How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinicians Evidencebas

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How to Increase Colorectal Cancer Screening
Rates in Practice A Primary Care Clinicians
Evidence-based Toolbox and Guide

• Carmen E. Guerra, M.D., M.S.C.E., F.A.C.P
• Associate Professor of Medicine
• Division of General Internal Medicine
• University of Pennsylvania School of Medicine
• Board Member
• Chair, Provider Awareness Work Group, Colorectal
  Cancer Screening Task Force
• American Cancer Society, Pennsylvania Division
• February 4, 2009

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Overview

• Colorectal cancer (CRC) incidence and survival
• Risk factors for CRC
• Pathogenesis
• CRC screening and surveillance guidelines
• CRC screening rates in the U.S.
• Increasing Colorectal Cancer Screening Rates in
  Practice
• Essential 1 Importance and Barriers of Physician
  Recommendation
• Essential 2 An Office Policy
• Essential 3 A Reminder System
• Essential 4 An Effective Communication System
• Summary

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Colorectal Cancer

• Colorectal cancer (CRC) is 2nd leading cause of
  cancer deaths in U.S.
• In 2008, an estimate 148,810 cases and 49,960
  deaths are expected
• Jemal A, Siegel R, Ward E, et al. Cancer
  statistics, 2008. CA Cancer J Clin
  20085871-a96

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Colorectal Cancer

• Average lifetime risk of CRC approaches 6 (1 in
  18)
• Incidence is decreasing
• 66.3 cases/100,000 in 1985
• 49.5 cases/100,000 in 2003
• Mortality is decreasing

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Incidence by Race/Ethnicity and Sex
Source SEER. http//seer.cancer.gov/csr/1975_200
4/, based on November 2006 SEER data submission,
posted to the SEER web site, 2007.
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Survival
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Survival by Race/Ethnicity

• The overall 5-year relative survival rate for
  1996-2003 from 17 SEER geographic areas was 64.0
  
• Five-year relative survival rates by race and sex
  were
• 64.9 for white men
• 64.9 for white women
• 55.2 for black men
• 54.7 for black women

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Risk Factors

• Age
• A personal history of colorectal cancer or polyps
• A family history of colorectal cancer or polyps
• A personal history of inflammatory bowel disease
• Ashkenazi Jewish ethnicity
• African American race
• Diet from animal sources
• Physical inactivity
• Obesity
• Smoking
• Alcohol intake
• Diabetes

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Pathogenesis

• Most CRCs develop from adenomatous polyps
• However, only 10 of adenomas progress to cancer
• Dwell time is approximately 10 years
• Prolonged dwell time allows for screening and
  intervention

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 U.S. Preventive Services Task Force Guidelines
2008

• The USPSTF strongly recommends that clinicians
  screen men and women 50 years of age or older for
  colorectal cancer
• Grade A recommendation
• http//www.ahrq.gov/clinic/3rduspstf/colorectal/co
  lorr.htm

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2008 ACS/USMSTF/ACR CRC Screening Guidelines

• Uniform guidelines from American Cancer Society,
  American College of Radiology and the U.S.
  Multisociety Task Force on Colorectal Cancer
• American Gastroenterological Association
• American College of Gastroenterology
• American Society of Gastrointestinal Endoscopists
• American College of Physicians
• Originally published in 1997, updated in 2003 and
  2008

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2008 ACS/USMSTF/ACR CRC Screening Guidelines
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Guidelines Article and CME Quiz

• Levin B, et al. Screening and Surveillance for
  the Early Detection of Colorectal Cancer and
  Adenomatous Polyps, 2008 A Joint Guideline from
  the American Cancer Society, the US Multi-Society
  Task Force on Colorectal Cancer, and the American
  College of Radiology. Ca Cancer J Clin
  200858130-160
• This article is available online at
  http//CAonline.AmCancerSoc.org
• Free CME credit for successfully completing the
  online quiz http//CME.AmCancerSoc.org

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Comparison of Recommendations
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Guidelines for Polypectomy Surveillance
Winawer SJ et al. Guidelines for colonoscopy
surveillance after polypectomy. A consensus
update by the US Multisociety Task Force on
Colorectal Cancer and the American Cancer
Society. CA Cancer J Clin 2006 56143-159
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Important Points About CRCS

• The digital exam is not a recommended CRCS
  strategy
• A single office FOBT is not adequate screening
• A positive FOBT should never be repeated it
  should always be followed up by colonoscopy
• FOBT is not adequate surveillance for patients
  with a history of adenomas
• Success of screening stool tests depends on
  participation in a screening program
• FOBTs, FITs and sDNA tests vary in sensitivity
  and specificity and guidelines recommend high
  sensitivity
• FOBT e.g. Hemoccult SENSA
• FIT e.g. immoCARE-C and FOB advanced have higher
  sensitivity and specificity
• sDNA e.g. EXACT Sciences

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CRC Screening Rates in the U.S.

