151
317
90
345
1170
8
116
256
2
Influenza and Pneumococcal Vaccination 2006a
143
116
a
Cholesterol 2006: high-risk patients only
136
279
113
405
1264
9
Alcohol Screening and Brief Intervention 2007
143
297
149
460
1688
12
Electronic Health Records 2007
221
216
109
339
1088
5
Child Abuse and Neglect 2007
154
240
119
345
1169
8
Adult Obesity 2008
199
410
166
588
2433
12
Medical Reserve Corps 2008
199
370
63
435
1742
6
Colon Cancer Screening 2008
189
279
133
413
1424
8
Intimate Partner Violence 2009
196
411
230
659
2234
11
Breastfeeding 2009
152
281
170
455
1452
10
175
684
4
Influenza and Pneumococcal Vaccination 2009a
157
170
a
Obesity in Children 2009
161
291
237
530
1588
10
Medication Adherence 2010
186
340
265
607
1727
9
a
No follow-up visits for 2004, 2005, 2006, and 2009 Influenza campaigns DOHMH, New York City Department of Health and Mental Hygiene
ported prescribing emergency contraception in advance increased from 7% at baseline to 17% at follow-up (p⫽0.01). During the Medication Adherence campaign, the percentage of providers who reported reconciling patients’ medication lists at every visit increased from 86% at baseline to 94% at follow-up (p⬍0.01). Additionally, the percentage of providers who reported prescribing combination pills increased from 26% at baseline to 43% at follow-up (p⬍0.01). Those prescribing generic or lower-cost branded drugs increased from 52% to 79% (p⬍0.01), and the percentage who prescribed longerlasting supplies (90 days vs 30 days), when appropriate, increased from 29% at baseline to 60% at follow-up (p⬍0.01).
Lifestyle Modification Increases in the proportion of providers who reported speaking with their patients about lifestyle modifıcation and behavior change—to aid in the management of certain chronic conditions—were seen throughout campaigns. During the Hypertension campaign, providers who discussed weight loss with their patients increased from 68% at baseline to 80% at follow-up (p⫽0.10), and those who discussed increasing physical activity with their patients rose from 88% to 94% (p⫽0.10). Similarly, during the Cholesterol campaign, at baseline, 52% of the providers reported recommending inwww.ajpmonline.org
Public Health Detailing of Primary Care Providers New York City’s Experience, 2003–2010 Michelle G. Dresser, MPH, Leslie Short, MPH, Laura Wedemeyer, BA, Victoria Lowerson Bredow, MPH, Rachel Sacks, MPH, Kelly Larson, MPH, Joslyn Levy, MPH, BSN, Lynn D. Silver, MD, MPH Background: Given evidence of widespread underuse of recommended clinical preventive services and chronic disease management, New York City developed the Public Health Detailing Program, a primary care provider outreach initiative to increase uptake of best practices on public health priorities.
Purpose: The goal of the study was to evaluate the effectiveness of the Public Health Detailing Program in helping primary care providers and their staff to improve patient care on public health challenges. Methods: An analysis was conducted of reported changes in clinical practice or behavior by examining providers’ retention and implementation of recommendations for campaigns.
