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David's Slides from AHRQ Kick-Off Event
 

David's Slides from AHRQ Kick-Off Event

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Colorectal cancer screening: overview & background

Colorectal cancer screening: overview & background

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    David's Slides from AHRQ Kick-Off Event David's Slides from AHRQ Kick-Off Event Presentation Transcript

    • Colorectal cancer screening: overview & background January 8,2007 David A. Haggstrom, MD, MAS LEADERS SYMPOSIUM “ Strategic Planning to Inform a Funded Project on how to Achieve Workflow Integration in Developing and Implementing CDS for CRC Screening”
    • Outline
      • CRC screening practice guidelines
      • Competing clinical demands for CRC screening
      • Applied research for screening
        • Clinical decision support
          • Facilitators & barriers
        • Practice-based interventions
    • Colorectal cancer screening Clinical practice guidelines
      • Target population : men & women 50 years of age & older at average risk for colorectal cancer
      • Caveat (VA/DoD) : providers should discuss screening with patients ages 80 & older, taking into account estimated life expectancy & presence of co-morbid disease
    • Colorectal cancer screening Clinical practice guidelines (USPSTF) Test Interval
      • Fecal occult blood testing (FOBT)
        • 3 cards done at home
      Annually Flexible sigmoidoscopy Every 5 years Colonoscopy Every 10 years Double-contrast barium enema Every 5 years
    • Competing clinical demands
        • Most clinical practice guidelines (CPGs) did not address their applicability for older patients with multiple comorbidities
        • Most didn’t discuss
          • burden, short- & long-term goals
          • give guidance for incorporating patient preferences into treatment plans (Boyd, Wu, JAMA , 2005)
        • To fully satisfy all USPSTF recommendations
          • 7.4 hrs/working day is needed for the provision of preventive services by physicians
      (Yarnall et al., AJPH , 2003)
    • Computer reminders – Regenstrief Institute
      • Clinical focus : FOBT, mammography, & Pap testing
      • Study design : 6-mo. RCT
      • Population : 31 GIM faculty & 145 residents at Indiana University
      • Intervention : “directed reminders” vs. routine reminders
        • 1) done/order today 3) patient refused
        • 2) NA to patient 4) next visit
      • Primary outcome : compliance with reminder
        • “ directed reminders” overall (46% vs. 38%, p = 0.002)
        • FOBT (61% vs. 49%, p = 0.0007)
      • Secondary outcomes :
        • 21% of time : NA to patient - due to inadequate data in pt’s EMR
        • 10% of time : patient refused
      • Conclusions :
        • Requiring MDs to respond to computer-generated reminders improved their compliance
        • However, 100% compliance with cancer screening reminders will be unattainable due to clinical appropriateness & patient refusal
      (Litzelman, Tierney, JGIM , 1993)
    • Electronic health record – Partners HealthCare Barriers to use
      • 24% of physicians “never/sometimes” used any EHR functionality during patient visit
      • Barriers to EHR use:
        • Loss of eye contact with patients (62%)
        • Falling behind schedule (52%)
        • Computers being too slow (49%)
        • Inability to type quickly enough (32%)
        • Using computer in front of patient is rude (31%)
        • Preferring to write long prose notes (28%)
      (Linder, AMIA Annu Symp Proc , 2006)
    • Computer reminders - VA Facilitators to adherence
      • In VA, overall adherence rate to 15 CRs:
        • 86% (67% - 97%)
        • Variation by clinic, individual clinician, & individual CR
      • Positive influence upon reminder completion rate:
        • full utilization of support staff in completion process
        • receiving frequent individual feedback on completion
      • No influence:
        • provider demographics
        • provider attitudes towards reminders
      (Mayo-Smith, Abha Agrawal, 2004 & 2006)
    • Computer reminders - VA Barriers to reminders
      • HIV clinical reminders
      • Design: ethnographic observations & semi-structured interviews
      • Barriers to effective use:
        • Workload
        • Time to remove inapplicable reminders
        • False alarms
        • Reduced eye contact
        • Use of paper forms rather than software
      (Patterson, Doebbeling, Asch et al., J Biomed Inform , 2005)
    • Colorectal cancer screening Primary care-based interventions
      • Practice-individualized facilitation of implementation of tools:
        • Group randomized clinical trial
        • 77 community family practices
      • Intervention:
        • 1-day practice assessment - nurse facilitator observed practice MDs & staff
        • 1.5 hour meeting with practice day after
        • frequent visits thereafter (unknown dose effect)
      • Outcomes at 12 months
        • Summary scores of preventive service delivery rates:
          • Intervention: 42% vs. 31%
          • Control: 37% vs. 35% (p=0.015)
        • Screening services, (p=0.048), not immunization services
      • Sustained after 24 months
      (STEP-UP - Study to Enhance Prevention by Understanding Practice) (Stange, Goodwin, Am J Prev Med , 2001 & 2003)
    • CRC screening in primary care practices
      • Most CRC screening interventions focus on either
        • patients or individual clinicians
        • without examining the office context
      • Methods:
        • chart review (795 pts eligible for CRC screening)
        • practice surveys (22 family medicine practices)
      • Factors associated with higher CRC screening:
        • Using nursing or health educator staff to provide behavioral counseling
        • Reminder system use
      (Hudson & Crabtree, Can Det Prev , 2007)
    • Conclusions
      • Generally positive, but sometimes mixed, results for clinical, computer reminders
        • Direct observation & qualitative methods provide opportunity to understand potential pathways for effectiveness of clinical reminders
      • Computer reminders
        • Need not only to incorporate evidence base, but address patient preferences & comorbidities
      • Prior positive experience with practice change
        • Computer reminder often key component
        • Team-based approach also important, particularly to help address competing time demands
      • Questions or comments?
    • Systems engineering framework
      • Identify system of interest
      • Choose appropriate performance measure
      • Select best modeling tool
      • Study model properties & behavior under variety of scenarios
      • Make design & operation decisions for implementation
      • previous applications in hemodialysis, radiation therapy, & patient flow modeling
      (Kopach-Konrad, Doebbeling et al., JGIM , 2007)