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Health promotion/disease prevention guideline development: process and results.

In developing a health screening guideline, a health plan or health care institution must identify an opportunity or need. Preferably, this is a common illness or health screening area. It must be visible and of importance to providers, enrollees, and employers. One must be able to measure the opportunity and present it to stakeholders. Barriers and inefficiencies in taking advantage of opportunities are identified by work groups: brainstorm and place these factors into a cause and effect diagram. By asking the "five whys," one is better able to identify the root causes of the gaps and to develop approaches to closing them.

The course PPIC took is based on quality improvement principles and Eisenberg's six factors that influence clinician decision-making. Of these factors, participation, education, and feedback were considered crucial to getting buy in. PPIC invited and received participation of its Quality and Utilization Management Committee (QUMC) and Physicians Plus Medical Group's primary care departments. It set up cross-functional work groups of clinicians, allied medical personnel, and support staff. It obtained advice from affected departments. It searched the literature and benchmarked with other departments and health care institutions. Subsequently, PPIC staff developed guideline drafts with the active participation of QUMC and appropriate primary care and nonprimary care departments. Last, participants signed off on the drafts. For controversial areas, such as mammography for women ages 40-49 and the PSA over age 50, after consultants provided input on disparate literature, a statement indicated that these are controversial areas.

In the development process, we obtained suggestions from the various stakeholder groups(medical, nursing, and health education(as to the ideal guideline form. Suggestions included: a part of the patient record, a handy booklet, individual laminated or vinyl cards, mobiles, wall charts, patient handouts, etc.

Patience is required. Champions of the process are important. Active participation of staff and providers is required in this stage. This time of development seems to be the difficult part. However, guideline development is the easier part of the process! The difficult part is obtaining acceptance, imprinting, and, finally, effecting behavior changes, as determined by outcome measures. Guideline development is only the beginning.

After guideline development, the next step is a marketing effort, both internal and external. Marketing efforts need to be ongoing, repetitive, and via different media. In internal marketing, hit the targeted stakeholder groups repeatedly through: one-page flyers and regular newsletters; department chair, departmental, and quality and utilization management committee meetings; and one-on-ones, clinic site visits, hospital medical staff meetings, education sessions, and the like. Utilize surrogate champions among the target stakeholder groups. Data, measures of health screening gaps, are important to advance the use of this guideline tool.

Subsequent to the internal effort comes external marketing to enrolles, employers, and the general community. A multimedia approach at PPIC occurs through the quarterly Plus You Newsletters, Health Sense patient booklets, the Health Education Department, sales and provider relations staff, newspaper articles, report cards to the community, public service advertisements, meetings with health forums, Good Health Bonus education program incentives, and so on.

Measures are important. Are the guidelines known and understood, accepted, and utilized and do they result in closing the identified and measured health screening gaps? By surveying target provider groups and analyzing utilization and claims data, one will be able to answer these questions. Both pre- and postguideline implementation health care screening measures are necessary.


A result of our efforts are the Health Promotion/Disease Prevention (HP/DP) Guidelines, a tool for clinicians and health educators to use as a teaching aid and memory jogger to advance patient and community health. Figure 1, page 15, shows Adult Health Promotion/Disease Prevention Guidelines for ages 30-39 years. Similar guidelines exist for the 0-18, 19-29, 40-49, 50-64, 65-74, and 75-plus age groups. The guidelines are in matrix form, with Physical Examination, Laboratory/ Diagnostic Procedures, Immunization, and Education sections. The Pediatric Guidelines also include Measurements, Screenings, and Development and Behavior Assessment.


The High-Risk (HR) categories for ages 30-39 years are provided in figure 2, page 16. The HP/DP Guidelines are in booklet form, with the guidelines page and the HR page for each age group facing one another.

We intend to update these guidelines yearly. A work group is looking at placing these guidelines into the electronic health information profile system of our primary provider, Physicians Plus Medical Group, a 220 plus physician, multispecialty group. This will be an excellent way to educate and remind providers and staff of the guidelines and to help notify enrollees or subscribers that they are due for periodic health examinations and health screenings.

