David Haggstrom Slides from AHRQ Kick-Off Event


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Colorectal cancer screening: overview & background

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David Haggstrom Slides from AHRQ Kick-Off Event

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