Colorectal Cancer Screening in the Medicare Population

1
Colorectal Cancer Screening in the Medicare
Population
AHQA 2008 Annual Meeting

• Anna Schenck, PhDDirector of Research

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Colorectal Cancer in U.S.

• 2rd leading cause of cancer death
• Over 148,000 new cases a year1
• Incidence increases with age
• Over 1 million prevalent cases in 20042
• 85 of which were age 60

• American Cancer Society, Cancer Facts and Figures
  2006, Atlanta American Cancer Society 2006.
• Ries LAG, Harkins D, Krapcho M, Mariotto A,
  Miller BA, et al. 2006. SEER Cancer Statistics
  Review, 1975 -2003. National Cancer Institute,
  Bethesda, MD.

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Impact of Colorectal Cancer on Medicare Program

• By the year 2020, it is estimated that
• Colorectal cancer prevalence will increase to 1.5
  million1
• Cost the Medicare program and beneficiaries for
  colorectal cancer will exceed 14 billion2

• Mariotto AB, Yabroff KR, Feuer EJ, De Angelis R,
  Brown M. 2006. Projecting the number of
  patients with colorectal cancer carcinoma by
  phases of care in the US 2000-2020. Cancer
  Causes and Control 171215-1226.
• Yabroff KR, Mariotto AB, Feuer E, Brown ML.
  Projections of the costs associated with
  colorectal cancer care in the United States
  2000-2020. Health Economics (2007).

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The good news

• Patients with colorectal cancer detected at an
  early stage have a 90 5 year survival rate1
• Effective methods of early detection and
  prevention are available
• Colorectal cancer screening is covered under
  Medicare

• Ries LAG, Harkins D, Krapcho M, Mariotto A,
  Miller BA, Feuer EJ, Clegg L, Eisner MP, Horner
  MJ, Howlader N, Hayat M, Hankey BF, Edwards BK
  (eds). SEER Cancer Statistics Review, 1975-2004,
  National Cancer Institute. Bethesda, MD,
  http//seer.cancer.gov/csr/1975_2004/, based on
  November 2006 SEER data submission, posted to the
  SEER web site 2007.

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Screening Recommendations

• Consensus guidelines support average risk
  individuals starting at age 50 should have
• FOBT yearly, or
• Sigmoidoscopy every 5 years, or
• Barium enema every 5 years, or
• Colonoscopy every 10 years

• Pignone M, Rich M, Teutsch SM, et al. 2002.
  Screening for colorectal cancer in adults at
  average risk a summary of the evidence for the
  US Preventive Services Task Force. Annals of
  Internal Medicine 137(2)132-141.

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Medicare coverage of screening

• FOBT
• yearly screening exam
• Colonoscopy
• every 24 months, for persons with high risk
  diagnosis
• every 120 months for persons of average risk (as
  of 7/1/2001) or 48 months after sigmoidoscopy
• Sigmoidoscopy
• every 48 months
• Barium Enema
• as alternative to sigmoidoscopy

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The bad news.

• Only 39 of colorectal cancer cases are diagnosed
  at an early stage1
• Only 45 of Medicare enrollees have claims
  indicating they have been appropriately tested

• Ries LAG, Harkins D, Krapcho M, Mariotto A,
  Miller BA, Feuer EJ, Clegg L, Eisner MP, Horner
  MJ, Howlader N, Hayat M, Hankey BF, Edwards BK
  (eds). SEER Cancer Statistics Review, 1975-2004,
  National Cancer Institute. Bethesda, MD,
  http//seer.cancer.gov/csr/1975_2004/, based on
  November 2006 SEER data submission, posted to the
  SEER web site 2007.

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The Colorectal Cancer Screening Special Project

• In 2000, CMS awarded CCME a colorectal cancer
  screening special project
• to develop a colorectal cancer screening measure
  and produce report with national, regional and
  state test use rates
• to develop and test an intervention to increase
  colorectal cancer screening
• Inter-agency collaboration with NCI
• Evaluation of interventions
• Assessment of validity of claims for measurement

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Colorectal Cancer Test Use Reports

• Web-based report, using Medicare enrollment and
  claims data
• 4 updates, current report contains test use rates
  from 1998 2005
• www.thecarolinascenter.org/crcreport

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Colorectal Cancer Test Use Measures

• Yearly rates for each type of test
• Test use rates for the nation, regions, states
  and by county
• Test use rates by demographic characteristic
• Summary test rates by year
• Complete in Medicare (CIM) test rates

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Measure Specifications

• Denominator
• Age 50 and older
• Alive at end of year
• Enrolled in FFS Medicare Part B
• Numerator for CIM rate
• Paid claim for
• FOBT in past year, or sigmoidoscopy or BE in past
  5 years, or colonoscopy since 1998
• Claims from all settings
• Screening and diagnostic tests

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Measures Considerations

• Test use not screening
• Although separate codes exist for screening and
  diagnostic tests, claims cannot reliably
  distinguish reason for test1
• Current in Medicare not Up to date
• Colonoscopy tests conducted (for diagnostic
  purposes) prior to 1998 not included
• Colonoscopy use prior to 1998 low

• Schenck AP, Klabunde CN, Warren JL, Peacock S,
  Davis WW, Hawley ST, Pignone M, Ransohoff D.
  Data Sources for Measuring Colorectal Endoscopy
  Use Among Medicare Enrollees. Cancer
  Epidemiology Biomarkers and Prevention, 2007 Oct
  16(10) 2118-2127. 

