How Do Providers Prioritize Prevention? A Qualitative Study

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The American Journal of Managed Care, October 2013, Volume 19, Issue 10

Primary care providers utilize many strategies for prioritizing preventive care during time-constrained clinical encounters, in addition to being prompted by clinical reminders.

Background: Preventive care is an essential element of comprehensive primary care medicine, yet many providers do not address the full range of recommended preventive care services. There is little understanding of how, during time-constrained clinical encounters, providers prioritize preventive care services.

Objectives: To identify and compare how Department of Veterans Affairs (VA) primary care providers (PCPs) prioritized general preventive care services, including HIV testing.

Study Design: A semistructured, qualitative interview design.

Methods: We conducted semistructured phone interviews with 31 PCPs across 2 urban VA facilities. Interviews entailed questions about the most common preventive care services in primary care, how decisions are made to address some preventive care services but not others, and the role of clinical reminders (CRs) in prioritizing care. Interviews were audio-recorded and transcribed verbatim. We conducted an iterative thematic analysis of interview transcripts, utilizing NVivo 8, a qualitative data management and coding software.

Results: Most PCPs indicated they did not utilize CRs as a primary means of prioritizing general preventive care. Instead, PCPs prioritized general preventive care by attending to patients’ individual needs and/or keeping in mind influential clinical training experiences. Prioritizing HIV testing included 1 or a combination of the following strategies: being attuned to HIV risk factors prior to the appearance of the CR, being prompted by the CR, and having a positive attitude toward CR design.

Conclusions: Prioritizing preventive care can be accomplished using various strategies, including CRs. Healthcare systems might benefit from encouraging PCPs to use a range of strategies.

Am J Manag Care. 2013;19(10):e342-e347Primary care providers (PCPs) lack time in clinical encounters to address all preventive care services, meaning they choose to prioritize some services over others. Until now, there has been little understanding of how PCPs prioritize these services.

  • PCPs prioritize general preventive care by attending to patients’ individual needs and keeping in mind influential clinical training experiences.

  • They prioritize human immunodeficiency virus (HIV) testing by being attuned to HIV risk factors, being prompted by clinical reminders (CRs), and having a positive attitude toward CR design.

  • Healthcare systems might wish to offer providers greater flexibility regarding prioritizing preventive care.

Addressing preventive care in primary care is crucial for avoiding or delaying the onset of disease and for mitigating the progression of preexisting disease.1-3 However, research indicates that providers do not regularly address the full range of recommended preventive care.4,5 A landmark study found that only 54.9% of recommended preventive care services were delivered to patients across 12 metropolitan areas in the United States.6

Although the low rate of preventive care delivery is attributable to a variety of factors,7,8 the most common explanations are clinical encounter time constraints and competing demands.9-11 Providers might be in full agreement with guidelines regarding preventive care, yet many note they do not have time to implement them and therefore must prioritize some preventive care services over others. For example, “health habit counseling,”12 administering various immunizations,10 adjusting diabetes medication,13 smoking cessation14 and other types of counseling,10 breast and cervical cancer screening,15,16 and initiating depression treatment17 were not addressed by providers due to limited time and competing demands.

To increase delivery of preventive care services by primary care providers (PCPs), the Department of Veterans Affairs (VA), like ome other healthcare systems, has implemented electronic clinical reminders (CRs). Clinical reminders are designed to reflect evidence-based clinical practice guidelines. Clinical reminders are VA-wide and appear in the form of text reminders when a provider opens a patient’s electronic record. Providers can resolve a CR when they click a check box indicating they have addressed the relevant preventive care topic. If providers do not click the requested check box, the CR remains unfulfilled and will appear at subsequent patient visits until it is resolved.

The purpose of our study was to identify how PCPs at 2 VA facilities prioritized general preventive care services. Because human immunodeficiency virus (HIV) testing had recently become a recommended preventive care service in the VA, we also examined the prioritization of HIV testing. Other studies have examined delivery of general preventive care services but with a specific focus on barriers to and facilitators of organizational and work processes,18-20 whether or not certain CRs were satisfied,20 and who initiated talk of preventive care and under what circumstances,21,22 rather than focusing on prioritization more broadly. Some studies were limited to behavioral health counseling21 or to specific diseases such as coronary heart disease23 or colorectal cancer screening.24 Several studies focused on patient populations other than veterans.18,21-25

Moreover, although other studies have examined the effects of introducing CRs on HIV testing rates,26-28 the current study is the only one we know of that addressed HIV testing prioritization in broader terms.

