Public Health Detailing of Primary Care Providers: New York City’s Experience, 2003–2010

Abstract

Objectives. We evaluated the effectiveness of the Public Health Detailing Program in helping primary care providers and their staff to improve patient care on public health challenges.

Methods. We analyzed reported changes in clinical practice or behavior by examining providers’ retention and implementation of recommendations for campaigns.

Results. During each campaign, 170 to 443 providers and 136 to 221 sites were reached. Among assessed providers who indicated changes in their practice behavior, the following statistically significant increases occurred from baseline to follow-up. Reported screening for clinical preventive services increased, including routinely screening for intimate partner violence (14%–42%). Clinical management increased, such as prescribing longer-lasting supplies of medicine (29%–42%). Lifestyle modification and behavior change, such as recommending increased physical activity to patients with high cholesterol levels, rose from 52% to 73%. Self-management goal setting with patients increased, such as using a clinical checkbook to track hemoglobin A1c goals (28% to 43%).

Conclusions. Data suggest that public health detailing can be effective for linking public health agencies and their recommendations to providers and influencing reported changes in clinical practice behavior.

The Public Health Detailing Program within the New York City Department of Health and Mental Hygiene (DOHMH) has worked closely with primary care providers and their staff since 2003 to improve patient care by addressing the leading, largely preventable, causes of illness, disability, and death. Drawing on evidence indicating that gaps in provider knowledge and the absence of office systems contribute to suboptimal care, the Public Health Detailing Program was designed to address these and other issues of care delivery.¹ Public health detailing focuses on neighborhoods facing the greatest health disparities and is part of New York City’s approach to reduce the disproportionate burden of poor health.

Public health detailing initiatives center on clinical topics chosen for their anticipated effect on morbidity and mortality and other public health priorities. Although the focus is on managing chronic conditions, the program has “detailed” issues ranging from intimate partner violence screening to recruitment for the New York City Medical Reserve Corps, promoting the implementation and use of electronic health records, supporting exclusive breastfeeding, and improving medication adherence in patients with cardiovascular disease and diabetes. Public health detailing develops its campaigns in collaboration with internal and external clinical experts.

The program strives to improve primary care physician practice through 1-on-1 visits, or “detailing,” a well-known and successful strategy usually associated with the pharmaceutical industry.^2,3 Whereas most public health interventions in the primary care setting focus on 1 condition or disease over time, public health detailing has developed a standard methodology for the delivery of a variety of public health messages. Highly trained Health Department representatives promote evidence-based, clinical preventive services and chronic disease management by delivering brief, targeted messages to the entire clinical care team of physicians, physician assistants, nurse practitioners, nurses, administrators, and other staff.^2,4

Through its campaigns, public health detailing supports providers and their staff by (1) outlining and discussing evidence-based key recommendations tailored to specific clinical interventions, (2) providing information on new public health policies or practice guidelines, and (3) assessing readiness to adopt key recommendations and supporting clinical tools that best suit the practice.³ The Public Health Detailing Program’s “Action Kits” contain clinical tools, provider resources, and patient education materials to promote evidence-based best-practices recommended by the DOHMH, which are the focus of discussion during office visits by representatives.

We have outlined the results of evaluations from 20 different campaigns.

METHODS

Between October 2003 and 2010, the Public Health Detailing Program completed a total of 49 campaigns. Public Health Detailing used survey data of the leading health indicators by zip code to prioritize the geographic areas of East and Central Harlem, South Bronx, and North and Central Brooklyn as target areas for its campaigns, although some were expanded citywide. After working initially from a list of Medicaid providers, Public Health Detailing sought to identify and subsequently detail all primary care providers working in these geographic areas. Evidence showed that residents in these neighborhoods were more likely than other New Yorkers to have asthma, cancer, HIV/AIDS, diabetes, and heart disease and to be overweight or obese. These target neighborhoods are the primary geographic focus of many DOHMH programs.⁵

The Public Health Detailing Program uses highly trained Health Department representatives to deliver consistent and repeat messaging to providers.³ All representatives are expert communicators, and most have graduate degrees or experience in public health or are health professionals. Preceding each campaign, representatives undergo an intensive weeklong training, with expert DOHMH faculty, to ensure proficiency in clinical content, communicating recommendations and materials, overcoming barriers and objections, and documentation for evaluation. Representatives usually visit providers 3 or 4 times a year with different campaigns, so they can develop relationships with them and their staff and are seen as a valuable resource from the DOHMH. This relationship building fosters open communication channels and promotes the DOHMH and its resources to providers. No monetary incentives were offered for participation.