Results: During each campaign, 170 to 443 providers and 136 to 221 sites were reached. Among providers who responded to questions on changes in their practice behavior, the following signifıcant increases occurred from baseline to follow-up. Screening for clinical preventive services increased, including routinely screening for intimate partner violence (14%– 42%). Clinical management increased, such as prescribing longer-lasting supplies of medicine (29%– 42%). Lifestyle modifıcation and behavior change, such as recommending increased physical activity to patients with high cholesterol levels, rose from 52% to 73%. Self-management goal-setting with patients increased, such as using a clinical checkbook to track hemoglobin HbA1c goals (28% to 43%). Conclusions: Data suggest that public health detailing can be effective for linking public health agencies and their recommendations to providers and influencing changes in clinical practice behavior. (Am J Prev Med 2012;42(6S2):S122–S134) © 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
T
he Public Health Detailing Program within the New York City Department of Health and Mental Hygiene (DOHMH) has worked closely with primary care providers and their staff since 2003 to improve patient care by addressing the leading, largely preventable, causes of illness, disability, and death. Drawing on evidence indicating that gaps in provider knowledge and the absence of offıce systems contribute to suboptimal care, the Public Health Detailing Program was designed From the Bureau of Chronic Disease Prevention and Control, New York City Department of Health and Mental Hygiene, New York, New York Address correspondence to: Michelle G. Dresser, MPH, Bureau of Chronic Disease Prevention and Tobacco Control, New York City Department of Health and Mental Hygiene, 42-09 28 St, CN-46, Queens, NY 11101. E-mail: [email protected]. 0749-3797/$36.00 http://dx.doi.org/10.1016/j.amepre.2012.03.014
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to address these and other issues of care delivery.1 Public health detailing focuses on neighborhoods facing the greatest health disparities and is part of New York City’s approach to reduce the disproportionate burden of poor health. Public health detailing initiatives center on clinical topics chosen for their anticipated effect on morbidity and mortality and other public health priorities. Although the focus is on managing chronic conditions, the program has “detailed” issues ranging from intimate partner violence screening to recruitment for the New York City Medical Reserve Corps, promoting the implementation and use of electronic health records, supporting exclusive breastfeeding, and improving medication adherence in patients with cardiovascular disease and diabetes. Public health detailing develops its campaigns
© 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
Dresser et al / Am J Prev Med 2012;42(6S2):S122–S134
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Table 3. 2003–2010 public health detailing campaigns: self-reported changes in clinical practice: DOHMH (continued) Baseline (Initial), %
Follow-up, %
39
44
0.45
13
20
0.19
64
76
0.05
Recommends increased physical activity
52
73
0.01
Recommends statins
54
51
0.01
62
73
0.1
35
59
⬍0.01
67
76
0.1
22
42
0.01
41
34
0.09
40
45
0.43
75
98
⬍0.01
39
40
0.79
25
47
0.01
25
91
0.01
78
96
0.01
57
100
⬍0.01
1
18
⬍0.01
51
0.31
Campaign HIV Testing 2006
Campaign assessment questions and responses
p
Who do you routinely offer HIV testing to within your practice? Offers routine testing to all patients (aged 18–64 years) What type of HIV testing do you perform in your office, if any? Uses rapid testing
Cholesterol 2006
For patients with high cholesterol, diabetes, and/or atherosclerotic disease, what interventions do you routinely recommend for their cholesterol? Recommends general diet change
For patients with diabetes and no other complication, what is your LDL goal for treatment? LDL treatment goals of ⬍100 mg/dL When you prescribe medications, do you regularly provide patients with supporting materials or tools to address adherence? If yes, what are some examples? Provides educational materials on medication(s) and/or medication log Alcohol Screening and Brief Intervention 2007
What types of patients do you generally assess for problem drinking? Screens all patients for problem drinking Do you use a standard screening tool to assess problem drinking? Assesses using the CAGE-AID
Electronic Health Records 2007
Are you considering adopting an electronic health record system for your practice?
Identifying & Reporting Child Abuse & Neglect 2007
Have you reported a case of child abuse and neglect within the last 2 years?
Yes
Yes How do/would you report suspected child abuse and neglect? Call the State Central Register Have you had any training on identifying child abuse and neglect other than the New York State training requirement? Yes
Adult Obesity 2008
How do you assess your patients for obesity? Assesses using BMI and weight history In the past week, have you used nutritional visuals or props when speaking with your patients about obesity? Uses nutritional visuals or props In the past week, have you done formal goal-setting with your patients to address obesity? Uses formal goal-setting with patients
Medical Reserve Corps 2008
Have you heard of New York City Medical Reserve Corps? Yes Are you currently a New York City Medical Reserve Corps volunteer? Yes Would you like become a New York City Medical Reserve Corps volunteer? Yes
44
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Table 3. (continued) Baseline (initial), %
Follow-up, %
93
82
0.01
9
16
0.09
39
67
⬍0.01
At every visit
27
28
0.75
Routine inquiry and dialogue
14
42
⬍0.01
Refer to domestic violence hotline
13
33
⬍0.01
Schedule a follow-up appointment
9
20
⬍0.01
51
50
0.96
32
33
0.76
20
26
0.13
77
88
⬍0.01
59
73
⬍0.01
67
85
⬍0.01
86
94
⬍0.01
Prescribe once-daily formulations, if possible
43
58
⬍0.01
Prescribe combination pills to decrease number of medications
26
43
⬍0.01
Prescribe generic or lower-cost branded drug
52
79
⬍0.01
Prescribe longer-lasting supplies
29
60
⬍0.01
Adjust dosages
52
66
0.04
Depends on Insurance
36
52
⬍0.01
36
41
0.02
Campaign Colon Cancer Screening 2008
Campaign assessment questions and responses
p
What test do you usually recommend for colon cancer screening? Colonoscopy When you refer patients for screening, what referral form do you use? DERS form
Intimate Partner Violence 2009
Whom do you screen for intimate partner violence? All patients How often do you screen for intimate partner violence?