METHODS

We conducted qualitative interviews with front-line PCPs, which included physicians and nurse practitioners (NPs). Eligibility and Recruitment

Primary care providers from 2 urban VA facilities—1 on the East Coast and 1 on the West Coast—were eligible for participation in the study (n = 71). Both VA facilities were targeted for inclusion in the study because they utilized a CR prompting providers to offer HIV testing to at-risk patients, and one of our objectives was to compare how providers prioritized HIV testing with how they prioritized general preventive care services. The West Coast site had an HIV testing CR for 2 years; the East Coast site had the HIV CR for a few months.

The directors of primary care at each VA facility assisted with recruitment by announcing the study to their providers at regularly scheduled team meetings. In these meetings providers were notified that participation in the study was voluntary; refusal to participate would not affect professional status, pay, or benefits; and the principal investigator (JLS) would be sending an e-mail invitation to participate in an interview. The directors of primary care were not informed who chose to participate.

The principal investigator sent e-mail invitations to all 71 providers at both clinics. In addition to requesting providers’ participation in interviews, the e-mails contained explanations of the study, the general nature of the interviews, providers’ rights, and an information sheet outlining the elements of informed consent.

Follow-up e-mails were sent every 2 weeks, on 3 occasions, to providers who did not respond. A total of 31 providers participated in interviews (44% participation rate): 22 from the West Coast and 9 from the East Coast. The study was approved by institutional review boards at all sites.

Semistructured Interviews

In-depth, semistructured telephone interviews were conducted by the principal investigator. Interviews ranged in length from 30 minutes to 1 hour, were audio-recorded with the consent of all participants, and were transcribed verbatim. Transcriptions were imported into a software program designed for qualitative data management (NVivo 8; QSR International Pty Ltd, Victoria, Australia).

Interviews were designed to elicit the perspectives and experiences of PCPs in relation to prioritizing preventive care services during clinical encounters. Questions dealt with topics such as the range of preventive care services faced by providers; how providers become aware of preventive care services; how providers prioritize among multiple preventive care services, including HIV testing; and the roles of CRs and clinical guidelines in prioritizing preventive care services (Table).

Data Analysis

We conducted a thematic analysis of all interview transcripts. In the first phase of analysis investigators with expertise in qualitative methods (JLS, BGB, NM) used an inductive approach to code and “discover” initial themes pertaining to prioritizing preventive care.29-31 All 3 investigators read the same 10 interview transcripts and met regularly to discuss, debate, and ultimately come to consensus about the codes and emerging themes.

In the second phase of analysis, investigators coded the remaining transcripts in rotating combinations of pairs and met regularly to discuss and refine the coding scheme and the eveloping themes. Investigators also began to map relationships across some of the themes and to delineate, in some cases, salient subthemes that further illuminated how providers prioritized preventive care.

In the third and final phase of analysis, investigators directly involved in the analysis reported the themes and subthemes to the entire research team, to solicit feedback. Based on the team’s feedback, investigators further refined some of the themes and presented the themes once again to the team, at which point the team achieved consensus regarding the findings.

RESULTS

Of the 31 interviews conducted, audio recording malfunctioned once, resulting in a total data set of 30 interview audio files and transcripts. Of these 30 providers, 21 (70%) were physicians and 9 (30%) were NPs. Of the providers, 23 (77%) were women, and the providers had been in the VA for a mean of 13 years.

To contextually situate our findings, we first describe PCPs’ mostly negative perceptions of CRs and their limited roles in prioritizing preventive care. Most providers explained that they do not rely on CRs as a primary strategy for prioritizing general preventive care topics (other than HIV). Of these providers, several said they consulted CRs as a secondary, back-up method after having prioritized care by other means. A few providers did describe relying on CRs to prioritize care. Below we describe briefly why most providers did not rely on CRs to prioritize care.

First, providers argued that certain preventive care procedures that appear in CRs might do more harm than good for patients with advanced-stage disease or a diminished quality of life. For example, a NP explained this view, noting, “If the patient is a dialysis patient and [has] severe congestive heart failure, we are not going to screen them [colonoscopy].”

Second, providers characterized CRs as burdensome, in the sense of being too time-consuming and too cumbersome to navigate. For example, an NP explained that CRs are:

A colossal waste of my time…. So, clinical reminders for me are … most of them are unnecessary. It would be very helpful if there were a little box that just said, “Pneumovax, tetanus, flu: Did ya’ do it?” But when I get to that box, when I click it, it’ll have me put in all this other stuff, and so there’ll be 2 on hypertension. “Did you recheck the blood pressure? Yes. What is it? Did you adjust the medication? Yes.”