Each representative is assigned between 35 and 45 primary care sites. A new campaign is implemented approximately every 3 to 4 months and typically lasts 10 to 14 weeks. Most campaigns focus on internal medicine and family practices; however, some have targeted others depending on the topic. For example, the Contraception campaign was expanded to include obstetricians, gynecologists, and pharmacists; the Identifying and Reporting Child Abuse and Neglect campaign was limited to family and pediatric practices.

The core costs of personnel are covered by the Public Health Detailing Program, but many campaign expenditures are covered by grants or other DOHMH bureaus that the program collaborates with to improve its sustainability.

The Public Health Detailing Program’s communication strategy focuses on all staff in the practice—“the total office call”—a methodology shown to have a positive effect on chronic disease management, testing, and screening.^2,3 Campaign messaging centers on key recommendations developed by DOHMH clinical experts and is usually limited to a maximum of 3 recommendations per campaign topic. Key recommendations provide the basis for assessment questions for evaluation. Representatives are trained to integrate the recommendations verbatim into their interactions with providers and staff at each visit. During visits, representatives promote the graphically appealing “Action Kits,” which contain printed clinical tools, provider resources, and patient education materials and are designed to have the look, feel, and quality of a commercially developed product so as to compete with private industry materials (Figure 1).² The kit contents address the 6 components of the Chronic Care Model⁶ in support of informed clinical decision-making, enhanced patient self-management, improved delivery system design, expanded use of clinical information systems, increased collaboration with community organizations, and heightened understanding of health system issues pertinent to the topic detailed.

FIGURE 1—

New York City Public Health Detailing Program Medication Adherence Action Kit cover.

During each campaign, representatives visit providers and staff at their assigned sites at least 2 times.^7,8 At these visits, representatives introduce and reinforce the key recommendations and campaign materials as well as answer any questions from the care team about the campaign. Representatives collect survey data by asking providers an identical short set of assessment questions at initial and follow-up visits. Responses help representatives tailor their presentation to align with providers’ interests and needs.

In addition to the 2 standard visits, representatives often visit sites to deliver current and past campaign materials or fulfill other requests, such as providing supplemental influenza and pneumococcal vaccines. Multiple visits to the entire office team are an integral part of the Public Health Detailing Model, providing opportunities to reinforce key recommendations, ensuring consistency of campaign messaging, and developing relationships with care teams.

Of the 24 campaigns carried out in the priority underserved neighborhoods from 2003 to 2010, 20 were studied. Those excluded from the analysis were 4 Influenza and Pneumococcal Vaccination campaigns, which consisted of only 1 visit.

Providers’ retention and implementation of key recommendations for every campaign are evaluated through responses to the assessment questions. Changes in clinical practice or behavior are measured by providers’ self-reported status from initial to follow-up visit. At the beginning of each initial face-to-face visit, representatives recite assessment questions to providers. At follow-up visits, usually 4 to 6 weeks later, representatives attempt to conduct a second assessment with all providers initially visited. Questions are posed to only licensed prescribers (physicians, nurse practitioners, and physician assistants) because they are usually the decision-makers to implement key recommendations and system changes in the practice.

On average, 3 or 4 assessment questions are designed for every campaign. The provider is not given a list of answer choices to select from; rather, he or she states to the representative his or her practice behavior, and answers are coded in predetermined categories, including “other,” so that all possible answers can be captured. Representatives receive training and practice to code and evaluate each visit before the campaign begins.

Typically, the first assessment question examines the hoped-for effectiveness and uptake of individual campaigns by asking whether providers use specific guidelines for screening or how they implement recommended strategies for chronic disease management. A second question usually determines how providers identify specific populations for particular interventions, such as influenza and pneumococcal vaccination or screening all patients for intimate partner (domestic) violence. In many campaigns, a third assessment question explores providers’ choice of standard screening or testing tools related to the campaign content. Although this is the standard methodology used to develop the assessment questions, each campaign has its own unique needs.

In addition to these questions, representatives ask providers their level of adoption or readiness to adopt the key recommendations by obtaining a commitment from the practitioners. Committing to 1 or more of the DOHMH evidence-based key recommendations is voluntary on the part of the medical provider and is gauged by self-report. Representatives record intended or adopted use of Public Health Detailing Program Action Kit clinical tools, provider resources, and patient education materials. They also rate the receptiveness of providers and staff to the key recommendations and materials on a 6-point scale ranging from “refusal to meet” to “adopted clinical tool(s)/key recommendations.”

Representatives record visit data, including assessment question responses, material use, and rating scale, on a paper visit record and then enter them into an electronic database, allowing Public Health Detailing to analyze campaign data, track campaign reach and frequency, and gauge providers’ interest in the topic and materials. Statistical analysis of the assessment questions is conducted with SPSS version 17.0 (SPSS, Inc, Chicago, IL). Chi-squared tests are used to determine provider practice change between initial and follow-up visits.

