The Impact of a Multifaceted Intervention on the Rate of Preventive Services Offered in a Student-Run Clinic

Background: The importance of preventive services has been well established, yet rates of preventive service delivery continue to lag behind national goals. While numerous studies have identified barriers to preventive service delivery and implemented interventions to improve delivery, research into this important area is lacking in the setting of student-run clinics. Methods: In this study a multifaceted intervention consisting of patient and provider education, provider check list, pre-clinic chart review, and financial assistance for preventive services was implemented for 14 months in a student-run clinic. Results: Rates of delivery of United States Preventive Services Task Force (USPSTF) Grade A and B recommended preventive services were evaluated before and after implementation of the intervention with 16 of 26 services improving during the intervention but only tetanus immunization reaching significance. In addition, rates of delivery of preventive services were compared to reported national averages and targets set by Healthy People 2020 with 16 of 20 services being offered at or above reported national averages and 10 of 16 services meeting the targets laid out in Healthy People 2020. Conclusions: The rate of preventive services can be improved in student-run clinics through the implementation of multi-faceted interventions to a level that meets national averages and targets.


Introduction
3][14][15][16][17] Furthermore, the vast disparity in receipt of these services based on race, [18][19][20] socioeconomic status, 20,21 education level, and insurance coverage [18][19][20][21][22] contributes to the growing inequality in health outcomes. 6,15,16,21,22To effectively improve the distribution of preventive services and the resultant health outcomes, interventions must be targeted at these underserved populations. 23umerous factors account for the disconnect between the importance ascribed to preventive services and the rates of delivery actually achieved.Many interventions have been implemented to overcome barriers to delivery with the most successful employing multifaceted interventions that address multiple interplaying barriers.Multifaceted interventions result in up to 60% improvement in delivery of services 8,9,17,20,[24][25][26][27][28] and have a duration of at least 24 months after the initial intervention. 27,28hile the amenability of preventive services to interventions has clearly been demonstrated, there is a paucity of research on the level of preventive services provided as well as the effectiveness of these proven interventions in student-run clinics (SRCs).0][31][32][33] While the number of SRCs has burgeoned over the last decade, 29,30 research into these unique clinical setups has lagged behind. 31,32he limited research on SRCs revealed that many preventive services are underutilized in relation to Healthy People 2020 goals and national averages.Zucker et al. found that one SRC offered tobacco cessation counseling and alcohol abuse screening above the national average, but fell short on colonoscopies, mammograms, Pap smears, and pneumococcal and influenza vaccination. 34Likewise, Butala et al. found that another SRC provided HIV testing and fasting blood glucose screening at or above the national average while other services, such as fasting lipid panels and Pap smears, fell short of the national average. 35In a later study, Butala et al. demonstrated that implementing a pre-visit review to identify preventive services to be addressed at the visit resulted in a significant improvement in HIV testing and fasting lipid panels. 36his study will evaluate the impact of a multifaceted intervention consisting of patient and provider education, provider checklists, and pre-clinic chart review on adherence to the United States Preventive Services Task Force (USPSTF) guidelines 37 (Table 1) within a SRC.In addition, this study will evaluate the quality of preventive care delivered at a national level of care and goals set in Healthy People 2020.

Setting
The Student Health Alliance Reaching Indigent Needy Groups (SHARING) clinic is an interprofessional student-run medical clinic for low-income, uninsured adults in Omaha, Nebraska.The clinic, affiliated with the University of Nebraska Medical Center (UNMC), serves as a medical home for patients providing acute and chronic medical care, preventive services, physical therapy, dietitian consultation, social work consultation, and psychological services.In addition, sub-specialty referrals are provided at no additional expense to the patient.Spanish interpreters are available at every clinic and a language line is available for other language needs.The pre-intervention period occurred between January 1, 2012 and October 28, 2013.The intervention period occurred between October 29, 2013 and December 18, 2014.All patients older than 19 years of age who presented to the clinic between January 1, 2012 and December 18, 2014 were included in the study.