The third reason providers cited for choosing not to use CRs to prioritize general preventive care was that they perceivedsome CRs as irrelevant to primary care medicine. A NP noted, for instance, that, “Some of the reminders are very silly…[and shouldn’t] be there in a medical chart, such as: ‘Is patient using a seat belt?’ But that’s a law to use a seat belt. It’s not a medical issue.” Furthermore, providers who characterized some CRs as irrelevant noted that attending to them would use valuable time that could be spent on more important topics.

We next describe the ways in which PCPs said they prioritized general preventive care services and HIV testing.

General Preventive Care Services

Attending to Patients’ Individual Needs. The first way in which PCPs described prioritizing general preventive care services was attending to patients’ individual needs. Primary care providers described learning about a patient’s individual needs through ongoing clinical interactions and then weighing these needs against the range of preventive care options appearing in CRs. For example, a physician explained:

We have a desire, if we’re giving the best [preventive] care, to individualize … what should be done, which, I think, is the best way of doing this. [It] is to give thought about what’s appropriate in this particular setting, in the sense that the package [CRs] does not allow you, in an easy fashion, to do.

Notably, this physician explicitly contrasted the concept of individualizing care with CRs (“the package”), indicating his view of the importance of assessing patients’ individual needs to decide whether to offer recommended services. Some PCPs described addressing patients’ individual needs by offering preventive care in the context of urgent care visits. For example, a physician explained:

If it’s something that’s sort of semiurgent and I’ve addressed that issue within the first 5 to 10 minutes of the clinic visit, generally … if it’s been more than 6 months since I’ve seen that patient, I’ll pull out that [preventive care] sheet, and I try and go through each element of it with them so they know where they stand.

This physician consciously assessed the severity of each urgent care visit and how recent the patient’s last appointment was to decide which preventive care topics, if any, to address.

Some PCPs described a different approach for attending to patients’ individual needs during urgent care visits. This group of providers explained that they only broached preventive care services in urgent care visits if they were related to the patients’ presenting complaint, noting that otherwise raising preventive care issues would not be in patients’ best interests. A physician noted:

It’s one thing for smoking cessation counseling to be addressed at a visit for bronchitis. But it’s not so appropriate necessarily to be bringing up their mammogram, getting a mammogram. It kind of disrupts the flow, and as I said, there’s that competing agenda problem of: “Okay, they came in ’cause they’re feeling like junk and then they get harangued by their doctor about getting the mammogram done, or getting a Pap smear done.”

For this physician, discussion of smoking cessation in such an encounter was warranted because of its direct relation to the patient’s presenting problem.

Keeping in Mind Influential Clinical Training Experiences. A second broad strategy many providers described using for prioritizing general preventive care was keeping in mind clinical training experiences they deemed influential. Overall, NPs spoke more than physicians about their clinical training because, they noted, NP training programs tend to have more of an explicit preventive care focus than medical schools do. For example, an NP said:

I was educated to really focus on preventive care…. Even from my basic nursing education and my first nursing staff experience, but when I went to X the big focus was on preventive care for our whole shebang…. I knew tons about preventive care…. My scope of practice started out really preventive [care] and expanded as I went along as an individual…. The premise of my practice was preventive primary care and how to treat, how to follow chronic conditions like diabetes, hypertension, a lot of training in that, women’s health.”

Prioritizing HIV Testing

Being Attuned to Risk Factors Before Appearance of the Clinical Reminder. Primary care providers described using 3 overarching strategies, either singly or in combination, for prioritizing offering HIV testing to patients. The first strategy is being attuned to risk factors before the appearance of the CR. For example, a physician explained:

I don’t wait for the reminder to pop up. If I have somebody, a … veteran returning from war and he is drinking, well, I guess that’s high risk, right? I think of it as just a good thing to check, and then I’ll add it on if somebody has like abnormal liver enzymes or whatever. I’m not necessarily going into any detailed sexual history before I [offer testing]. I will get fasting lipids and I’ll add on HIV.

In this example the provider considered drinking by a recently returned veteran or the appearance of abnormal liver enzymes to be sufficiently high risk factors by themselves to prompt offering testing, independent of the CR.

Being Prompted by the Clinical Reminder. The second way in which PCPs prioritized HIV testing was being prompted by the CR. In these cases PCPs noted that being prompted by the CR led them to offer HIV testing to patients whom they would otherwise not have deemed at risk for contracting IV. Here’s how an NP characterized this strategy of prioritization:

People who are in stable, monogamous relationships, if I didn’t have the clinical reminder, I probably wouldn’t offer them HIV testing routinely, and I might not ask if someone has been married that many years and stuff…. I think the HIV clinical reminder is a good idea in that it would be good to have that there because it gives people an option … that puts that on the table and they go, “Oh, yeah.”