The visit data also include practice information, clinician and staff descriptions, and visit details. Representatives also record qualitative notes for each visit, observed best practices, and any other comments and suggestions for the Public Health Detailing Program.

In addition to the detailing visit, Public Health Detailing Program staff collect order information from the DOHMH’s call center, which distributes agency-produced literature throughout New York City free-of-charge. With each campaign, select materials from the Action Kit are made available through the call center so that providers and their staff can call to replenish their supply as needed. Data are specifically collected on these materials to determine who is ordering them, which materials are being ordered, and the quantity and frequency of orders. These data help Public Health Detailing know which materials continue to be used by practices even after a campaign ends.

A final campaign report containing all quantitative and significant qualitative data is generated and distributed to key stakeholders throughout the DOHMH.

RESULTS

All 24 campaigns implemented between 2003 and 2010 in our high-risk neighborhoods and their associated key recommendations are outlined in Table 1. The 20 individual campaigns analyzed for this article reached between 136 and 221 clinical sites, and representatives “detailed” between 170 and 443 providers per campaign. In Table 2, the “All Provider Contacts” and “All Contacts (Providers and Staff)” columns indicate the total number of detailing visits (initial and follow-up visits) during the campaign with providers only and with providers and office staff together, respectively. Among all providers who received an initial campaign visit, on average 45% received a follow-up visit during the same campaign (2005–2007: 38% follow-up rate; 2008–2010: 53% follow-up rate).

TABLE 1—

2003–2010 Public Health Detailing Campaigns, Key Recommendations, and Targeted Providers: New York City Department of Health and Mental Hygiene (DOHMH)