Intervention
Preliminary studies found the SHARING clinic performed many services above reported national averages rates for all clinics in general but fell below average for breast, cervical, and colorectal cancer screening, as well as tetanus vaccination.In response, students in the UNMC Preventive Medicine Enhanced Medical Education Track (PM-EMET) implemented a multifaceted intervention consisting of patient and provider education, provider checklists, and pre-clinic chart review as described below.The clinic also partnered with local clinics to provide colonoscopy and mammography to patients free of charge regardless of their qualification for Every Woman Matters or the Nebraska Colon Cancer Screening Program.
Before each clinic, students of the PM-EMET reviewed patients' charts to identify needed preventive services and reported their findings to student providers in the preclinical meeting.The importance of preventive services was emphasized with special attention given to the under-provided services previously identified.Students were provided a checklist of preventive services for which patients may be eligible and were instructed how to find the relevant information in the electronic medical record.In addition, posters in both English and Spanish were placed in all exam rooms encouraging patients to ask providers about preventive services.

Method of Evaluation
Information regarding patient demographics, family history, personal medical history as documented in the problem list, social history and appropriate use of preventive screening measures as determined by USPSTF recommendations were abstracted from the electronic health record.

Statistical Analysis
8][39][40][41][42] Patient demographic data was compared between periods using a two-tailed chi-square analysis for categorical variables and a t-test for continuous variables.International Business Machines' Statistical Package for the Social Sciences version 21.0 was used in the analysis of the data.

Ethics Statement
This study was approved by the UNMC institutional review board committee.

Results
There were 583 visits for 81 individuals during the pre-intervention period and 345 visits for 72 individuals during the intervention period.The two populations were similar in regard to demographic factors, health status (Table 2), level of provider, and use of an interpreter (Table 3).As fewer than five patients qualified for skin cancer screening, aortic aneurysm screening, and fall prevention these services were not reported.
Comparative rates of cancer screening and vaccination at the SHARING clinic during the pre-intervention and intervention periods are depicted in Figure 1 and Figure 2.
During the intervention, the SHARING clinic offered preventive services at or above the national average for mammography, colonoscopy (Table 4, Figure 3), influenza vaccination in individuals 18-64 as well as individuals age 65 and over, tetanus vac-cination (Table 5, Figure 4), alcohol abuse screening/counseling, chlamydia screening, healthy diet counseling, HIV screening, tobacco use screening/cessation counseling (Table 6), blood pressure screening, depression screening, lipid screening, obesity screening, and osteoporosis screening (Table 7).The SHARING clinic offered the following services below the national average: Pap smear (Table 4, Figure 3), pneumococcal vaccination (Table 5, Figure 4), hepatitis C screening (Table 6), and folate supplementation (Table 7).

