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Can We Change Physicians' Practices in the Delivery of Cancer-Preventive Services?
Arch Fam Med. 1998;7:317-319.
THE HEALTHY People 2000 overall goals were to increase the span of healthy life for Americans, to reduce health disparities among Americans, and to achieve access to preventive services for all Americans.1 Part of the responsibility to achieve these goals falls on physicians and their practices. In this issue, there are 3 studies2-4 investigating various interventions to improve the delivery of preventive services in practices among a variety of community settings. All of these studies were initiated in response to the Healthy People 2000 goals under the support of the National Cancer Institute research effort designated Prescribe for Health. The goal of these projects was to determine whether the interventions increased the percentage of patients getting the desired screening procedure. If the goal was reached, then physicians, practice managers, and numerous other leaders could look to implement these interventions to deliver more preventive services to their patients.
Your delivery of preventive services to your patients is inadequate and unacceptable! You need to change!
The screening procedures of interest in each study were breast self-examination,3 clinical breast examination, mammograms, Papanicolaou smears, digital rectal examination, fecal occult blood testing studies,2-4 flexible sigmoidoscopy, and oral cavity examination.3-4 Each of these procedures has a direct link to the aim of Healthy People 2000 to reverse the rise in cancer deaths to no more than 130 per 100000 people.1 With respect to specific procedures, the goal was to increase clinical breast examinations and mammography every 2 years to at least 60% of women aged 50 years and older (80% for women aged 40 years and older). Similarly, the goal for cervical cancer screening was to increase the percentage getting a Papanicolaou smear every 1 to 3 years to at least 85% of women aged 18 years and older. For colorectal cancer, the goal was to increase to at least 40% of people aged 50 years and older getting a digital rectal examination in the past year, to increase to at least 50% of people aged 50 years and older getting a fecal occult blood test every 1 to 2 years, and to increase to at least 40% of those aged 50 years and older ever having had a protosigmoidoscopy or flexible sigmoidoscopy. For oral cancer, the goal was at least 40% of people aged 50 years and older getting an oral examination in the past year. As of 1994, the national data suggested we were making substantial progress toward achieving these goals.5
Your delivery of preventive services to your patients is inadequate and unacceptable! You need to change!
In contrast, the studies in this issue suggest we are not making substantial progress to reaching the goals for 2000. The percentages of women in these studies having received screening tests for breast or cervical cancer in the past 2 years were 28% to 52% for clinical breast examination, 24% to 59% for mammogram, and 19% to 56% for Papanicolaou smears.2-4 This was consistently well below the target for the year 2000. The performance for colorectal screening fell substantially below the target of 40%.2-4 For oral cavity cancer, only 2 of the studies addressed oral cavity examination3-4 and only 1 reached the 2000 goal.3 Unfortunately, none of the interventions had large enough increases to shift the practices' performance toward realistically reaching the target for the year 2000.
Each study2-4 used chart audits as a source of data regarding the outcomes of interest. Some would argue that there is some screening occurring that was not captured by this data source. For example, oral cavity screening may have taken place in dentists' offices, which was not reflected in physicians' office records. Similarly, women may be obtaining Papanicolaou smears, breast examinations, and even mammograms in other settings than their primary care office, such as in family planning centers, at health fairs, or by gynecologists. However, our data in similar studies suggest that the percentage of men or women getting care outside of their primary care offices is extremely small and would impact little on the conclusions (M.T.R. and D. Gorenflo, PhD, unpublished data, May 1998).
The investigators determined the performance of each practice on the basis of a random sample of 50 to 60 active charts per practice. Thus, the estimates of practice performance for a single screening procedure for an age group (for example, clinical breast examinations and mammograms in women aged 40 years and older) may be based on as few as 20 charts.2 Are these limited numbers a reasonable and stable estimate of a practice's performance in delivering preventive services? From my experience in planning and implementing similar studies, 100 randomly sampled active medical records per age group and sex are needed to establish a stable estimate of the practice's performance of screening for cancer. Chart samples of 25 or 50 provided estimates that were not stable or changed significantly between sampling without any intervention. Therefore, I am concerned that any difference between baseline and postintervention assessment is a result of unstable estimates of performance.
Did some of the charts reviewed actually need the screening procedure, for example, women with a hysterectomy and Papanicolaou smears? Hysterectomy is second only to cesarean delivery as the most common major surgical procedure performed in the United States.6 It is estimated that more than a third of all women in the United States will have undergone a hysterectomy by the age of 60 years.7 Thus, as many as one third of the women in these studies may not have needed a Papanicolaou smear in the most recent 24 months, given the ineffectiveness of a vaginal Papanicolaou smear after total hysterectomy for benign disease.8 Similarly, men and women having received a colonoscopy or air contrast barium enema for diagnostic reasons would not need a flexible sigmoidoscopy for screening. However, the percentage of patients in this category would be extremely small and not as likely to affect the results as in the case of hysterectomy.
Your delivery of preventive services to your patients is inadequate and unacceptable! You need to change!
All of the interventions used in these studies were resource intensive and were expected to have significant impact on the delivery of preventive services. In fact, the interventions were so resource intensive that many of the practices were not completely exposed to the intervention.2 Yet, the authors did not attempt to determine whether this played a significant role in the effect of the intervention. Dietrich and colleagues3 did address some aspects of the intensity of the intervention and practice variables, such as continuity of medical director. Even if these interventions had a significant impact on the percentage of patients getting cancer screening, could the interventions be used in a cost-effective manner across a large number of practices?
