Preventive care is a cornerstone in the practice of family medicine, but is often difficult to provide because of a lack of time and logistic difficulties.
To develop an evidence-based practice-relevant preventive care checklist form to be used by family physicians during complete health assessment of adults.
Guidelines for preventive health care of adults at average risk from the Canadian Task Force on Preventive Health Care and from other Canadian sources where the Task Force guidelines were not up-to-date were reviewed. Checklist forms covering recommended preventive health care maneuvers were created. The forms incorporate evidence-based preventive care guidelines as well as non–evidence-based components that are a part of routine practice. The forms require few resources to implement, are cost-effective, and are easy to use. The forms list items needed to meet provincial billing requirements for complete health assessments and have space for physicians to make notes. The forms can be used electronically or printed off and photocopied for use in paper-based charts.
The Preventive Care Checklist Form © is a low-cost, easy-to-use tool that merges practice maneuvers with evidence-based recommendations. It could help improve preventive care practices in Canada.
La prévention fait partie intégrante de la pratique familiale, mais le manque de temps et les obstacles logistiques rendent souvent son application difficile.
Développer, à l’intention du médecin de famille et à partir de données probantes, une fiche de contrôle sur les soins de santé préventifs devant faire partie du bilan de santé chez l’adulte.
On a recensé les directives concernant les soins de santé préventifs des adultes à risque moyen formulées par le Groupe de travail canadien sur les soins de santé préventifs ou par d’autres sources canadiennes lorsque les directives du Groupe de travail n’étaient pas à jour. Des fiches de contrôle couvrant l’ensemble des soins de santé préventifs recommandés ont ensuite été créées. Ces fiches incluent, outre des directives de santé préventive fondées sur des preuves, des composantes de l’examen de routine non appuyées par des preuves. Les fiches sont rentables et faciles à utiliser, et leur mise en œuvre exige peu de ressources. Elles énumèrent aussi les éléments requis pour satisfaire aux exigences provinciales de facturation pour des bilans de santé et réservent de l’espace pour les observations du médecin. Elles peuvent être utilisées en mode électronique ou encore imprimées et photocopiées pour incorporation au dossier-papier.
La Fiche de contrôle des soins de santé préventifs est un outil peu coûteux et facile d’utilisation qui associe des gestes cliniques et des recommandations fondées sur des preuves. Elle est susceptible d’améliorer la façon de prodiguer les soins de santé préventifs au Canada.
This article describes forms that help guide annual physical examinations and focus on preventive health guidelines based on Canadian evidence.
The forms incorporate evidence from the Canadian Task Force on Preventive Health Care and from other sources. They list items that meet provincial billing requirements for complete assessments and have separate versions for men and women.
Levels of evidence behind recommendations are indicated; the forms are available on the College of Family Physicians of Canada’s website at http://www.cfpc.ca under Health Policy, Family Practice Resources.
Evaluation in several academic teaching units indicated that using the forms was associated with increased recording of preventive maneuvers and that most family physicians intended to continue to use the forms in practice.
Preventive medicine is an integral component of primary care. Unlike most specialists, family physicians have an opportunity for primary prevention of many diseases through addressing risk factors in asymptomatic adults. During complete health assessment of adults, many family physicians focus on prevention and keep patients up-to-date on their health status. 1 - 3
The Canadian Task Force on the Periodic Health Examination, established in 1976 by the deputy health ministers of the 10 Canadian provinces, set out “to determine how the periodic health examination might enhance the health of Canadians and recommend a plan for a lifetime program for periodic health assessments of persons living in Canada.” 4 The Task Force which was renamed the Canadian Task Force on Preventive Health Care (CTFPHC) in 1984, grades existing published medical evidence for preventive maneuvers and gives greatest weight to study designs and analyses that minimize bias. In addition to the CTFPHC guidelines, there are numerous other evidence-based guidelines with recommendations for clinical preventive care.
Despite the existence of these evidence-based guidelines, not all physicians apply them in clinical practice. 5 , 6 Reasons cited as obstacles to providing preventive care include physicians forgetting about preventive care, patients refusing to follow preventive measures, and logistic difficulties in practice. 7 , 8
Efforts to narrow the gap between evidence and practice have had mixed results. Continuing medical education and continuing professional development have been the traditional way of encouraging changes in clinical practice, but their effectiveness has been disappointing. 9 - 11 Knowledge translation is a new method of putting knowledge into practice; it incorporates tools, such as prompts, reminders, and patient-mediated methods, to overcome barriers to change. 12
We developed the Preventive Care Checklist Form, © a flow chart and checklist, to help implement evidence-based preventive guidelines in primary care and to incorporate the principles of knowledge translation.
To develop a simple form that could be used by family physicians during complete health assessment of adults to enhance and facilitate preventive care within existing patterns of care.
