title: Developing clinical decision tools to implement chronic disease prevention and screening in primary care: the BETTER 2 program (building on existing tools to improve chronic disease prevention and screening in primary care).
abstract: BACKGROUND
  The Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial demonstrated the effectiveness of an approach to chronic disease prevention and screening (CDPS) through a new skilled role of a 'prevention practitioner'(PP). The PP has appointments with patients 40-65 years of age that focus on primary prevention activities and screening of cancer (breast, colorectal, cervical), diabetes and cardiovascular disease and associated lifestyle factors. There are numerous and occasionally conflicting evidence-based guidelines for CDPS, and the majority of these guidelines are focused on specific diseases or conditions; however, primary care providers often attend to patients with multiple conditions. To ensure that high-level evidence guidelines were used, existing clinical practice guidelines and tools were reviewed and integrated into blended BETTER tool kits. Building on the results of the BETTER trial, the BETTER tools were updated for implementation of the BETTER 2 program into participating urban, rural and remote communities across Canada.
  
  
  METHODS
  A clinical working group consisting of PPs, clinicians and researchers with support from the Centre for Effective Practice reviewed the literature to update, revise and adapt the integrated evidence algorithms and tool kits used in the BETTER trial. These resources are nuanced, based on individual patient risk, values and preferences and are designed to facilitate decision-making between providers across the target diseases and lifestyle factors included in the BETTER 2 program. Using the updated BETTER 2 toolkit, clinicians 1) determine which CDPS actions patients are eligible to receive and 2) develop individualized 'prevention prescriptions' with patients through shared decision-making and motivational interviewing.
  
  
  RESULTS
  The tools identify the patients' risks and eligible primary CDPS activities: the patient survey captures the patient's health history; the prevention visit form and integrated CDPS care map identify eligible CDPS activities and facilitate decisions when certain conditions are met; and the 'bubble diagram' and 'prevention prescription' promote shared decision-making.
  
  
  CONCLUSIONS
  The integrated clinical decision-making tools of BETTER 2 provide resources for clinicians and policymakers that address patients' complex care needs beyond single disease approaches and can be adapted to facilitate CDPS in the urban, rural and remote clinical setting.
  
  
  BACKGROUND
  The registration number of the original RCT BETTER trial was ISRCTN07170460 .
authors.affiliation: Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, T6G 2T4, Canada. dpmanca@ualberta.ca.|Covenant Health, Grey Nuns Community Hospital, 1100 Youville Drive Northwest, Edmonton, Alberta, T6L 5X8, Canada. dpmanca@ualberta.ca.
authors.forename: Donna Patricia
authors.initials: DP
authors.lastname: Manca
authors.affiliation: Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, T6G 2T4, Canada. dlcampbe@ualberta.ca.|Covenant Health, Grey Nuns Community Hospital, 1100 Youville Drive Northwest, Edmonton, Alberta, T6L 5X8, Canada. dlcampbe@ualberta.ca.
authors.forename: Denise
authors.initials: D
authors.lastname: Campbell-Scherer
authors.affiliation: Discipline of Family Medicine, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John's, Newfoundland, A1B 3V6, Canada. kaubrey@mun.ca.
authors.forename: Kris
authors.initials: K
authors.lastname: Aubrey-Bassler
authors.affiliation: Department of Health and Social Services, Government of Northwest Territories, P.O. Box 1320, Yellowknife, Northwest Territories, X1A 2L9, Canada. kami_kandola@gov.nt.ca.
authors.forename: Kami
authors.initials: K
authors.lastname: Kandola
authors.affiliation: Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, T6G 2T4, Canada. carolina.aguilar@ualberta.ca.
authors.forename: Carolina
authors.initials: C
authors.lastname: Aguilar
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada. better.project@utoronto.ca.
authors.forename: Julia
authors.initials: J
authors.lastname: Baxter
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada. christopher.meaney@utoronto.ca.
authors.forename: Christopher
authors.initials: C
authors.lastname: Meaney
authors.affiliation: Department of Family Medicine, University of Alberta, 6-10 University Terrace, Edmonton, Alberta, T6G 2T4, Canada. ginetta@ualberta.ca.
authors.forename: Ginetta
authors.initials: G
authors.lastname: Salvalaggio
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada. jcarroll@mtsinai.on.ca.
authors.forename: June C
authors.initials: JC
authors.lastname: Carroll
authors.affiliation: Department of Health and Social Services, Government of Northwest Territories, P.O. Box 1320, Yellowknife, Northwest Territories, X1A 2L9, Canada. vfaria@auroracollege.nt.ca.
authors.forename: Vee
authors.initials: V
authors.lastname: Faria
authors.affiliation: School of Public Health, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada. candace.nykiforuk@ualberta.ca.
authors.forename: Candace
authors.initials: C
authors.lastname: Nykiforuk
authors.affiliation: Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario, M5G 1V7, Canada. eva.grunfeld@utoronto.ca.|Ontario Institute for Cancer Research, 661 University Avenue, Suite 510, Toronto, Ontario, M5G 0A3, Canada. eva.grunfeld@utoronto.ca.
authors.forename: Eva
authors.initials: E
authors.lastname: Grunfeld
mesh_terms: D002908:Chronic Disease / Q000517:prevention & control*; D003661:Decision Support Techniques; D006801:Humans; D008403:Mass Screening / Q000379:methods / Q000592:standards; D017410:Practice Guidelines as Topic; D011315:Preventive Medicine / Q000379:methods* / Q000592:standards; D011320:Primary Health Care / Q000379:methods* / Q000592:standards; D058996:Quality Improvement