This NP noted that it would not occur to her to offer HIV testing to patients in stable, monogamous relationships. However, the appearance of the HIV testing CR results in her giving patients the option to be tested and, ultimately, become aware of their serostatus.

Positive Attitude Toward the Qualities of HIV Clinical Reminder. The third way in which PCPs prioritized HIV testing was by having a positive attitude toward the qualities of the HIV CR itself. Specifically, providers remarked that the HIV CR’s one-time (rather than repeated) occurrence for most patients, its ease of use, and the short amount of time needed to fulfill it led them to satisfy the CR. For example, a physician noted, “The HIV reminder is not too onerous ’cause it’s pretty easy to satisfy it.” As another example, an NP commented, It’s not that difficult to complete. You just say to the patient: ‘I just got an alert—you’re eligible to be tested for HIV. Would you be interested?’”

Related to this ease-of-use theme, some providers also noted that fulfilling the HIV CR had become easier recently because the VA no longer required them and their patients to go through the cumbersome and time-consuming process of reading and signing informed consent forms. Instead, providers now only had to obtain verbal consent from patients to be tested, which made satisfying the HIV CR considerably less burdensome.

DISCUSSION

The purpose of this study was to examine how PCPs at 2 VA facilities prioritized preventive care services during time-constrained clinical encounters. In addition to examining the broad range of preventive care topics in primary care, we identified the ways in which providers prioritized offering HIV testing to patients.

Our findings reveal that most providers prioritized general preventive care by attending to patients’ individual needs and/or keeping in mind influential clinical training experiences. As we showed, part of attending to patients’ individual needs is determining whether or not, depending on the patient’s chief complaint, to address preventive care services during urgent care visits.

Prioritizing HIV testing entailed 1 or a combination of some of the following: being attuned to HIV risk factors before the appearance of the CR, being prompted by the CR, and having a positive attitude toward the qualities of the CR.

A notable difference between HIV testing prioritization strategies and the ones mentioned for general preventive care is that, with the exception of being attuned to risk factors, PCPs are far more reliant on the CR for HIV testing than they are on CRs for general preventive services. Our interviews did not focus on risk factors for diseases other than HIV, nor did participants spontaneously raise this topic. Our findings suggest that relying on CRs for HIV testing can be attributed to the CR’s ease-of-use and its one-time appearance, which, as described earlier, contrasts with PCPs’ characterizations of general preventive care CRs.

Our study had limitations. Our sample size was small, with data limited to 2 facilities in the VA, which means findings might not be generalizable to other VA facilities or to PCPs outside the VA. Moreover, we relied on providers’ descriptions of their clinical practices, rather than observing their actual behavior.

Our findings have some important implications. Chief among these is the notion that providers might use a range of strategies to address evidence-based recommendations, depending on the needs and circumstances of patients. In this light, CRs should be regarded by providers and management/administration as a flexible tool, and perhaps 1 among many. Indeed, ongoing collaboration between providers and management to document the array of strategies for achieving compliance with evidencebased recommendations might benefit all parties concerned.Author Affiliations: From Center for Health Quality, Outcomes and Economic Research (JLS, ALG, NM, BGB), ENRM VA Hospital, Bedford, MA; Boston University School of Public Health (ALG, BGB), Boston, MA; Boston University School of Medicine (ALG), Boston, MA; VA Palo Alto Healthcare System (SMA), Los Angeles, CA; VA San Diego Healthcare System (CMT), San Diego, CA; VA New Jersey Healthcare System (JMS), East Orange, NJ.

Funding Source: This study was funded by the Department of Veterans Affairs, Health Service Research and Development (RRP 09-126).

Author Disclosures: The authors (JLS, ALG, SMA, NM, CMT, JMS, BGB) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (JLS, ALG, SMA, NM, CMT, JMS, BGB); acquisition of data (JLS, CMT, JMS); analysis and interpretation of data (JLS, ALG, SMA, NM, BGB); drafting of the manuscript (JLS); critical revision of the manuscript for important intellectual content (JLS, ALG, NM, SMA, CMT, JMS, BGB); provision of study materials or patients (CMT, JMS); obtaining funding (JLS, ALG, SMA, BGB); administrative, technical, or logistic support (ALG, CMT, JMS); and supervision (ALG, BGB).

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