The Preventive Care Checklist Form was developed in 2002 and updated in June 2004. Its format was inspired by the Rourke Baby Record that facilitates evidence-based well-baby care. 13 - 16 Separate forms were created for male and female patients along with an explanation sheet detailing the evidence for the recommendations (many recommendations and maneuvers differ for men and women). The Preventive Care Checklist Form for average-risk, routine, female health assessments is shown in Figure 1 ; all the forms are available on the College of Family Physicians of Canada’s website (http://www.cfpc.ca) under Health Policy, Family Practice Resources, Preventive care checklists.
Form shown is for female patients at average risk; forms for male patients, explanation sheets, and French-language versions of all forms are available on the College of Family Physicians of Canada’s website at http://www.cfpc.ca under Health Policy, Family Practice Resources.
The primary goal of the forms was to enhance delivery of preventive care. Another goal was to incorporate non–evidence-based, but practice-relevant, components into the form to ensure it would meet both family physicians’ needs during complete health assessments and Ontario provincial billing requirements for general assessments. The forms had to be user-friendly, not take too much time to fill out, and make it easy to document findings. Checklists for recommended or completed maneuvers were included, and there was adequate space for additional notes.
Recommendations for preventive health care for asymptomatic adults at average risk were adopted from the CTFPHC guidelines. Grade A recommendations (good evidence to include) and grade B recommendations (fair evidence to include) were added to the form in bold and italics, respectively. Recommendations from other Canadian sources were reviewed where the CTFPHC recommendations were not up-to-date. These recommendations were presented in plain text.
We had considerable debate over which recommendations to include in the forms. Some argued that American recommendations, particularly from the United States Preventive Services Task Force (USPSTF), should be included because their methodology is also evidence based. The USPSTF and the CTFPHC, however, occasionally differ on recommendations. Since the form was designed to represent a standard of preventive care among Canadian family physicians, we decided to use the CTFPHC recommendations even though we knew some recommendations were not current. We reviewed other Canadian sources, particularly the Canadian Medical Association Journal, to ensure that most major disease and burden-of-illness recommendations were included.
Family physicians are encouraged to use the forms in the way they find most useful. Not all components need to be completed for all patients. At our centre, some family physicians completed the forms in two visits; after initial assessment of history and physical examination, necessary tests were ordered and a second visit was booked to discuss the results of investigations. Other physicians completed the whole assessment in one visit; completion took between 20 and 40 minutes. If a nurse was available, he or she could complete parts of the form, including the lifestyle section and parts of the physical examination. Forms photocopied on coloured paper were easily visible in charts and could be referred back to during subsequent assessments.
The Preventive Care Checklist Form requires only minor office system changes to incorporate into practice. At our centre, clerical staff attached the forms to charts of patients booked for complete health assessments. Nothing else is required. Forms can also be incorporated into electronic medical records. The forms and an explanation sheet were endorsed by the College of Family Physicians of Canada in July 2004 and are available in English and French on the College’s website at http://www.cfpc.ca under Health Policy, Family Practice Resources. The forms will be updated periodically to incorporate changes in evidence-based practice.
In April 2003, a questionnaire was distributed to all 34 resident and staff physicians who used the Preventive Care Checklist Form for a 5-month period between November 2002 and March 2003 as part of a separate trial. That trial aimed to determine whether the forms helped improve performance and documentation of preventive health maneuvers. The survey was approved by the Research Ethics Board at St Michael’s Hospital in Toronto, Ont, in September 2002.
Participating staff physicians worked in two teaching practices in Toronto and were paid on a fee-for-service basis. Table 1 17 shows the characteristics of the population surveyed. Residents were involved in complete health assessment of adults 7% of the time.
Mean age of patients was 47 (± 16) years; mean age of physicians was 46 (± 10) years. Physicians had been in practice a mean of 16 (± 9) years.
*Described in Albertsen. 17
Thirty-one of the 34 physicians returned completed questionnaires for a response rate of 91%. Nineteen respondents (63%) were female; 21 (68%) were staff physicians; and 10 (32%) were family medicine residents. Staff physicians had been in practice from 2 to 30 years (mean of 14.5 years).
When asked how often the form was used during complete health assessments, 97% said often (n = 14) or always (n = 16) ( Table 2 ). The most common reasons for not using the form consistently were because it was not attached to the chart when the health assessment was being done (n = 8), it was considered too time-consuming (n = 3), or physicians forgot about it (n = 3).
Responses regarding the usefulness of the Preventive Care Checklist Form©
*At half of all assessments.
†At less than half of all assessments.