Campaign	DOHMH Key Recommendations	Targeted Providers
Influenza Vaccination 2003	All persons aged ≥ 50 y should receive an influenza vaccine every year.	Internal medicine
	All healthy children aged 6–23 mo should receive an influenza vaccine.	Family practice
	All persons aged ≥ 6 mo (and their close contacts) who have a chronic medical condition should receive an influenza vaccine every year.	Pediatrics
	All health care workers should be vaccinated early in the influenza season.
	The optimal time to receive influenza vaccine is during October and November, although vaccination should continue to March.
Colon Cancer Screening 2004	Refer patients ≥ 50 y, or with a family history of colon cancer, for a colonoscopy.	Internal medicine
	Colonoscopy is the New York City–recommended screening method.	Family practice
	Any screening method is better than no screening method at all.
Smoking Cessation 2004	Assess smoking status and readiness to quit at every visit.	Internal medicine
	Prescribe medications to assist patients in becoming tobacco-free.	Family practice
	Provide brief counseling on cessation techniques.
Asthma 2004	Assess each patient’s asthma severity at every visit and prescribe accordingly.	Internal medicine
	Prescribe inhaled corticosteroids, the most effective treatment for most patients with persistent asthma.	Family practice
	Partner with your patients; give them a written “Asthma Action Plan.”	Pediatrics
Influenza Vaccination 2004	Only people at risk for serious illness or death from influenza should be vaccinated this year.	Internal medicine
	People aged ≥ 65 y and children aged 6–23 mo are at high risk.	Family practice
	Most healthy people aged 2–64 should not be vaccinated.	Pediatrics
Diabetes 2005	A - Assess hemoglobin A1c level every 3–6 mo; goal: < 7%.	Internal medicine
	B - Measure blood pressure at every visit; goal: < 130/80 mm Hg.	Family practice
	C - Monitor cholesterol (low-density lipoprotein) level annually; goal: < 100 mg/dL.
	S - Ask about smoking status at every visit; goal: help to quit and to establish a smoke-free home.
Contraception 2005	Take a brief sexual history of all patients.	Internal medicine
	Encourage the appropriate use of contraception.	Family practice
	Offer emergency contraception in advance and as needed.	Pediatrics
Influenza Vaccination 2005	People aged ≥ 65 y and children aged 6–23 mo should receive an annual influenza vaccine.	Internal medicine
	All health care workers should receive an influenza vaccine to protect themselves, their families, and their patients.	Family practice
	Physicians can implement strategies that increase influenza vaccine coverage in their practice.	Pediatrics
Hypertension 2005	Encourage patients with hypertension and prehypertension to adopt healthy lifestyle changes.	Internal medicine
	Prescribe thiazide diuretics as the initial drug of choice for most patients.	Family practice
	Aim for target blood pressure of < 140/90 mm Hg for most patients with hypertension and < 130/80 mm Hg for those with diabetes or kidney disease.
Depression Screening 2006	Primary care physicians can effectively detect and manage depression.	Internal medicine
	Routinely screen for depression with a simple 2-question tool (Patient Health Questionnaire-2).	Family practice
	Depression can be treated. Medication and psychotherapy, alone or in combination, can help most patients.
HIV Testing 2006	Offer HIV testing as a routine part of medical care to all persons aged 18–64 y.	Internal medicine
	Counseling requirements have been greatly reduced.	Family practice
Influenza and Pneumococcal Vaccination 2006	Vigorously recommend an influenza vaccine for all patients who need to receive one.	Internal medicine
	Be sure you and your staff get influenza vaccines early in the season.	Family practice
	Continue to vaccinate into the late winter and spring.	Pediatrics
	Screen all patients to determine whether they need a pneumococcal vaccine.
Cholesterol 2006	Counsel all patients on lifestyle modification, the cornerstone of cardiovascular disease prevention.	Internal medicine
	Treat all patients with coronary or other atherosclerotic disease or diabetes to reach a low-density lipoprotein goal of < 100 mg/dL.	Family practice
	Consider a low-density lipoprotein goal of < 70 mg/dL for very high-risk patients.
	Prescribe statins for most patients at increased risk to lower low-density lipoprotein and reduce cardiovascular events and mortality by ≥ 30%.
Alcohol Screening and Brief Intervention 2007	Use a simple 4-question screening tool (CAGE-AID) to ask every patient about alcohol.	Internal medicine
	Provide clear, personalized advice, and set mutually acceptable goals.	Family practice
	Offer information and treatment referrals.
Electronic Health Records 2007	Adopt an electronic record that can improve the quality, safety, and efficiency of your primary care practice.Take all steps necessary to protect and secure electronic patient information.	Internal medicine
		Family practice
		Pediatrics
		Obstetrics/gynecology
Child Abuse and Neglect 2007	Report all suspected child abuse and neglect by calling the state central register.	Family practice
	Do not assume someone else will report. You might be the only person to identify and report an abused or neglected child.	Pediatrics
Adult Obesity 2008	Assess BMI and weight history in all adult patients.	Internal medicine
	If BMI is > 25 kg/m2, tell patient he or she is overweight, and address readiness to lose weight.	Family practice
	If ready, help patient set a realistic, achievable goal and a plan to achieve that goal.
Medical Reserve Corps 2008	Distribute antibiotics or vaccine during an emergency requiring mass prophylaxis.Assist with mass sheltering operations during a coastal storm.	All health care professionals
	Increase medical surge capacity during an influenza pandemic.
Colon Cancer Screening 2008	Refer patients aged ≥ 50 y or patients aged ≥ 40 y with a family history of colon cancer for colonoscopy.	Internal medicine
	Directly refer appropriate patients for colonoscopy rather than first sending patients to a gastrointestinal consultation.	Family practice
Intimate Partner Violence 2009	Screen all patients for intimate partner violence and encourage disclosure through routine inquiry and dialogue.	Internal medicine
	Conduct a clinical assessment of all patients who disclose abuse or for whom abuse is suspected, and document findings thoroughly.	Family practice
	If patients disclose intimate partner violence, promptly refer them to social and legal services.	Obstetrics/gynecology
Breastfeeding 2009	Encourage and prescribe exclusive breastfeeding with no supplementation immediately following birth.	Family practice
	Schedule a newborn visit 3–5 d after birth to assess and support breastfeeding.	Pediatrics
	Routinely reinforce the importance of exclusive breastfeeding.	Obstetrics/gynecology
	Remove formula manufacturers’ samples and educational materials from your office.
	Know the breastfeeding resources in your community and encourage your patients to use them.
Influenza and Pneumococcal Vaccination 2009	Strongly recommend the appropriate influenza vaccine(s) for all at-risk patients.	Internal medicine
	Screen all patients to determine whether they also need pneumococcal vaccination.	Family practice
	Be sure you and your staff get vaccinated against both the seasonal and the novel H1N1 influenza as early as possible this fall.	Obstetrics/gynecology
	Continue to vaccinate high-risk patients throughout the entire influenza season.
	Pneumococcal vaccine should be given to people aged ≥ 65 y and anyone with long-term health problems.
Obesity in Children 2009	Assess all children and adolescents for overweight and obesity.	Family practice
	Educate children, adolescents, and families about healthful eating and physical activity.	Pediatrics
	Work with families to set realistic goals for healthy eating and exercise.
Medication Adherence 2010	Assess adherence and discuss possible barriers to adherence at every patient visit.	Internal medicine
	Reconcile your medication lists with the patient’s list, adjust doses, and eliminate unneeded medications.	Family practice
	Prescribe once-daily formulations, less-expensive generics, and longer-lasting supplies of medicine whenever possible.
	Provide tools such as pill boxes and medication logs to help patients remember to take their medications.

Note. BMI = body mass index (defined as weight in kilograms divided by the square of height in meters).