The impact on cancer screening observed in these 3 studies was modest. Manfredi and colleagues2 found only statistically significant gains in percentages of patients getting Papanicolaou smears, fecal occult blood testing, and clinical breast examinations. Note, the Papanicolaou smear increase was 11.9% only because the rate in the control group of women declined by 7.9%. The intervention itself had a negligible effect of a 4.0% increase. In the other studies, only breast self-examination,3 clinical breast examination, and mammography4 increased in response to the interventions. The increase in breast self-examination may simply be a matter of documentation change, which does not reflect a change in the percentage of women getting this education.
So why could these seasoned investigators with extensive experience and resources not change physicians' practices? One only need read in this issue the study by Preisser and colleagues9 for possible answers. They examined the predictors of a health maintenance examination in community-based practices. A health maintenance visit may be the prime time patients receive cancer screening. Their results suggested that patients in practices that have 3 or more providers, in which physicians contemplated changing their approaches to cancer screening, or in which they saw a female physician, were more likely to receive a health maintenance visit in the previous year. The practices in the other 3 studies were primarily small, with 54% to 67% having 2 or fewer providers,2, 4 presumably predominantly male physicians, and extremely unlikely to contemplating changes in their cancer-screening approaches given the high rate of turnover among physicians.2-3 So the investigators testing interventions to change physician practice performance in cancer screening were targeting the most difficult-to-change settings. This is equivalent to trying to stop smokers who are not interested (precontemplators) and have many other issues that take a higher priority. Therefore, the real question is, how can we get all physicians to move from precontemplating to contemplating or action with regard to their approaches to delivering cancer screening or preventive services?
Your delivery of preventive services to your patients is inadequate and unacceptable! You need to change!
After spending the last 8 years trying to change physicians' practice of cancer screening and other preventive services, I have some answers and insights. The vast amount of literature is clear: physicians are failing to deliver preventive services to their patients. It is time to stop pointing fingers at everyone else as the source of the problem. It is not insurance companies. It is not patients. It is not a lack of training or experience. The prime reasons are physicians. We have seen the problem every day in the mirror. As I have stated repeatedly throughout this editorial, your delivery of preventive services to your patients is inadequate and unacceptable! You need to change! This may be the equivalent to telling precontemplating smokers that the single best thing they can do for their health is to stop smoking. It works eventually to move patients into contemplation or action, but you can never stop saying it.
Those of you who have read this far are most likely in the contemplative or action phase with respect to changing your approach to delivering preventive services. This is the first critical step to behavior change. From my experience, there are several further steps that will lead to change. The next step is to gather your office colleagues and staff together regularly to discuss preventive services. The goal is to generate dissatisfaction with your current level of preventive care and create enthusiasm for change. This requires questioning every aspect of everyone's job, including the physicians. Remember, you have a finite amount of resources that need to be targeted at the key deficits of care in your office. The next step is to pick a specific area of preventive services with a consensus in your office with respect to the screening test and interval. Choose something simple where there is a high chance for success, such as identifying smokers in your office, adult immunizations, mammograms in women aged 50 years and older, or blood pressure screening. Try to develop a systematic approach to delivering it to your patients. A systematic approach means you explore your current approach to delivering the care, identify possible problems, and develop solutions. This approach also implies viewing every aspect of your interaction with patients as an opportunity to deliver screening message or services. Do not forget all of the contacts outside of the office, such as bills, letters, or information from insurance companies. You do not have to create solutions by yourself, since there are many materials available to help physicians, such as Put Prevention Into Practice (available from the American Academy of Family Physicians). After you make an intervention, it is essential that you evaluate how well you did—not an easy task, since it usually requires pulling and reviewing some charts. However, other entities, such as insurance companies, may already be doing this for you. In addition, most malpractice insurance providers will give you a discount on premiums if you report this type of quality improvement activity.
This is a never-ending process that requires that you place it at the top of your practice priorities, much like smokers trying to quit. You can never give up or quit trying to make change. If you do not change, then you will eventually be traumatized by the premature death of a patient from a preventable cause or rudely awakened by an attorney one day. For physicians to carry their share of the responsibility to reach the goals of Healthy People 2000, it is time we acknowledge our problems and take action to make change.
Mack T. Ruffin IV, MD, MPH
Department of Family Medicine
University of Michigan Medical Center
1018 Fuller St
Ann Arbor, MI 48109-0708
REFERENCES
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1. US Dept of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Dept of Health and Human Services; 1990:114-115.
2. Manfredi C, Czaja R, Freels S, Trubitt M, Warnecke R, Lacey L. Prescribe for Health: improving cancer screening in physician practices serving low-income and minority populations. Arch Fam Med. 1998;7:329-337.
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3. Dietrich AJ, Tobin JN, Sox CH, et al. Cancer early-detection services in community health centers for the underserved: a randomized controlled trial. Arch Fam Med. 1998;7:320-327.
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4. Williams R, Boles M, Johnson RE. A patient-initiated system for prevention: a randomized trial in community-based primary care practices. Arch Fam Med. 1998;7:338-345.
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5. National Center for Health Statistics. Healthy People 2000. Hyattsville, Md: Public Health Service; 1997:146-153.
6. Graves E. National hospital discharge survey: annual summary, 1990. Vital Health Stat 13. 1992;(112):1-62.
7. Pokras R, Hufnagel VG. Hysterectomy in the United States, 1965-84. Am J Public Health. 1988;78:852-853.
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8. Fetters MD, Fischer G, Reed BD. Effectiveness of vaginal Papanicolaou smear screening after total hysterectomy for benign disease. JAMA. 1996;275:940-947.
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9. Preisser JS, Cohen SJ, Wofford JL, et al. Physician and patient predictors of health maintenance visits. Arch Fam Med. 1998;7:346-351.
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