Preventive care forms are meant to improve delivery and documentation of preventive maneuvers. While delivery of services is most important, if it is not documented, by medicolegal standards it is considered not done. Most of the physicians surveyed thought the forms helped improve delivery (65%) and documentation (71%) of preventive health care at most assessments ( Table 2 ).
The most-liked aspects of the Preventive Care Checklist Form included the evidence-based recommendations, the checklist format, and the helpful reminders ( Table 3 ). Suggested improvements included changing the layout (n = 11, 35%) and leaving more room for documentation (n = 7, 23%).
Physicians could mention more than one attribute.
Most physicians (94%) said they conducted most of their preventive health care during complete health assessments. The most common reasons for this included being thorough, finding it easier to remember preventive health maneuvers during complete health assessments, providing continuity of care, fulfilling patients’ expectations, and finding it difficult to provide preventive care at other visits ( Table 4 ).
Physicians could mention more than one reason.
Overall, 77% of physicians stated they would continue to use the Preventive Care Checklist Form in practice. The most common reasons for not using the forms during routine care were that the layout was thought not to flow easily and to be cluttered (3/7), that there was too much repetition (2/7), that the forms took too much time to fill out (1/7), or that they did not like using standardized forms (1/7).
Before the Preventive Care Checklist Form, there were no standardized or endorsed evidence-based forms that family physicians could use during complete health assessment of adults. In 1987 and 1992, two American studies evaluated the effectiveness of a checklist reminder form to improve preventive health care in primary care practice. 18 , 19 Since then, use of paper-based checklist forms has rarely been reported in the literature, and despite being proven effective, checklist forms are underused. 20 No other trials have focused exclusively on checklist reminder forms. Some have studied similar concepts in computer-based reminder systems. They too have been successful, but require the appropriate technology and software to incorporate. Other studies have looked at a multifaceted approach where a variety of aids, including checklist reminders, nurse facilitators, and patient-mediated tools were incorporated. 19 While some of these interventions were effective, they required many resources and were harder for average family physicians to incorporate.
Results of our trial showed that physicians thought using the Preventive Care Checklist Form helped improve preventive care during complete health assessment of adults. We compared rates of 13 preselected preventive health maneuvers performed by a control group during periods before and after the trial. Eight of the 13 maneuvers (counseling on brushing and flossing teeth [RR 9.2], counseling on folic acid [RR 7.5], fecal occult blood testing [RR 6.7], counseling on smoking cessation [RR 3.9], tetanus immunization [RR 1.33], history of smoking [RR 1.28], and blood-pressure measurement [RR 1.05]) were performed statistically significantly more often using the Preventive Care Checklist Form after controlling for potentially confounding variables. In the control group, 49% of patients received recommended preventive health maneuvers based on age and sex; in the intervention group who used the Preventive Care Checklist Forms, 72% of patients received them. This represented a 23% absolute increase and a 47% relative increase in delivery of preventive services. In most prevention trials, a 10% improvement is considered excellent.
Our form is unique because it incorporates evidence-based preventive care guidelines and maneuvers that are not evidence-based but are relevant to practice, such as functional inquiry. More than 90% of physicians surveyed said they did most of their preventive health care at complete health assessments. This supports use of the Preventive Care Checklist Form exclusively during complete health assessments. Time constraints and forgetfulness were the most commonly cited reasons for not providing preventive care. 21
The form was designed for documenting assessment of adults at average risk. Recommendations for patients at high risk of disease are not included. While recommendations for elderly patients are included in the form, physicians might want to supplement it with geriatric-specific inquiries. The recommendations are based only upon the references consulted; other evidence-based recommendations were not considered. Although the form is comprehensive and has many sections, physicians do not necessarily have to complete all the steps. Physicians should use their discretion and knowledge of their patients to determine what is required.
The Preventive Care Checklist Form is a user-friendly evidence-based tool for family physicians to use at complete health assessment of adults to enhance delivery and documentation of preventive health care. The form incorporates existing practice patterns, and the items listed meet Ontario provincial billing requirements for complete health assessments. The forms have been endorsed by the College of Family Physicians of Canada and are easily accessible at http://www.cfpc.ca. They will be updated periodically to ensure they are current. They can be used in hard copy or as part of electronic medical records.
We thank Drs Roy Mathew and Karl Iglar for help in research and development of the forms, and the physicians and staff at St Michael’s Hospital for participating in development and implementation of the forms. This research was funded by the physicians of Ontario through the Physicians’ Services Incorporated Foundation.
Dr Dubey is a fifth-year Community Medicine Resident in the Department of Public Health Sciences at the University of Toronto in Ontario and works as an emergency physician at Lakeridge Health Bowmanville Hospital in Bowmanville, Ont.
Dr Glazier is an Associate Professor of Family and Community Medicine at the University of Toronto and a Scientist in the Inner City Health Research Unit at St Michael’s Hospital.
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