Table 1.
Preventive Care and Chronic Disease Management Decisions Investigated in This Study.a
| Lifestyle factors | |
| Tobacco cessation advice | Patient is using tobacco |
| Alcohol counseling | Patient reports problems with alcohol |
| Lifestyle counseling | BMI is >30 kg/m2 |
| Blood tests | |
| Fasting glucose | Hyperglycemic with no glucose test in 1 year |
| Glycated hemoglobin (HbA1c) | Diabetic with no HbA1C report |
| Lipid panel | Nondiabetic with no cholesterol, HDL, or triglycerides in the past 5 years or diabetic with no cholesterol, HDL, or triglycerides in past 1 year |
| LDL | High risk for cardiovascular disease and has a high recent LDL |
| Creatinine | No creatinine report in the last 1 year, and patient is diabetic or receives diuretics, ARB, or ACE inhibitors |
| Microalbumin | Diabetic patient with no microablumin result in past year |
| TSH | Patient on thyroid meds, with no TSH in past year |
| Issue examinations/screenings | |
| Eye examination | Diabetic with no eye examinations in the past year |
| Urinalysis | On cyclophosphamide, no urinalysis reported in the past 6 months |
| Echocardiogram | Heart failure with no reported ejection fraction |
| Papanicolaou (Pap) | If abnormal Pap or high-risk condition was not followed by Pap test in past year, or no Pap report for 21- to 30-year-old females in past 2 years, or 30- to 65-year-old female with no Pap report in past 3 years |
| Mammogram | 40- to 75-year-old female with no mammogram in past year |
| Colonoscopy | (i) Polyp not followed up in past 3 years, or colon cancer diagnosis not followed up in past year. (ii) Family history of colon cancer with no colonoscopy in past 5 years. (iii) 50- to 80-year-old with no colonoscopy in the past 10 years, occult blood in the past 12 months, flexible sigmoidoscopy, colon x-ray or colonography in the past 5 years |
| Abdominal aortic aneurysm | 65- to 75-year-old male with past tobacco habit and no imaging of abdominal aorta |
| BMD | >65-year-old female with no BMD since age 50 years |
| PSA | 50- to 70-year-old male with no PSA in past year |
| STI screening | 16- to 25-year-old with no report of chlamydia/gonorrhea screening |
| Depression screening (PHQ9) | Last PHQ9 with high score more than 6 months ago or PHQ9 not reported in past year for patients diagnosed with depression |
| AICD consult | CHF with ejection fraction less than 35%, who have no AICD |
| Immunizations due | |
| Influenza | No immunization in flu season |
| HPV | 9- to 25-year-old female with (i) no previous HPV vaccination, or (ii) first vaccination more than 2 months ago, or (iii) second vaccination more than 4 months ago |
| Pneumococcal | 20- to 65-year-old with high risk and no pneumococcal immunizations in the past 5 years. Greater than 65 years with no vaccine in the past 5 years |
| Herpes zoster | More than 60 years with no zoster vaccine in the past |
| Tdap | 20- to 64-year-old with no Tdap ever |
| Tetanus | >60 years with no Tdap or tetanus dose in the past 10 years |
| Hepatitis B | Diabetic, aged 19 to 59 years and (i) no past immunization, (ii) 1 month after first immunization, (ii) 2 months after second immunization and 4 months after first immunization |
| Start medication | |
| Beta blocker | Not asthmatic or depressed, is not currently on beta blockers, and has either (i) heart rate is greater than 60 beats per minute, with CHF and ejection fraction is less than 0.4 or (ii) diagnosis of CAD |
| Warfarin | Has atrial fibrillation, who is not on warfarin, has no bleeding disorder and has high CHADS2 score |
| Aspirin | Not on aspirin or warfarin, and has no bleeding disorder but has either of CAD, DM, cerebrovascular accident, or peripheral vascular disease |
| ACE inhibitors/ARBs | On ACE or ARB, has DM, hypertension, high microalbumin, CAD or CHF, and has no history of renal failure |
| Medication-related blood work | |
| Digoxin level | On digoxin with no digoxin report in past year |
| Potassium level | On diuretics, ARBs or ACE inhibitors with no potassium report in past year |
| Sodium level | On diuretics, with no sodium report in past year |
| Vitamin B12 | No vitamin B12 in past year with anemia, bypass surgery, Crohns, achlorhydria, alcohol dependency, or bacterial overgrowth |
| Dilantin level | On anticonvulsants and dilantin, with no dilantin report in past year |
| Carbamazepine level | On carbamazepine, and no carbamazepine report in past year |
| ALT | On cyclosporin and no ALT report in past 3 months |
| AST | On azathioprine, leflunomide, methotrexate or tocilizumab, and no AST report in past 8 weeks |
| CBC | On cyclophosphamide, no CBC in last 6 weeks. On azathioprine or leflunomide or methotrexate or tocilizumab, and no CBC in last 8 weeks. On cyclosporin, sulfasalazine, anti-IL1β or anti-TNF, or rituximab and no CBC result in the past 3 months |
| INR | On warfarin and no INR in past month |
Abbreviations: ACE inhibitor, angiotensin-converting enzyme inhibitor; AICD, automatic implantable cardioverter defibrillator; ALT, alanine aminotransferase; ARB, angiotensin II receptor blocker; AST, aspartate transaminase; BMD, bone mineral density; CAD, coronary artery disease; CBC, complete blood count; CHADS2, congestive heart failure, hypertension, age, diabetes mellitus, stroke or transient ischemic attack; CHF, chronic heart failure; DM, diabetes mellitus; HbA1c, glycated hemoglobin; HDL, high-density lipoprotein; HPV, human papillomavirus; IL1β, interleukin-1 beta; INR, international normalized ratio; LDL, low-density lipoprotein; Pap, Papanicolaou test; PHQ9, Patient Health Questionnaire 9; PSA, prostate-specific antigen; STI, sexually transmitted infection; Tdap, tetanus, diphtheria, pertussis; TNF, tumor necrosis factor; TSH, thyroid-stimulating hormone.
a
The left column gives the recommendation, and the right column summarizes the applicable trigger conditions.