TABLE 2—

2003–2010 Public Health Detailing Campaign Reach: New York City Department of Health and Mental Hygiene

Campaign	Sites, No.	Unique Providers, No.	Providers With Initial and Follow-Up Visits, No.	All Provider Contacts, No.	All Contacts (Providers and Staff), No.	Contacts Per Site, No.
Influenza Vaccination 2003	151	…	…	377	674	4
Colon Cancer Screening 2004	193	…	109	530	982	5
Smoking Cessation 2004	151	…	…	494	911	6
Asthma 2004	168	…	…	246	514	3
Influenza Vaccination 2004a	164	a	a	350	666	4
Diabetes 2005	176	…	…	339	1340	8
Contraception 2005	214	443	146	528	1732	8
Influenza Vaccination 2005a	204	129	a	129	255	1
Hypertension 2005	157	349	90	679	1294	8
Depression Screening 2006	198	352	127	366	1030	5
HIV Testing 2006	151	317	90	345	1170	8
Influenza and Pneumococcal Vaccination 2006a	143	116	a	116	256	2
Cholesterol 2006: high-risk patients only	136	279	113	405	1264	9
Alcohol Screening and Brief Intervention 2007	143	297	149	460	1688	12
Electronic Health Records 2007	221	216	109	339	1088	5
Child Abuse and Neglect 2007	154	240	119	345	1169	8
Adult Obesity 2008	199	410	166	588	2433	12
Medical Reserve Corps 2008	199	370	63	435	1742	6
Colon Cancer Screening 2008	189	279	133	413	1424	8
Intimate Partner Violence 2009	196	411	230	659	2234	11
Breastfeeding 2009	152	281	170	455	1452	10
Influenza and Pneumococcal Vaccination 2009a	157	170	a	175	684	4
Obesity in Children 2009	161	291	237	530	1588	10
Medication Adherence 2010	186	340	265	607	1727	9

^aNo follow-up visits for 2004, 2005, 2006, and 2009 Influenza campaigns.

Table 3 illustrates changes in self-reported provider behavior documented during the individual campaigns. Campaigns worked to improve providers’ practice behavior to screen patients for clinical preventive services and chronic disease management, provide clinical management, and address lifestyle modification and self-management goal setting with patients. In most campaigns, significant increases were seen among providers who positively changed their practice behavior from baseline to follow-up.

TABLE 3—

2003–2010 Public Health Detailing Campaigns: Self-Reported Changes in Clinical Practice: New York City Department of Health and Mental Hygiene (DOHMH)