Discussion
SRCs face many unique challenges in providing quality care, including limited patient-provider continuity and providers in early years of training with limited clinical experience.Given the numerous challenges, it is essential that SRCs regularly assess the quality of care they are delivering.Overall the SHARING clinic performed at or above national average for delivering preventive services despite serving a traditionally underserved population.The SHARING clinic was below average for only 4 of the 20 preventive services (Pap smear (Table 4, Figure 3), pneumococcal vaccination (Table 5, Figure 4), hepatitis C screening (Table 6), and folate supplementation (Table 7)).In addition, the SHARING clinic met 10 of the 16 targets laid out in Healthy People 2020, falling short for Pap smear (Table 4, Figure 3), influenza vaccination in individuals age 18-64 as well as individuals age 65 and over, pneumococcal vaccination (Table 5, Figure 4), chlamydia screening (Table 6), folate supplementation, and lipid screening (Table 7).Interestingly, a previous study also found that another SRC offered Pap smear, pneumococcal vaccination and influenza vaccination at rates below the national average. 34Likewise, the HAVEN SRC fell below the reported national average and the Healthy People 2020 targets in providing Pap smears. 35he findings from the current study are consistent with a previous report that quality improvement interventions improve the quality of preventive services provided at SRCs. 36 While the present study was limited by a small sample size, there was a trend toward improvement in the offering of preventive services with improved rates during the intervention period seen for 16 of 26 services including: mammography, Pap smear, lung cancer screening, colonoscopy (Figure 1, Table 4), influenza, pneumococcal vaccination (Figure 2, Table 5), alcohol abuse screening/counseling, healthy diet counseling, gonorrhea, hepatitis C and HIV screening (Table 6), aspirin prophylaxis, BP screening, and osteoporosis screening (Table 7) as well as the only service to reach significance (p<0.001),tetanus vaccination.No change or a decrease, though not significant, was seen in the rates for tobacco use screening and cessation counseling, folate supplementation, and screening for: chlamydia, intimate partner violence, syphilis, depression, lipididemia, obesity and diabetes mellitus type 2. The intervention placed special emphasis on improving rates of immunization and cancer screening of which all eight services improved, including the only service that met significance, tetanus immunization.Pap smears improved the least, which is in agreement with findings previously described by Butala et al. 36 We hypothesize this minimal improvement is a result of students and clinical faculty avoiding this service due to lack of comfort performing the procedure, misconception that the procedure cannot be performed in clinic, and the significant time commitment required to perform the procedure in comparison to giving a vaccination or completing a referral form for colonoscopy or mammography.Further research is needed to better delineate the barriers to Pap smear screening at SRCs.SRCs face the unique challenge of balancing education with providing proper clinical care.Students must balance their need to develop history taking and physical exam skills, learn basic diagnostics and management principles, and find their role within an interdisciplinary team with the needs of the patient to receive quality health care in a timely manner.Given the time constraints of the clinical encounter it is not surprising that preventive services may be overshadowed by more acute concerns.We believe these unique characteristics of SRCs make them especially amendable to provider prompts for preventive care.
In conclusion, the SHARING clinic performed multiple preventive services at or above the national average and at levels meeting the Healthy People 2020 targets.The implementation of a multifaceted quality improvement intervention resulted in a statistically significant increase in the rate of tetanus immunization as well as improvement in rates of many preventive services though these did not reach significance.A similar interventional approach may improve the rate of preventive services at other student run clinics.
Journal of Student-Run Clinics | The Impact of a Multifaceted Intervention on the Rate of Preventive Services Offered in a Student-Run Clinic journalsrc.org| J Stud Run Clin 2

Figure 1 .Figure 2 .
Figure 1.Rates of Cancer Screening at the SHARING Clinic During the Pre-intervention and Intervention Periods

Figure 3 .Figure 4 .
Figure 3.Rates of Cancer Screening at the SHARING Clinic During the Intervention Period in Comparison to Reported National Averages and Healthy People 2020 Targets

Journal of Student-Run Clinics |
The Impact of a Multifaceted Intervention on the Rate of Preventive Services Offered in a Student-Run Clinic journalsrc.org | J Stud Run Clin 2;2 | 3

Table 1 .
United States Preventive Services Task Force A and B Recommendations for Preventive Services

Table 2 .
Characteristics of Pre-intervention and Intervention Period Participants

Table 3 .
Characteristics of Visits M: medical student followed by year of training; NP: nurse practitioner student; PA: physician assistant student followed by year of training

Table 4 .
Rates of Preventive Cancer Screening Services Offered Pre-intervention and Intervention Period Compared to National Averages and Healthy People 2020 Targets

Table 5 .
Rates of Immunizations Pre-intervention and Intervention Period Compared to National Averages and Healthy People 2020 Targets

Table 6 .
Rates of Preventive Behavior Services Offered During the Pre-intervention and Intervention Period Compared to National Averages and Healthy People 2020 Targets The Impact of a Multifaceted Intervention on the Rate of Preventive Services Offered in a Student-Run Clinic journalsrc.org | J Stud Run Clin 2;2 | 7

Table 7 .
Rates of Preventive General Health Services Offered During the Pre-intervention and Intervention Period Compared to National Averages and Healthy People 2020 Targets