• 60.8 of adults over 50 years of age have had
  FOBT within the previous year of lower endosocopy
  within the previous 10 years
• BRFSS, 2006
• 90 of patients who have not had CRCS report
  that a doctors recommendation would motivate
  them to undergo CRCS

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Barriers to Recommending CRCS

• All eligible patients do not consistently receive
  a provider recommendation for CRCS
• Barriers are at all levels patient, physician,
  system
• Interventions are needed to address the multiple
  barriers to address patient, physician and system
  level barriers
• Guerra, CE et al. Barriers to Physician
  Recommendation of Colorectal Cancer Screening. J
  Gen Intern Med. 200722(12)1681-8.

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How to Increase Colorectal Cancer Screening
Rates in Practice A PCC Evidence-based Toolbox
and Guide

• Educational guide and compendium of tools to
  increase primary care providers recommendation
  of colorectal cancer screening
• Written by
• Mona Sarfaty, M.D., Research Assistant Professor,
  Dept of Health Policy, Thomas Jefferson
  University
• Edited by
• Karen Peterson, Ph.D., Cancer Research and
  Prevention Foundation
• Richard Wender, M.D., Professor and Chair, Dept
  of Family and Community Medicine, Thomas
  Jefferson University
• Published
• The National Colorectal Cancer Roundtable
• Funded by
• American Cancer Society and Centers for Disease
  Control and Prevention
• Available at http//www.nccrt.org/Documents/Gener
  al/IncreaseColorectalCancerScreeningRates.pdf

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The Toolbox Article and CME Quiz

• Sarfaty M, Wender R. How to increase colorectal
  cancer screening rates in practice. Ca Cancer J
  Clin 200757354-366
• This article is available online at
  http//CAonline.AmCancerSoc.org
• Free CME credit for successfully completing the
  online quiz http//CME.AmCancerSoc.org

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Toolbox

• Your recommendation
• Office policy
• Reminder system
• Communication strategies

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Essential 1 Physician Recommendation

• Although many physicians recommend CRCS for their
  patients, few screen every eligible patient
• Why screen for CRCS?
• Screening prevents CRC and reduces mortality
• Insurance reporting requirements (HEDIS)
• P4P
• Malpractice suits involving missed diagnosis of
  CRC are costly
• CME

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Impact of Physician Recommendation

• Physician recommendation is strongly associated
  with patient intent to undergo CRCS and
  completion of CRCS

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Physician Recommendation

• Requires an opportunistic/global approach
• Dont limit efforts to check-ups or physicals
• Requires a system that doesnt depend on the
  doctor alone

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Essential 2 An Office Policy

• An office policy is vital because it provides a
  systematic approach
• Only a systematic approach can insure that the
  physicians recommendation is delivered to all
  patients

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Essential 2 An Office Policy

• Policy takes into account
• patient risk level average, increased, high
• Tools included on how to risk stratify patients
• local medical resources
• Access to CRCS tests in region FOBT requires no
  facilities or personnel
• insurance coverage
• Insured? Covered? Deductible? Copay?
• patient preference
• Tools are available for determining patient
  adherence

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Office Policy Determining Patient Risk

• Have you or any members of your family had CRC?
• Have you or any members of your family had an
  adenomatous polyp?
• Has any member of your family had a CRC or
  adenomatous polyp when they were under the age of
  50? (If yes, consider a hereditary syndrome)
• Do you have a history of Crohns disease or
  ulcerative colitis (for more than 8 years)?
• Do you or any members of your family have a
  history of cancer of the endometrium, small
  bowel, ureter, or renal pelvis? (If yes,
  consider HNPCC)

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Office Policy Determining Patient Risk

• Average risk
• No personal history or first degree relatives
  with colorectal polyps or cancer
• Options for screening
• Flex sig every 5 years
• Colonoscopy every 10 years
• Double contrast barium enema every 5 years
• CT colonography every 5 years
• Guaiac-based FOBT
• FIT
• stool DNA

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Office Policy Determining Patient Risk

• Increased Risk
• Has a personal or family history of colorectal
  polyps or CRC
• Or
• Has a personal history of inflammatory bowel
  disease for more than 8 years
• 18-20 of population is at increased risk
• Patients are not given options for screening
• Colonoscopy is the preferred screening test
• Screening should begin earlier (age 40 or younger)

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Office Policy Determining Patient Risk