Campaign	Campaign Assessment Questions and Responses	Baseline (Initial), %	Follow-Up, %	P
Influenza and Pneumococcal Vaccination 2003	Who do you offer flu vaccines to?
	To patients in all groups under the CDC recommendation	94	99	.02
	Do you use an office system to prompt you to offer flu vaccine to patients at the time of their visit?
	Use office system as reminder to offer flu vaccine	54	67	.04
Colon Cancer Screening 2004	What primary screening method do you recommend for colon cancer?
	Colonoscopy as primary method	26	42	.01
	What is the clinic’s policy/practice regarding colon cancer screening?
	Has an office system in place to promote colon cancer screening	52	62	.01
Smoking Cessation 2004	How often do you assess smoking status?
	Assess smoking status at every visit	42	a	…
Asthma 2004	For patients with asthma, do you indicate a level of severity on their chart?
	Yes	68	a	…
	How do you usually assess severity?
	History, spirometry, or peak flow at time of visit	72	a	…
	Do you usually prescribe controller medications for patients with persistent asthma?
	Yes	96	a	…
	What type of controller medication do you most often prescribe?
	Inhaled corticosteroids	85	a	…
	Do you routinely provide patients with a written self-management plan?
	Yes/sometimes	50	a	…
Diabetes 2005	What are your specific clinical management goals for hemoglobin A1c?
	At least every 6 months	66	92	<.01
	A1c target level ≤ 7%	61	83	<.01
	What tools/systems do you use to track patients who are meeting their goals?
	Checkbook (clinical tracking tool developed by the DOHMH)	28	43	<.01
Contraception 2005	How is sexual history documented?
	Has an office system to document sexual history	15	21	.17
	Do you ever prescribe emergency contraception in advance?
	Advance prescribing of emergency contraception	7	17	.01
Hypertension 2005	What lifestyle changes do you routinely discuss with your patients with high blood pressure?
	Discusses lifestyle change with patients re: weight loss	68	80	.1
	Discusses lifestyle change with patients re: physical activity	88	94	.1
	For which patients with hypertension do you recommend home blood pressure monitoring?
	Recommends for self-motivated patients	23	27	.1
Depression Screening 2006	What type of patients do you generally screen for depression?
	Screens all patients as part of routine screening	41	40	.1
	Do you use a standard instrument to screen for depression?
	Uses PHQ-2 and/or PHQ-9 to screen for depression	13	40	.01
HIV Testing 2006	Who do you routinely offer HIV testing to within your practice?
	Offers routine testing to all patients (18–64)	39	44	.45
	What type of HIV testing do you perform in your office, if any?
	Uses rapid testing	13	20	.19
Cholesterol 2006	For patients with high cholesterol, diabetes, and/or atherosclerotic disease, what interventions do you routinely recommend for their cholesterol?
	Recommends general diet change	64	76	.05
	Recommends increased physical activity	52	73	.01
	Recommends statins	54	51	.01
	For patients with diabetes and no other complication, what is your LDL goal for treatment?
	LDL treatment goals of < 100 mg/dL	62	73	.1
	When you prescribe medications, do you regularly provide patients with supporting materials or tools to address adherence? If yes, what are some examples?
	Provides educational materials on medication(s) and/or medication log	35	59	<.01
Alcohol Screening and Brief Intervention 2007	What types of patients do you generally assess for problem drinking?
	Screens all patients for problem drinking	67	76	.1
	Do you use a standard screening tool to assess problem drinking?
	Assesses using the CAGE-AID	22	42	.01
Electronic Health Records 2007	Are you considering adopting an electronic health record system for your practice?
	Yes	41	34	.09
Identifying & Reporting Child Abuse & Neglect 2007	Have you reported a case of child abuse and neglect within the last 2 y?
	Yes	40	45	.43
	How do/would you report suspected child abuse and neglect?
	Call the State Central Register	75	98	<.01
	Have you had any training on identifying child abuse and neglect other than the New York State training requirement?
	Yes	39	40	.79
Adult Obesity 2008	How do you assess your patients for obesity?
	Assesses using BMI and weight history	25	47	.01
	In the past week, have you used nutritional visuals or props when speaking with your patients about obesity?
	Uses nutritional visuals or props	25	91	.01
	In the past week, have you done formal goal setting with your patients to address obesity?
	Uses formal goal setting with patients	78	96	.01
Medical Reserve Corps 2008	Have you heard of New York City Medical Reserve Corps?
	Yes	57	100	<.01
	Are you currently a New York City Medical Reserve Corps volunteer?
	Yes	1	18	<.01
	Would you like become a New York City Medical Reserve Corps volunteer?
	Yes	44	51	.31
Colon Cancer Screening 2008	What test do you usually recommend for colon cancer screening?
	Colonoscopy	93	82	.01
	When you refer patients for screening, what referral form do you use?
	DERS form	9	16	.09
Intimate Partner Violence 2009	Whom do you screen for intimate partner violence?
	All patients	39	67	<.01
	How often do you screen for intimate partner violence?
	At every visit	27	28	.75
	Routine inquiry and dialogue	14	42	<.01
	What do you do when a patient discloses intimate partner violence?
	Refer to domestic violence hotline	13	33	<.01
	Schedule a follow-up appointment	9	20	<.01
Breastfeeding 2009	What infant feeding method do you recommend during prenatal visits?
	Exclusive breastfeeding	51	50	.96
	For breastfeeding babies, how soon after birth do you schedule newborn visit?
	3–5 d after birth	32	33	.76
	What is your policy regarding hospital staff giving formula during admission and/or at discharge in the form of samples?
	Does not allow formula during hospital stay or in discharge packs	20	26	.13
Obesity in Children 2009	How do you currently assess for overweight or obesity in children aged 2–18?
	BMI percentile-for-age	77	88	<.01
	How often do you assess for overweight or obesity in children aged 2–18 y?
	At every visit	59	73	<.01
	In the past month, whom have you counseled for healthy eating and physical activity?
	All patients and their parent/caregiver	67	85	<.01
Medication Adherence 2010	How often do you reconcile patient’s medication lists?
	At every visit	86	94	<.01
	What prescribing practices do you use to increase patients’ adherence to their medications?
	Prescribe once-daily formulations, if possible	43	58	<.01
	Prescribe combination pills to decrease number of medications	26	43	<.01
	Prescribe generic or lower-cost branded drug	52	79	<.01
	Prescribe longer-lasting supplies	29	60	<.01
	Adjust dosages	52	66	.04
	Depends on Insurance	36	52	<.01
	How frequently do you write prescriptions of greater than a 30-d supply for patients on long-term maintenance medications?
	Often	36	41	.02

Note. BMI = body mass index (defined as weight in kilograms divided by the square of height in meters); CAGE-AID = CAGE Questionnaire Adapted to Include Drugs; CDC = Centers for Disease Control and Prevention; DERS = Direct Endoscopic Referral System; LDL = low-density lipoprotein; PHQ = Patient Health Questionnaire.

^aNo data available.