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Claims accuracy

• Claims are accurate for measuring sigmoidoscopy
  and colonoscopy use1
• Claims measurement of FOBT use is less precise2
• Small percent of enrollees tested by FOBT only

• Schenck AP, Klabunde CN, Warren JL, Peacock S,
  Davis WW, Hawley ST, Pignone M, Ransohoff D.
  Data Sources for Measuring Colorectal Endoscopy
  Use Among Medicare Enrollees. Cancer
  Epidemiology Biomarkers and Prevention, 2007 Oct
  16(10) 2118-2127. 
• Schenck AP, Klabunde CN, Warren JL, Peacock S,
  Davis WW, Hawley ST, Pignone M, Ransohoff D.
  Evaluation of Claims, Medical Records and
  Self-Report for Measuring Fecal Occult Blood Test
  Use Among Medicare Enrollees in Fee for Service.
  Cancer Epidemiology Biomarkers and Prevention (in
  press).

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Test use trends
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Current in Medicare state variations
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Current in Medicare county variations
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Current in Medicare by Age
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Current in Medicare by Race
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Current in Medicare by Sex
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Current in Medicare by Eligibility Status
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Current in Medicare by Entitlement Reason
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Why arent test rates higher?

• Consumer Barriers
• Lack of physician recommendation
• African Americans less likely to receive a
  recommendation for CRC test than whites1
• Enrollees without usual source of care and
  without routine care visits less likely to
  receive recommendation for CRC test
• Lack of knowledge about the tests
• 51-62 of consumers had never heard of the tests1

• Klabunde CN, Schenck AP, Davis WW. Barriers to
  Colorectal Caner Screening Among Medicare
  Consumers. Am J Prev Med 200630(4)313-319.

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Why arent test rates higher?

• Physician Barriers
• Confusion about recommendations
• Use of digital rectal exam or single office FOBT1
• Lack of office system to identify those in need
  of test
• Lack of approach to educate patients about test
  options
• Lack of system for patient reminders

• Schenck AP, Klabunde CN, Warren JL, Peacock S,
  Davis WW, Hawley ST, Pignone M, Ransohoff D.
  Evaluation of Claims, Medical Records and
  Self-Report for Measuring Fecal Occult Blood Test
  Use Among Medicare Enrollees in Fee for Service.
  Cancer Epidemiology Biomarkers and Prevention (in
  press).

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CCME Intervention Project

• Physician toolkit
• In-office tools to increase ability to identify
  those in need of testing, provide education on
  test options and assure recommendation
• Education for physicians and their staff
• Consumer mailings
• Targeted mailings based on age, preventive
  service use
• Physician letters

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Lessons from our project

• Getting physicians interested was difficult
• Approach may need to be tailored to state
• Two states, same interventions, differing results
• Promising components1
• Educational teleconference with CME
• Letters from physicians to patients encouraging
  screening
• Cautionary advice about screening intervals and
  payments

1. Schenck AP, Peacock S, Pignone M, Jackson E,
Gunter N, Klabunde CN. Increasing colorectal
cancer testing translating physician
interventions into population-based practice.
Health Care Financing Review 2006, 27(3)25-36.
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QIO colorectal cancer screening tasks in 9th SoW

• Work with selected physician office practices
  with EHRs to improve CRC screening rates
• Assist practices in use of EHR to implement care
  management for preventive services
• Educate practices on using EHR to improve CRC
  screening rates
• Successfully encourage data submission on
  screening
• Achieve 15 relative improvement in test use
• Monitor statewide rates and report on disparities

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Increasing screening in physician offices

• In reach1,2
• Feedback on test use rates
• Education
• Communication skills
• System to monitor compliance
• Out reach1,2
• Physician letter
• CDC Screen for Life Materials

1. Ferreira MR, Dolan NC, Fitzgibbon ML, et al.
Health care provider-directed intervention to
increase colorectal cancer screening among
Veterans results of a randomized controlled
trial. J Clin Oncol 2005 (23)1548-54.
2. Khankari K, Eder M, Osborn CY, et al.
Improving colorectal cancer screening among the
medically underserved a pilot study within a
Federally Qualified Health Center. J Gen Intern
Med 2007 22(10)1410-4.
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Monitoring Disparities

• Different patterns of test use within different
  population groups and by geography
• Practice patterns
• Cultural preferences
• May have implications for different approaches
• Focus on particular type of test

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Resources

• CDC Screen for Life Campaign
• http//www.cdc.gov/cancer/colorectal/pdf/backgrou
  nder_2007.pdf
• Universal symbol -Blue star
• http//www.nccrt.org/News/NewsDetail.aspx?artic
  le_id413
• Colorectal Cancer Roundtable Physician Office
  Toolkit

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For more information
Anna Schenck, PhD The Carolinas Center for
Medical Excellence aschenck_at_thecarolinascenter.org