• High Risk (hereditary colorectal cancer
  syndromes)
• Hereditary non-polyposis colorectal cancer
  (HNPCC)
• Familial adenomatous polyposis (FAP)
• Attenuated FAP

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Office Policy Determining Patient Risk

• High Risk
• Suspect in someone with
• A family history of an adenomatous polyp or CRC
  in relative under age 50
• Two or more relatives with CRC
• Multiple colorectal adenomas (usually 10 or more)
  diagnosed over one or more exams
• Refer to local cancer genetic counselor
  www.nsgc.org

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Recommendations at a Glance Using Risk
Stratification
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Office Policy Determining Patient Risk
Assess Risk Personal and Family
Increased risk family or personal hx of CRC
or adenomatous polyp, IBD gt 8 yrs High risk
HNPCC related ca, FAP, aFAP
Average Risk no personal or family hx of CRC or
adenomatous polyp
gt50 yrs
lt50 yrs
Personal history
Family History
Screen
Do Not Screen
Adenoma CRC Or IBD
Adenoma or Cancer
Germline Syndrome
If f/u with diagnostic Colonoscopy
Surveillance Colonoscopy begin in childhood
Screen 10 yrs before youngest relative or age 40
Surveillance Colonoscopy
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Insurance Coverage

• Currently, there is no federal legislation that
  requires insurers to cover preventive health
  screening
• As of 2009, only 28 states including the District
  of Columbia required insurance coverage of
  colorectal cancer screening
• Entertainment Industry Foundation

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Insurance Coverage

• States that have enacted legislation that
  requires insurers to cover all CRCS options
• New Jersey, Maryland, Washington, DC, and
  Delaware, Pennsylvania (as of Jan 1, 2009)

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Local Medical Resources

• The screening options available to the patients
  in your community
• FOBT requires no facilities or personnel other
  than the patient and staff of the office practice
• However, a positive screen requires a complete
  diagnostic exam by colonoscopy

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Patient Preference

• Video decision aid for colorectal cancer
  screening (CHOICE) developed by UNC-Chapel Hill
  investigators
• Pignone M, et al. Videotape-based decision aid
  for colon cancer screening. A randomized,
  controlled trial. Ann Intern Med,
  2000133(10)761-9.
• CRCS was ordered in 47.2 of intervention and
  36.8 of the control (auto safety video)
  (difference 20.8, CI 8.6-32.9)
• CRCS was completed in 36.8 of intervention and
  22.6 of control (difference 14.2, CI 3.0-25.4)
• Available in VHS or DVD format for 25 from
• Jennifer Griffith, Sheps Center for Health
  Services Research, 725 Martin Luther King Jr.
  Blvd, CB 7590, Chapel Hill, NC 27599-7590
• Most physicians have a preferred screening
  strategy and will offer alternative strategies if
  patients refuse the preferred strategy

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Example of Office Policy FOBT
Give FOBT kit to all patients over 50 at average
risk
Patient returns FOBT kit in 1 month
No
Yes
Place patients letter/postcard in next years
ticker
Send reminder letter/postcard
Patient returns FOBT w/in 1 month
Record results in chart and notify pt of results
No
Yes
Negative
Positive
Direct Contact
Repeat in 1 yr or offer FS or CS
Schedule CS
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Office Policy

• Once an office policy is created, the office
  staff must be engaged to actualize it
• Present office policy to staff and offer them the
  opportunity to ask questions
• Depict it using an algorithm
• Post it
• Disseminate it
• Staff reminders

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Office Policy

• Physicians fall into the pattern that they alone
  must change in order to improve practice patterns
• Physicians often fail to recognize that to effect
  change, the office system must be changed
• By engaging other office members, staff
• By developing reminder systems and cues to action

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Office Policy Sample Script

• Dr. Smith would like for you to be tested for
  CRCS. You have two choices
• You may choose the take home method called fecal
  occult blood test or FOBT. With an FOBT, if a
  problem is found, you will need a colonoscopy or
• You may go directly to colonoscopy.

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Essential 3 An Office Reminder System

• Reminder systems are Cues to Action
• Reminder systems can be directed at patients,
  clinicians, or both
• Reminder systems can be simple, or complex, with
  the more complex systems having the greatest
  benefit
• 58 of physicians do not use reminder systems
  37 have a paper reminder system

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Essential 3 An Office Reminder System

• Reminders for patients
• Passive
• Letters
• Postcards
• Prescriptions
• Pamphlets
• DVDs, videos
• Websites
• List of agencies that have available educational
  material included in Toolbox
• Active
• Telephone scripts
• In-person
• Electronic For highly motivated patients
  myhealthtestreminder.com

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Patient Reminder Letters
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Patient Reminder Postcard
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Telephone Scripts
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www.MyHealthTestReminder.com
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Patient Cues to Action

• Patient educational material
• ACS posters, brochures, videos can be ordered for
  free via the web cancer.org/colonmd

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American Cancer SocietyPatient Education Tools

• This free brochure encourages your patients to
  talk with you about colorectal cancer screening
  and provides a list of questions to ask to help
  facilitate the conversation.