Screening for Preventive Services and Chronic Disease Management

Several campaigns showed increases among providers who screened for clinical preventive services. The 2004 Colon Cancer campaign showed improvement in the proportion of providers who reported colonoscopy as their primary screening method for colon cancer, from 26% at baseline to 42% at follow-up (P = .01). When repeated in 2008, an even greater proportion of providers stated that colonoscopy was their preferred screening method 82% to 93% of the time (P = .01). The Depression campaign showed a marked increase in the percentage of providers who used the Patient Health Questionnaire-2,⁹ from 13% at baseline to 40% at follow-up (P = .01). Greater uptake in the use of clinical tools to assess problem drinking was documented in the Alcohol Screening and Brief Intervention campaign. At baseline, 22% of the providers reported using the CAGE Questionnaire Adapted to Include Drugs (CAGE-AID)¹⁰ tool to assess for problem drinking, and at follow-up, 42% of the providers reported adopting the CAGE-AID tool (P = .01).¹⁰ Among providers visited for the Intimate Partner Violence campaign, those who reported screening all patients for intimate partner violence increased from 39% at baseline to 67% at follow-up (P < .01), and those who reported making screening for intimate partner violence a part of routine inquiry and dialogue increased from 14% to 42% (P < .01).

During the Adult Obesity campaign, the number of providers who reported assessing body mass index and weight at every visit rose from 25% at baseline to 47% at follow-up (P = .01). The Obesity in Children campaign also showed an increase in providers who assessed body mass index percentile-for-age at every visit from 59% at baseline to 73% at follow-up (P < .01).

The proportion of providers addressing chronic disease management was shown in the Diabetes campaign. Providers who reported setting specific clinical management goals for patients to check their hemoglobin A1c levels at least every 6 months increased from 66% at baseline to 92% at follow-up (P < .01), and having as well as indicating a target hemoglobin A1c level of 7 or less increased from 61% at baseline to 83% at follow-up (P < .01).

Clinical Management

Improvements seen in the provision of clinical management to patients include changes in prescribing practice. During the Contraception campaign, providers who reported prescribing emergency contraception in advance increased from 7% at baseline to 17% at follow-up (P = .01). During the Medication Adherence campaign, the percentage of providers who reported reconciling patients’ medication lists at every visit increased from 86% at baseline to 94% at follow-up (P < .01). Additionally, the percentage of providers who reported prescribing combination pills increased from 26% at baseline to 43% at follow-up (P < .01). Those prescribing generic or lower-cost branded drugs increased from 52% to 79% (P < .01), and the percentage who prescribed longer-lasting supplies (90 days vs 30 days), when appropriate, increased from 29% at baseline to 60% at follow-up (P < .01).

Lifestyle Modification

Significant increases in the proportion of providers who reported speaking with their patients about lifestyle modification and behavior change—to aid in the management of certain chronic conditions—were seen throughout campaigns. During the Hypertension campaign, providers who discussed weight loss with their patients increased from 68% at baseline to 80% at follow-up (P = .10), and those who discussed increasing physical activity with their patients rose from 88% to 94% (P = .10).

Similarly, during the Cholesterol campaign, at baseline, 52% of the providers reported recommending increased physical activity to patients with high cholesterol levels, whereas 73% reported doing so at follow-up (P = .01). At baseline, 64% of the providers reported routinely recommending diet change to patients with high cholesterol value. At follow-up, this proportion increased to 76% (P = .05). Additionally, during the Obesity in Children campaign, providers who reported counseling all pediatric patients and their caregivers for healthy eating and physical activity increased from 67% at baseline to 85% at follow-up (P < .01).

Self-Management Goal Setting

In several campaigns, providers reported an increased use of self-management goal setting with their patients. During the Diabetes campaign, the percentage of providers who reported using a “checkbook-style” diary with patients to track their hemoglobin A1c level increased from 28% at baseline to 43% at follow-up (P < .01). Data from the Adult Obesity campaign showed that almost all providers used goal-setting strategies for weight loss with their patients: from 78% at baseline to 96% at follow-up (P = .01). Those reporting use of nutritional visuals or props when speaking about obesity management increased from 25% at baseline to 91% at follow-up (P = .01).

DISCUSSION

By establishing open channels of communication; providing valuable information, evidence-based tools, resources, and patient education materials; and building strong relationships with primary care team members in high-need neighborhoods, the Public Health Detailing Program has developed a successful strategy for communicating public health recommendations to clinical care teams. Results of the campaign evaluation indicate that representatives are highly skilled at facilitating conversations and gaining agreements to implement the DOHMH’s recommendations. In the early days of the program, occasionally providers would reject visits, at times confusing them with regulatory activities of other agencies, but by 2010, all practices in the target communities were routinely receiving visits. Evaluation data from individual public health detailing campaigns suggest potential effectiveness of this model, which involves repeat personal visits to office teams, as well as the importance of clear, consistent messaging around key clinical recommendations. All of the responding providers indicated that the detailing visits have changed their practice in a positive way, and 73% of practices implemented clinical tools (including 15% who adopted an electronic health record into their practice), key recommendations, and patient education materials. Care teams reported that they value these tools and resources to help reinforce key recommendations, initiate conversations, improve mutual understanding, and facilitate goal setting with their patients during and after campaigns.