Figure 2. High Risk Categories Ages 30-39

HR1 Pap smear: Persons who had first intercourse at an early age, multiple sexual partners, any history of STD (especially history of condyloma), prior dysplasia or abnormal PAP, DES exposure, immunologic illnesses, oral contraceptives.

HR2 Complete oral cavity exam: Persons with exposure to tobacco or excessive amounts of alcohol, or those with suspicious symptoms or lesions detected through self-examination.

HR3 Palpation for thyroid nodules: Persons with a history of upper-body irradiation.

HR4 Clinical testicular exam: Men with a history of cryptorchidism, orchiopexy, or testicular atrophy.

HR5 Complete skin and eye exam: Persons with a family or personal history of skin cancer, increased occupational or recreational exposure to sunlight, or clinical evidence of precursor lesions (e.g., dysplastic nevi, certain congential nevi) or persons with a diagnosis of cataracts, glaucoma or change in vision.

HR6 Mammogram: Women aged 35 and older with a family history of premenopausally diagnosed breast cancer in a first-degree relative. Annual mammography for this population is supported by the ACP, USPSTF and CTF (Sox, JAMA 1994; 330:1589-95).

HR7 Fasting plasma glucose: The markedly obese, persons with a family history of diabetes, or women with a history of gestational diabetes.

HR8 Urinalysis for bacteriuria: Persons with diabetes.

HR9 VDRL/RPR: Prostitutes, persons who engage in sex with multiple partners in areas in which syphilis is prevalent, or contacts with persons with active syphilis.

HR10 Chlamydial testing: Persons who attend clinics for sexually transmitted diseases; attend other high-risk health care facilities (e.g., adolescent and family planning clinics); or have other risk factors for chlamydial infection (e.g., multiple sexual partners or a sexual partner with multiple sexual contacts, age less than 20).

HR11 Gonorrhea culture: Prostitutes, persons with multiple sexual partners or a sexual partner with multiple contacts, sexual contacts of persons with culture-proven gonorrhea, or persons with history of repeated episodes of gonorrhea.

HR12 Counseling and testing for HIV: Persons seeking treatment for sexually transmitted diseases; homosexual and bisexual men; past or present intravenous (IV) drug users; persons with a history of prostitution or multiple sexual partners; women whose past or present sexual partners were HIV-infected, bisexual or IV drug users; persons with long term residence or birth in an area with high prevalence of HIV infection or persons with a history of transfusion between 1978 and 1985.

HR13 Hearing: Persons exposed regularly to excessive noise in work, recreational or other settings.

HR14 TB skin test/PPD: Household members of persons with tuberculosis or others at risk for close contact with the disease (e.g. volunteer & staff of tuberculosis clinics, shelters for homeless, nursing homes, substance abuse treatment facilities, dialysis units, correctional institutions); recent immigrants or refugees from countries in which tuberculosis is common; migrant workers; residents of nursing homes, correctional institutions, or homeless shelters; or persons with certain underlying medical disorders (e.g. HIV infection).

HR15 Colonoscopy: Persons with a family history of familial polyposis coli or cancer family syndrome, a) two or more first degree relatives with colon cancer, start colonoscopy at age 35 or 5 yrs less than youngest relative with cancer and continue every 3-5 years.; b) symptomatic patients with one first degree relative with colon cancer, start at age 35 and continue every 3-5 years.

HR16 Depression/Suicide risk factors: Recent divorce, separation, unemployment, depression, alcohol or other drug abuse, serious medical illnesses, living alone, or recent bereavement.

HR17 Sharing/using unsterilized needles and syringes: Intravenous drug users.

HR18 Back-conditioning exercises: Person at increased risk for low back injury because of past history, body configuration, or type of activities.

HR19 Prevention of childhood injuries: Persons with children.

HR20 Falls in the elderly: Persons with older adults in the home.

HR21 Skin and eye protection form ultraviolet light: Persons with increased recreational or occupational exposure to sunlight, a family or personal history of skin cancer, or clinical evidence of precursor lesions (e.g., dysplastic nevi, certain congenital nevi).

