Priorities among effective clinical preventive services in British Columbia, Canada.

BACKGROUND: Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing. METHODS: We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a 'strong or conditional (weak) recommendation for' by the Canadian Task Force on Preventive Health Care or an 'A' or 'B' rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained. RESULTS: Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services. CONCLUSIONS: These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Initial experience with routine selective carotid arteriography by vascular surgeons.

We report the results of our first 2 years of experience with routine carotid angiography with an emphasis on technique and complications. We reviewed the hospital records, office charts, and prospective quality-assurance database records of 336 patients undergoing cerebrovascular arteriograms and collected data on the indications, complications, and technical aspects of the procedures. Indications for angiography included carotid stenosis in 331 (95%) patients, subclavian steal syndrome in 9 patients, vertebrobasilar insufficiency in 6 patients, and carotid body tumor in 2 patients. Selective catheterizations were performed on 654 common carotid arteries, 63 subclavian arteries, and 63 vertebral arteries. Both common carotid arteries were not selectively catheterized in 34 (9.8%) patients. Reasons for not selecting one or both common carotid arteries included physician choice to limit contrast administration in patients with renal insufficiency in 16 cases, proximal occlusion in 4 cases, proximal stenosis thought to be at risk of embolization if instrumented in 3 cases, imaging equipment malfunction in 2 cases, and in only 9 (2.6%) cases was selective carotid catheterization attempted but unsuccessful. There were no procedure-related deaths. Complications were documented in six (1.8%) patients, including cerebrovascular accident (CVA) in 1 (0.3%) patient. One hundred forty-two (41%) patients went on to carotid endarterectomy, and we performed 16 carotid bifurcation stents during the study period. Routine selective carotid angiography is a low-risk procedure that can be performed safely by vascular surgeons with catheter/guide wire skills.

Information system support as a critical success factor for chronic disease management: Necessary but not sufficient.

UNLABELLED: Improvement of chronic disease management in primary care entails monitoring indicators of quality over time and across patients and practices. Informatics tools are needed, yet implementing them remains challenging. OBJECTIVE: To identify critical success factors enabling the translation of clinical and operational knowledge about effective and efficient chronic care management into primary care practice. DESIGN: A prospective case study of positive deviants using key informant interviews, process observation, and document review. SETTING: A chronic disease management (CDM) collaborative of primary care physicians with documented improvement in adherence to clinical practice guidelines using a web-based patient registry system with CDM guideline-based flow sheet. PARTICIPANTS: Thirty community-based physician participants using predominantly paper records, plus a project management team including the physician lead, project manager, evaluator and support team. ANALYSIS: A critical success factor (CSF) analysis of necessary and sufficient pathways to the translation of knowledge into clinical practice. RESULTS: A web-based CDM 'toolkit' was found to be a direct CSF that allowed this group of physicians to improve their practice by tracking patient care processes using evidence-based clinical practice guideline-based flow sheets. Moreover, the information and communication technology 'factor' was sufficient for success only as part of a set of seven direct CSF components including: health delivery system enhancements, organizational partnerships, funding mechanisms, project management, practice models, and formal knowledge translation practices. Indirect factors that orchestrated success through the direct factor components were also identified. A central insight of this analysis is that a comprehensive quality improvement model was the CSF that drew this set of factors into a functional framework for successful knowledge translation. CONCLUSIONS: In complex primary care settings environment where physicians have low adoption rates of electronic tools to support the care of patients with chronic conditions, successful implementation may require a set of interrelated system and technology factors.

The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model.

Given the increasing incidence of chronic diseases across the world, the search for more effective strategies to prevent and manage them is essential. The use of the Chronic Care Model (CCM) has assisted healthcare teams to demonstrate effective, relevant solutions to this growing challenge. However, the current CCM is geared to clinically oriented systems, and is difficult to use for prevention and health promotion practitioners. To better integrate aspects of prevention and health promotion into the CCM, an enhanced version called the Expanded Chronic Care Model is introduced. This new model includes elements of the population health promotion field so that broadly based prevention efforts, recognition of the social determinants of health, and enhanced community participation can also be part of the work of health system teams as they work with chronic disease issues.