This is a continuation in our series of MD Tech Tips — Technology tips to help physicians improve their craft and work more efficiently.
A 60 year-old sexually active female smoker with a past medical history of type 2 diabetes, hypertension and hyperlipidemia presents for her annual exam. The patient’s most recent A1c is 7.0, most recent LDL-C is 70 on a moderate intensity statin. According to your nurse she likely needs some cancer screening tests. The patient asks if she needs a mammogram (she had one last year) or a pap smear (she had one 6 years ago). What preventive services do you offer her?
How to use ACC’s LDL-C Manager app to determine care for this patient
We previously favorably reviewed the Agency for Healthcare Research and Quality (AHRQ) app called ePSS (electronic preventive services selector). The app includes all of the current recommendations from the United States Preventive Services Task Force (USPSTF). The recommendations from the USPSTF are routinely used by primary care providers and covered by Medicare. At times, their recommendations, such as those on prostate cancer (just revised) screening and breast cancer screening, have caused significant controversy. Overall, their strict adherence to the best available medical evidence is admirable.
Using the ePSS app, we can quickly determine which preventive services this patient needs. By inputting her age, gender, sexual activity and tobacco hx, we can quickly calculate lists of items that we should ensure this patient receives based on the best available evidence. The app divides the lists into letter categories–A, B, C, D, and I–based on the quality of the evidence. Typically, anything in the A or B categories should be recommended as it has the highest supporting evidence. Items in the “D” category (such as carotid artery stenosis screening in our particular case) are not recommended as the risks of harm outweigh the benefits. Items in the “I” category are uncertain as there is currently “insufficient evidence for or against” the recommendation (such as bladder cancer screening in our patient’s case).
For our patient, the category “A” items we can discuss with our patient include cervical cancer screening, colorectal cancer screening and tobacco cessation in addition to the “obvious” screening for hypertension. Our patient is due for cervical cancer screening since her last pap was 6 years ago, but according to our electronic medical record she is up to date on her colon cancer screening. We counsel the patient at length on tobacco cessation and she agrees to attend our clinic tobacco cessation program and likely start a medication such as nicotine replacement therapy.
The category “B” items for our patient include screening for alcohol misuse, breast cancer screening with mammography, lung cancer screening with low dose CT and some lab work such as hepatitis B/C screening. The patient is already on a statin, but the app also includes that recommendation. The patient has no family history of breast cancer so we don’t offer her BRCA screening and since her last mammogram was last year, we can use the app’s “clinical rationale” section to help explain to the patient why she doesn’t need a mammogram for another year. The USPSTF continues to get pushback from some groups regarding its breast cancer screening recommendations, especially in patients under 50. Interestingly, the group was aggressive in adopting LDCT for lung cancer screening which is associated with a high false positive rate for lung nodules. After discussing the risks/benefits with the patient, she decides not to undergo the LDCT test.
Interestingly, the app places aspirin use in category “C” for our patient. For aspirin use, I recommend providers use the outstanding Aspirin Guide app since the recommendations for aspirin use in the ePSS app are challenging to understand since it requires the use of multiple risk calculators (not included in the app). The USPSTF was the first major organization to make a recommendation for using aspirin both for CV disease AND colorectal cancer prevention.
There are some items in the “D” category worth mentioning to our patient–especially since many women may ask about them or are currently using them. For example, the USPSTF recommends against the use of hormone therapy in postmenopausal women for the prevention of chronic conditions and recommends against the use of vitamin D and calcium to prevent fractures in noninstitutionalized women. Many patients’ jaws drop when reviewing category “D” items, so make sure to show them this section too.
Finally, it is sometimes worth mentioning the “I” category items, as some patients may be curious about these recommendations. For our patient, perhaps mentioning the “I” recommendation for the pelvic exam (do the pap, just not the pelvic) and/or the electronic nicotine delivery recommendation (use proven cessation methods, not the e-cigarette).
In the end, our patient agrees to have her pap smear completed, accepts a referral for tobacco cessation counseling/medications, starts a baby aspirin, continues her statin, waits a year for her mammogram and declines lung cancer screening. By using this app with nearly EVERY patient (especially those for “annual exams”), you can ensure your patients receive the recommended preventive services and improve your provider-patient relationship by showing patients “why” you do/don’t do certain medical treatments based on the best available evidence.
Evidence based medicine
Please read our full review to learn more about the AHRQ ePSS app; it consistently is one of our top apps for primary care providers!