Research article
The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites

https://doi.org/10.1016/S0749-3797(01)00311-7Get rights and content

Abstract

Objective: To determine whether the implementation of the Put Prevention Into Practice (PPIP) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics.

Methods: Chart review was conducted before (n=372) and 33 to 39 months after (n=376) the implementation of the PPIP office-based system in two community health centers and three family practice residency programs in Texas. The population included all adult patients aged ≥19 years who had presented to the clinic during the study periods.

Results: Documentation of timely cholesterol screening increased from 70% to 84%; smoking assessment, from 56% to 80%; for women, up-to-date Papanicolaou smear, from 70% to 81%; annual mammograms (women aged ≥51), from 30% to 48%; and up-to-date tetanus–diphtheria immunizations, from 19% to 59%. For adults aged ≥66 years, documentation of pneumococcal immunization increased from 22% to 48%, while influenza immunizations improved, although not significantly (45% to 49%). Blood pressure screening was almost universal (99%) at baseline and at 33- to 39-month follow-up.

Conclusion: PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services.

Introduction

T he consistent delivery of clinical preventive services (CPS), which includes screening tests for early diagnosis, immunizations, and chemoprophylaxis for disease prevention and counseling to modify risk factors, can reduce premature mortality and morbidity and help preserve a high quality of life.1 Providing universal CPS to Americans was one of the three main goals of the Year 2000 Objectives for the Nation.2 The importance and effectiveness of CPS is recognized,1, 3 and several preventive services–delivery measures are among the indicators used to rate the performance of clinicians, clinicians’ practices, and health plans in the Health Plan Employer Data Information Set (HEDIS).4

The initial results of tests of the effectiveness of the Put Prevention Into Practice (PPIP) office-based system have been mixed. PPIP materials were pilot tested in a residency training program in Harlem, New York, and, in comparison to a control site, produced physician self-reports of increased provision of services for smoking, nutrition and weight control, exercise, and immunizations, but not for breast cancer screening. Patients reported increased counseling for physical activity and breast self-examination, as well as overall prevention services.5 Similarly, Kikano et al.6 found increased chart documentation of education for smoking cessation, diet, exercise, and clinical breast examinations, but not for other screening tests. Melnikow et al.7 also reported the effects of PPIP materials in improving the delivery of eight CPS by family practice providers serving a diverse, low-income population. The delivery rates of seven clinical preventive services (screening and immunization) were higher in the intervention site at 6 months compared to comparison site. However, these rates had flattened or decreased by 30 months.

The U.S. Department of Health and Human Services developed the PPIP initiative to support primary care clinicians in the provision of CPS.8 The delivery of CPS is facilitated by a well-established office system.9, 10 The PPIP program utilizes a research-based set of tools that targets providers, patients, and the office system (and staff) to increase the provision of CPS in primary care practices. This campaign was developed by the U.S. Public Health Services in collaboration with numerous professional organizations and is now being disseminated by the Agency for Healthcare Research and Quality.11

This is the one of the first long-term studies using multiple clinical sites and chart audit data to examine whether the implementation of a PPIP-type, office-system intervention would increase the delivery rates of specific CPS among demonstration clinics as measured. The CPS represented screening assessments (blood pressure [BP], cholesterol, Papanicolaou smear, and mammogram), immunizations (tetanus–diphtheria, pneumococcus, and influenza), and assessment (tobacco/smoking).

Section snippets

Methods

In 1994, the Texas Department of Health (TDH) used federal, preventive health block-grant monies to fund, through a competitive process, three community health centers (CHCs) and four family practice–residency (FPR) programs to conduct the PPIP program. Implementation included pre-auditing of charts with reminder notices; use of chart flowsheets with space to document counseling related to 19 behavioral topics/actions to be taken, ten examinations/screening tests, and four immunizations;

Results

As seen in Table 4, documentation of timely cholesterol screening increased from 70% to 84%; for women, up-to-date Papanicolaou smears increased from 70% to 81%, and yearly mammograms (women aged ≥51) from 30% to 48%. Documentation of up-to-date smoking assessment increased from 56% to 80%, and tetanus–diphtheria immunizations from 19% to 59%. For adults aged ≥66, documentation of pneumococcus immunization increased from 22% to 48%, while influenza immunizations did not improve significantly

Comment

This study offers one of the first long-term multisite evaluations of the PPIP program, and Texas is the first state health department to provide funding to implement PPIP. Our results regarding delivery of CPS after 33 to 39 months are more positive than other PPIP intervention studies,6, 7 possibly because all sites received technical assistance and monitoring by the TDH across the 3 years of intervention. With the exception of influenza immunization for the elderly, the CPS increased or

Acknowledgements

This research was supported by a contract from the Texas Department of Health to NH Gottlieb, PhD.

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