What do you do when a patient discloses intimate partner violence?
Breastfeeding 2009
What infant feeding method do you recommend during prenatal visits? Exclusive breastfeeding For breastfeeding babies, how soon after birth do you schedule newborn visit? 3–5 days after birth What is your policy regarding hospital staff giving formula during admission and/or at discharge in the form of samples? Does not allow formula during hospital stay or in discharge packs
Obesity in Children 2009
How do you currently assess for overweight or obesity in children aged 2–18 years? BMI percentile-for-age How often do you assess for overweight or obesity in children aged 2–18 years? At every visit In the past month, whom have you counseled for healthy eating and physical activity? All patients and their parent/caregiver
Medication Adherence 2010
How often do you reconcile patient’s medication lists? At every visit What prescribing practices do you use to increase patients’ adherence to their medications?
How frequently do you write prescriptions of greater than a 30-day supply for patients on long-term maintenance medications? Often a
No data available CAGE-AID, CAGE Questionnaire Adapted to Include Drugs; DERS, Direct Endoscopic Referral System; DOHMH, New York City Department of Health and Mental Hygiene; LDL, low-density lipoprotein; PHQ, Patient Health Questionnaire.
June 2012
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creased physical activity to patients with high cholesterol levels, whereas 73% reported doing so at follow-up (p⫽0.01). At baseline, 64% of the providers reported routinely recommending diet change to patients with high cholesterol value. At follow-up, this proportion increased to 76% (p⫽0.05). Additionally, during the Obesity in Children campaign, providers who reported counseling all pediatric patients and their caregivers for healthy eating and physical activity increased from 67% at baseline to 85% at follow-up (p⬍0.01).
Self-Management Goal-Setting In several campaigns, providers reported an increased use of self-management goal-setting with their patients. During the Diabetes campaign, the percentage of providers who reported using a “checkbook-style” diary with patients to track their hemoglobin HbA1c level increased from 28% at baseline to 43% at follow-up (p⬍0.01). Data from the Adult Obesity campaign showed that almost all providers used goal-setting strategies for weight loss with their patients: from 78% at baseline to 96% at follow-up (p⫽0.01). Those reporting use of nutritional visuals or props when speaking about obesity management increased from 25% at baseline to 91% at follow-up (p⫽0.01).
Discussion By establishing open channels of communication; providing valuable information, evidence-based tools, resources, and patient education materials; and building strong relationships with primary care team members in high-need neighborhoods, the Public Health Detailing Program has developed a successful strategy for communicating public health recommendations to clinical care teams. Results of the campaign evaluation indicate that representatives are highly skilled at facilitating conversations and gaining agreements to implement the DOHMH’s recommendations. In the early days of the program, occasionally providers would reject visits, at times confusing them with regulatory activities of other agencies, but by 2010, all practices in the target communities were routinely receiving visits. Evaluation data from individual public health detailing campaigns suggest potential effectiveness of this model, which involves repeat, personal visits to offıce teams, as well as the importance of clear, consistent messaging around key clinical recommendations. All of the responding providers indicated that the detailing visits have changed their practice in a positive way, and 73% of practices implemented clinical tools (including 15% who adopted an electronic health record into their practice), key recommendations, and patient education materials.