Since the inception of the Public Health Detailing Program, providers have allotted more time to each visit. Initially, visits lasted an average of 12 minutes, but by 2010, visits increased to an average of 17 minutes, an indication of the providers’ interest in the topic and a reflection of the relationships representatives developed with the practices throughout the years.

An essential ingredient is having highly trained, knowledgeable representatives consistently working directly with providers.¹¹ Literature shows that this multifaceted approach is an effective strategy for influencing provider attitudes and behavior and is more effective than certain other types of educational outreach. “Academic detailing” linked with other educational strategies may be the most effective paired intervention, because print-only or mailing interventions generally have not been found to be effective in modifying physician behavior.^12,13

Public health detailing serves as a bridge between the DOHMH and community providers, creating a 2-way flow of information. The valuable qualitative and quantitative feedback from providers has been used by the DOHMH to guide clinical interventions and programmatic initiatives.

Economic sustainability of public health programs, in times of recession, continues to pose a challenge. Public health detailing has an average cost in New York City of approximately $95 per contact, of which $40 is for staff. Similar programs ideally might be financed by organizations to which savings would accrue as a result of improved care, such as Medicaid or Medicare, which therefore have direct interest in their continuity. Because the Public Health Detailing Program is run by a local health department—focusing on population health—and is without the evident financial interests private insurers might have, this appears to be a source of credibility for the program’s recommendations.

Limitations

As stated earlier, the Public Health Detailing Program’s reach varied among the different campaigns. Fluctuation in the program’s reach for number of sites visited and providers seen varied on several factors, including length of the campaign, size of the target group of providers, variation in staff size, and provider or staff receptivity to messaging. However, a general trend of an increasing number of contacts per site has continued since the Public Health Detailing Program implemented its first campaigns. Sites’ increasing familiarity with the program and representatives’ improving communication skills over the last several years enhanced the reach at each site and reduced wait time to see key office staff and providers.

Loss of follow-up visits with the same providers during the course of individual campaigns was another limitation of the Public Health Detailing Program. Providers and staff often work at multiple sites on certain days and hours of the week, so the number of providers reached at follow-up is always lower than the number reached during initial visits. Strategies were implemented to increase the percentage match of initial and follow-up visits, particularly with physicians, nurse practitioners, and physician assistants, to 80% or higher, a goal subsequently achieved with at least 2 campaigns.

Changes in the data structure since the program began also limited the conclusions drawn from these results. Some of the early campaigns did not capture data in the same format, and data were unavailable for a few campaigns. Most importantly, this evaluation relied on provider self-reported practices. Self-report may fail to accurately reflect providers’ actual clinical behavior. Use of clinical data to verify changes in clinical practice would be an important complement to assess effectiveness of this program. The power of electronic medical records also could be used to assess the effect of campaigns on clinical practice. When the Public Health Detailing Program began, electronic medical records were not as widely used as today, and they should be used for evaluating this and other clinical systems improvement efforts. However, counseling and provider-patient conversations around a disease topic and self-management goal setting are often not adequately captured in the patient record. Patient exit surveys or other mechanisms to evaluate the messages patients received during an office visit, as well as which ones they intend to act on, would be another possible evaluation approach for the program.

Finally, the extent to which the assessed practices would have changed in the absence of the Public Health Detailing Program effort is unknown. Providers are regularly exposed to numerous opportunities that may influence the way they practice medicine, such as continuing education courses, medical journals, conferences, and other means by which evidence-based recommendations and materials can be acquired. These factors alone, or in conjunction with public health detailing, could have affected clinical practice and behavior.

Conclusions

Overall, the Public Health Detailing Program has been received very positively by the medical community in the underserved communities prioritized by the program. Despite the limitations noted, evaluation data based on provider self-report suggest that public health detailing can be an effective strategy for linking public health agencies and their recommendations to medical providers and staff as well as assisting in the development of future program and policy initiatives. The professional relationships developed between the providers and their staff and the DOHMH permit a dialogue described by Avorn:

These conversations enable a talented communicator to understand the physician’s current practices, beliefs, and attitudes, making it possible to tailor a behavior-change message specifically to that individual’s decision-making process.¹¹

Other public health agencies may find this approach for promoting important clinical practices a useful strategy to assist in improving population health.