HR22 Hepatitis B vaccine: Sexually active people (multiple partners, bisexual & homosexual activity), intravenous drug users, recipients of some blood products, persons in health related jobs with frequent exposure to blood or blood products, or household members of carriers.

HR23 Pneumococcal vaccine: Persons with medical conditions that increase the risk of pneumococcal infection (e.g., chronic cardiac or pulmonary disease, sickle cell disease, nephrotic syndrome, Hodgkin's disease, asplenia, diabetes mellitus, alcoholism, cirrhosis, multiple myeloma, renal disease, or conditions associated with immunosuppression).

HR24 Influenza vaccine: Residents of chronic care facilities or persons suffering from chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction; health care workers.

HR25 Hemoglobin: Evaluation for menstruating women.

HR26 Flexible Sigmoidoscopy (60 cm): Asymptomatic patients with one first degree relative with colon cancer, start flexible sigmoidoscopy at age 35 and continue every 3-5 years.

HR27 Rubella Antibodies: Females of childbearing age lacking evidence of immunity.

* ACP denotes the American College of Physicians, USPSTF the U.S. Preventive Services Task Force and CTF the Canadian Task Force.

Marketing and health education have surveyed enrollees and developed a less complex consumer HP/DP Guidelines card for men, women, and youths. The consumer versions are actively marketed via newsletters to enrollees and providers, by provider relations and sales during their visits, and by provider offices. Figure 3, page 17, shows the women's HP/DP Guidelines card.


What are the measures of success? In the short term, we have seen improved health screening: higher immunization, mammography, and pap smear rates, all exceeding the Health in People 2000 goals. Long-term measures will be lower smoking, cardiovascular disease, and cancer rates; higher health status measures; improved patient and employer satisfaction; and, eventually, healthier communities.

The response to the HP/DP Guidelines from the area employer community has been remarkable. Employers are impressed that we go to such efforts to develop and internally and externally market such guidelines and to advance health screenings and the health status of our enrollees. They are also impressed that we go beyond our enrollees and work with the community to improve the community's health status.

Thus, a process to work on health screening opportunities has been provided.

* Select a visible opportnity.

* Select a topic that is important to the health plan, the provider, and the enrollee.

* Measure the health screening opportunity.

* Have patience.

* Use participation, feedback, and education.

* Create work groups that sunset

* Utilize champions.

* Identify barriers and root causes that create and prevent closing the gaps.

* Market internally and externally.

* Develop incentives.

* Implement guidelines and systems.

* Remeasure.

* Continually improve the process.

As we increasingly move from managing sickness to managing health and improving the health status of patient populations, Health Promotion/Disease Prevention Guidelines and health screening measures will be developed. The processes, tools, and measures described here will become commonplace in integrated managed care systems and accountable health plans. These processes, tools, and measures will meet the increasing expectations of individual employers, local employer health care coalitions, and the Health Plan Employer Data and Information Set (HEDIS) and the increasing requirements of accreditation bodies such as the National Committee for Quality Assurance (NCQA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Nicholas E. Mischler, MD, MS, FACP, was Medical Director, Physicians Plus Insurance Corp., Madison, Wis., at the time this article was written. He is now Senior Physician Consultant, Milliman and Robertson, Inc., Brookfield, Wis. For $3 per copy, including postage and handling, one may obtain the entire Health Promotion/Disease Prevention Guidelines. For $1, including postage and handling, one may obtain one set of the three consumer Health Promotion/Disease Prevention Guidelines. Volume discounts are available. Write to:

Physicians Plus Marketing

Attn: HP/DP Guidelines

340 W. Washington Ave.

Madison, Wis. 53703

COPYRIGHT 1995 American College of Physician Executives
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Article Details
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Author:Mischler, Nicholas E.
Publication:Physician Executive
Date:Aug 1, 1995
Previous Article:Clinical guidelines: a defense in medical malpractice suits.
Next Article:The theory of S-curve discontinuity in the medical care field.

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