Using survey data to plan a program to increase colorectal cancer screening the Medicare population

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Using survey data to plan a program to increase
colorectal cancer screening the Medicare
population
American Public Health Association 2002 Meeting

• Anna P. Schenck, PhD, MSPH
• Carrie Klabunde, PhD
• Renee Taylor, MPH
• Nelson Gunter, MD, MPH

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Collaborators

• Carolina Medical Review
• Sharon Eubanks, RN
• Aunyika Tocharoen, PhD
• Nelson Gunter, MD, MPH

• Medical Review of NC
• Renee Taylor, MPH
• Louise Henderson, MSPH
• Sue Hunter, MPH
• Leslie Hill
• Lee Hurley
• Robin Brown
• Anna Schenck, PhD

Centers for Medicare Medicaid Services Jim
Coan Catherine Gordon
National Cancer Institute Carrie Klabunde, PhD
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Who we are

• Medical Review of North Carolina and Carolina
  Medical Review (in South Carolina) are Quality
  Improvement Organizations
• Contract with Centers for Medicare Medicaid
  Services to assure quality of care for Medicare
  consumers in each state

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Background

• Colorectal cancer is the second most deadly
  cancer in the US
• Early detection and treatment are the best
  defenses against colorectal cancer
• Use of screening tests is low
• Medicare introduced screening benefit in 1998 for
  enrollees age 50 and older

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Medicare Coverage of Screening Tests

• FOBT
• yearly
• Sigmoidoscopy
• every 48 months
• Colonoscopy
• every 24 months for high risk
• every 10 years for average risk (as of 7/1/2001)
• Barium Enema
• as alternative to sigmoidoscopy or colonoscopy

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Project Overview

• Center for Medicare Medicaid Services awarded
  2-year project to NC and SC
• calculate national and state screening rates
• develop and pilot interventions
• NCI interest resulted in collaboration
• focus groups
• baseline and evaluation telephone survey

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Baseline Survey

• Design
• each state selected intervention and comparison
  counties
• SC (mixture of rural and urban)
• NC (primarily urban)
• Methodology
• telephone survey conducted before the
  intervention
• age 50 - 80, non-HMO, African American or White
• randomly selected Medicare enrollees in NC and SC
  intervention and control counties

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What did we want to know?

• Beliefs, knowledge and attitudes
• risk factors
• screening
• Medicare coverage
• Behaviors
• which screening tests are being done
• are guidelines being followed
• Barriers
• why are some not screened

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Response

• 2004 completed interviews
• NC 1003
• SC 1001
• Overall response rate 69
• NC 67
• SC 70
• Differential response among subgroups indicated a
  need for weighted analyses

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Characteristics of Sample

• Sex
• Male 43
• Race
• White 77
• African American 23
• Education
• Less than High School 25
• High School or Equivalent 36
• Post High School 32

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Understanding of Risk of Colorectal Cancer
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Physician Recommendation for Colorectal Cancer
Test
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Ever Had Any Colorectal Cancer Test
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Had Test According to Guidelines
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Potential Barriers to Colorectal Cancer Testing
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Use of other preventive services

• Women
• those who had mammogram in past year were more
  likely to have had colorectal cancer test
• those who had pap smear in last 3 years were more
  likely to have had a colorectal cancer test

• Men
• those who had PSA test in last year were more
  likely to have had a colorectal cancer test

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Reasons for no test

• Among those who had not had the test according to
  guidelines, two reasons most often listed
• I didnt think it was needed 12 - 18
  (depending on test)
• My doctor didnt order the test 77 - 82
  (depending on the test)

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Where do Medicare consumers get most useful
health information ?
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What the survey told us about consumers

• Plenty of room for improvement
• Lack of knowledge about risk factors and coverage
• Those who use other preventive services were more
  likely to have been tested
• Written information such as health pamphlets and
  booklets may be useful with this population
• Media are less influential with this population

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What the survey told us about physicians

• Patients expect their doctor to order the test
• Doctors may need to convince some patients of the
  importance of screening
• Physician recommendation strong influence of
  whether the patient gets a test

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Intervention Implications

• Consumer interventions need to address
• belief in importance and efficacy of screening
• lack of knowledge about risk factors and Medicare
  coverage
• use of other preventive services
• Provider interventions needed to address
• physician recommendation
• tools to convince patients

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Consumer Intervention CDC Screen for Life
Mailing

• CDC Screen for Life information was sent to
  beneficiaries selected in two ways
• randomly selected
• selected from persons with regular preventive
  service use
• Total of 16,400 packets were mailed
• 3,000 to randomly selected (NC only)
• 5,600 to those with regular preventive service
  use
• 7,800 to targeted aged groups (SC only)

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CDC patient fact sheet
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(No Transcript)
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Consumer Intervention Birthday Card

• Beneficiaries in intervention counties who turned
  65 were sent this card on their birthday
• Total of 3,514 cards were sent
• NC only

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Birthday card sent to NC beneficiaries
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Consumer Intervention NCI Cancer Information
Service Postcards

• Beneficiaries randomly selected
• First card did not generate many calls so the
  card was redesigned. NC sent 2 versions of a
  revised card while SC continued to send original
  cards
• Total of 15,300 cards mailed over 6 months period
  in both NC and SC

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Revised CIS Postcard - Positive
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(No Transcript)
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Physician Interventions

• Provider teleconferences
• 2 teleconferences
• promotion of the new screening benefit and
  project
• how to increase screening in the office and get
  paid for it
• Mailing of physician postcards (SC only)
• Distribution of FOBT kits through physician
  offices (SC only)
• Provider Toolkit

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Screen for Life Toolkit

• Promoted through mailings, web-site, regional
  meetings, fast-fax through NC Medical Society
• Ordered via fax-back forms, mail-in forms,
  web-site
• Contained screening guidelines, billing
  instructions, state testing data and office-based
  tools
• Total of 380 toolkits were distributed
• approximately 20 of MDs in target area

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Patient Assessment used as part of a reminder
system
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Chart Sticker from Physician Tool Kitused as
part of a reminder system
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Stage-of-change based patient education brochures
(used with video)
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Post Card for Physicians to send to Patients
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For more information, contact

• Anna Schenck
• Medical Review of NC5625 Dillard DriveCary, NC
  27511919 851-2955ncpro.aschenck_at_sdps.org
• Check out Medicare Statistics on our website
  www.mrnc.org/ncmed
• or www.mrnc.org/crcreport