Care teams reported that they value these tools and resources to help reinforce key recommendations, initiate conversations, improve mutual understanding, and facilitate goal-setting with their patients during and after campaigns. Since the inception of the Public Health Detailing Program, providers have allotted more time to each visit. Initially, visits lasted an average of 12 minutes, but by 2010, visits increased to an average of 17 minutes, an indication of the providers’ interest in the topic and a reflection of the relationships representatives developed with the practices throughout the years. An essential ingredient is having highly trained, knowledgeable representatives consistently working directly with providers.11 Literature shows that this multifaceted approach is an effective strategy for influencing provider attitudes and behavior and is more effective than certain other types of educational outreach. “Academic detailing” linked with other educational strategies may be the most effective paired intervention, because print-only or mailing interventions generally have not been found to be effective in modifying physician behavior.12,13 Public health detailing serves as a bridge between the DOHMH and community providers, creating a twoway flow of information. The valuable qualitative and quantitative feedback from providers has been used by the DOHMH to guide clinical interventions and programmatic initiatives. Economic sustainability of public health programs, in times of recession, continues to pose a challenge. Public health detailing has an average cost in New York City of approximately $95 per contact, of which $40 is for staff. Similar programs ideally might be fınanced by organizations to which savings would accrue as a result of improved care, such as Medicaid or Medicare, which therefore have direct interest in their continuity. Because the Public Health Detailing Program is run by a local health department—focusing on population health—and is without the evident fınancial interests private insurers might have, this appears to be a source of credibility for the program’s recommendations.
Limitations As stated above, the Public Health Detailing Program’s reach varied among the different campaigns. Fluctuation in the program’s reach for number of sites visited and providers seen varied on several factors, including length of the campaign, size of the target group of providers, variation in staff size, and provider or staff receptivity to messaging. However, a general trend of an increasing number of contacts per site has continued since the Public Health Detailing Program implewww.ajpmonline.org
Dresser et al / Am J Prev Med 2012;42(6S2):S122–S134
mented its fırst campaigns. Sites’ increasing familiarity with the program and representatives’ improving communication skills over the last several years enhanced the reach at each site and reduced wait time to see key offıce staff and providers. Loss of follow-up visits with the same providers during the course of individual campaigns was another limitation of the Public Health Detailing Program. Providers and staff often work at multiple sites on certain days and hours of the week, so the number of providers reached at follow-up is always lower than the number reached during initial visits. Strategies were implemented to increase the percentage match of initial and follow-up visits, particularly with physicians, nurse practitioners, and physician assistants, to 80% or higher, a goal subsequently achieved with at least two campaigns. Changes in the data structure since the program began also limited the conclusions drawn from these results. Some of the early campaigns did not capture data in the same format, and data were unavailable for a few campaigns. Most important, this evaluation relied on provider self-reported practices. Self-report may fail to accurately reflect providers’ actual clinical behavior. Use of clinical data to verify changes in clinical practice would be an important complement to assess effectiveness of this program. The power of electronic medical records also could be used to assess the effect of campaigns on clinical practice. When the Public Health Detailing Program began, electronic medical records were not as widely used as today, and they should be used for evaluating this and other clinical systems improvement efforts. However, counseling and provider–patient conversations around a disease topic and self-management goal-setting are often not adequately captured in the patient record. Patient exit surveys or other mechanisms to evaluate the messages patients received during an offıce visit, as well as which ones they intend to act on, would be another possible evaluation approach for the program. Finally, the extent to which the assessed practices would have changed in the absence of the Public Health Detailing Program effort is unknown. Providers are regularly exposed to numerous opportunities that may influence the way they practice medicine, such as continuing education courses, medical journals, conferences, and other means by which evidence-based recommendations and materials can be acquired. These factors alone, or in conjunction with public health detailing, could have affected clinical practice and behavior.
Conclusion Overall, the Public Health Detailing Program has been received very positively by the medical community in the June 2012
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underserved communities prioritized by the program. Despite the limitations noted, evaluation data based on provider self-report suggest that public health detailing can be an effective strategy for linking public health agencies and their recommendations to medical providers and staff as well as assisting in the development of future program and policy initiatives. The professional relationships developed between the providers and their staff and the DOHMH permit a dialogue described by Avorn: These conversations enable a talented communicator to understand the physician’s current practices, beliefs, and attitudes, making it possible to tailor a behavior-change message specifıcally to that individual’s decision-making process.11
Other public health agencies may fınd this approach for promoting important clinical practices a useful strategy to assist in improving population health. Publication of this article was supported by the U.S. DHHS Health Resources and Services Administration (HRSA) and the NIH National Institute on Minority Health and Health Disparities. The authors thank Tamara Dumanovsky, PhD, for her expertise and feedback as the former Director of Research and Evaluation for the Bureau of Chronic Disease Prevention and Control at the New York City Department of Health and Mental Hygiene as well as the many Health Department representatives for their detailing throughout the years. Human participant protection was not required because this review of the literature did not involve human participants. No fınancial disclosures were reported by the authors of this paper.
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