Available at www.cancer.org/colonmd
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American Cancer SocietyPatient Education Tools
This free kit includes a brochure, a seven
minute informational DVD, and a booklet on
testing options. The information explains the
most commonly used screening methods including
test preparation, in simple language.

• Available at www.cancer.org/colonmd

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Reminders for Physicians

• Behavioral
• Chart stickers
• Problem lists
• Screening schedules/flow sheets
• Integrated summary
• Paper tracking templates
• Electronic reminders EMR (Vista-Office
  Electronic Health Record AC-group/IOM
  requirements for EMRs)
• Tracking databases paper and electronic
  (COMMAND, PECS2)
• Cognitive Audit and Feedback, Ticklers (provides
  national benchmarks and targets)
• System Staff assignments

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Preventive Service Schedule
http//www.ahrq.gov/ppip/timelinead.pdf
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Flow Sheets
http//www.nyc.gov/html/doh/downloads/pdf/csi/hype
rkit-clin-ptvcare-flowsht.pdf
http//www.aafp.org/fpm/20010200/preventivecareflo
wsheets.pdf
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Sample Paper Tracking Template (Tickler)
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Electronic Medical Records

• Vista-Office Electronic Health Record (VOE)
  project. More information can be obtained at
  http//www.worldvista.org/
• Free, online rating system for electronic medical
  records by the AC group based on the Institute of
  Medicines requirements for a computerized
  patient record at www.acgroup.org/pages/396843/in
  dex.htm

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Electronic Tracking Systems

• COMORBID DISEASE MANAGEMENT DATABASE from MI
  Quality Improvement Organization
  http//www.iqh.org/index.php3?areacommandtopic1
  01671
• PATIENT ELECTRONIC CARE SYSTEM TX Assoc of
  Community Health Centers www.pecsusers.net

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Audit and Feedback

• Chart audit
• Review a prerequisite number of charts to
  document whether a certain elements are found on
  the chart
• Produces an 18.6 improvement in screening rates
• Can produce feedback for a provider or a practice
• Overcomes physician recall bias or inability to
  self-assess the proportion of their patients that
  have been screened
• A repeat audit may be conducted to assess the
  impact of an intervention
• Time interval for repeat audit varies depending
  on
• size of the practice
• patient population
• staffing level
• intervention that has been implemented

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Chart Audits Template
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Staff Involvement

• Key Point..the Doctor Cant Do It All
• The time that patients spend with non-physician
  staff is underutilized
• Standing orders can empower nurses, PAs, intake
  staff, etc. to distribute materials, distribute
  patient surveys to be completed in the waiting
  room, stool blood cards, schedule appointments
  for colonoscopy, etc.
• Involve staff in meetings to discuss progress in
  achieving office goals for improving the delivery
  of preventive services

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Essential 4 Effective Communication

• Stage-based communication
• Based on the Transtheoretical Model (Prochaska
  DiClemente)
• Individuals who are candidates for making a
  health behavior change do so in different stages
  of readiness

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Education
Examine patient barriers
Select a screening option and provide
motivational information
Readdress screening at a later time
Practical how-to information
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Summary

• Every eligible patient should receive a
  recommendation for CRCS
• This is most likely to occur if
• The provider or the staff provide a personal
  recommendation to each patient
• There is an office policy to assure that each
  patient receives a CRCS recommendation from their
  provider
• There are reminder systems in place targeting
  providers/staff and patients
• There is effective, stage-based communication
• The Toolbox contains many tools to systematically
  recommend CRCS to each eligible patient
• Toolbox can be accessed at cancer.org/colonmd

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Conclusion

• The barrier to reducing the number of deaths from
  colorectal cancer is not a lack of scientific
  data but a lack of organizational, financial and
  societal commitment.
• Daniel K. Podolsky, MD (NEJM, 7/20/00)

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Acknowledgement

• Funding support
• National Cancer Institute grant number
  K22CA133186
• Robert Wood Johnson Foundation Amos Medical
  Faculty Development Award
• American Cancer Society, PA division
• Diana Fox, Director, Strategic Collaborations
• Mauricio Conde, Project Manager, Health Systems
• Toolbox authors, editors, developers including
  the CDC, ACS and NCCRT

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Questions?