How to   Increase Colorectal Cancer Screening Rates in Practice:  A Primary Care Clinician’s Evidence-based Toolbox and Gu...
Overview <ul><li>Colorectal cancer (CRC) incidence and survival </li></ul><ul><li>Risk factors for CRC </li></ul><ul><li>P...
Colorectal Cancer <ul><li>Colorectal cancer (CRC) is 2 nd  leading cause of cancer deaths in U.S. </li></ul><ul><li>In 200...
Colorectal Cancer <ul><li>Average lifetime risk of CRC approaches 6% (1 in 18) </li></ul><ul><li>Incidence is decreasing <...
Incidence by Race/Ethnicity and Sex Source:  SEER. http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data...
Survival 19 36 39 Proportion diagnosed (%)  Metastatic Submucosa or Muscularis/ Regional Lymph Node Mucosa Extent of Disea...
Survival by Race/Ethnicity <ul><li>The overall 5-year relative survival rate for 1996-2003 from 17 SEER geographic areas w...
Risk Factors <ul><li>Age </li></ul><ul><li>A personal history of colorectal cancer or polyps </li></ul><ul><li>A family hi...
Pathogenesis <ul><li>Most CRCs develop from adenomatous polyps </li></ul><ul><li>However, only 10% of adenomas progress to...
  U.S. Preventive Services  Task Force Guidelines 2008 <ul><li>The USPSTF strongly recommends that clinicians screen men a...
 
2008 ACS/USMSTF/ACR  CRC Screening Guidelines <ul><li>Uniform guidelines from American Cancer Society, American College of...
2008 ACS/USMSTF/ACR  CRC Screening Guidelines Stool DNA test (sDNA), with high sensitivity for cancer, interval uncertain ...
Guidelines Article and CME Quiz <ul><li>Levin B, et al. Screening and Surveillance for the Early Detection of Colorectal C...
Comparison of Recommendations No specific prioritization of tests, though recommendations acknowledge that direct visualiz...
Guidelines for Polypectomy Surveillance Winawer SJ et al. Guidelines for colonoscopy surveillance after polypectomy.  A co...
Important Points About CRCS <ul><li>The digital exam is not a recommended CRCS strategy </li></ul><ul><li>A single office ...
CRC Screening Rates in the U.S. <ul><li>60.8% of adults over 50 years of age have had FOBT within the previous year of low...
Barriers to Recommending CRCS <ul><li>All eligible patients do not consistently receive a provider recommendation for CRCS...
How to Increase Colorectal Cancer  Screening Rates in Practice: A   PCC Evidence-based Toolbox and Guide <ul><ul><li>Educa...
 
The Toolbox Article and CME Quiz <ul><li>Sarfaty M, Wender R.  How to increase colorectal cancer screening rates in practi...
 
Toolbox <ul><li>Your recommendation </li></ul><ul><li>Office policy </li></ul><ul><li>Reminder system </li></ul><ul><li>Co...
Essential 1: Physician Recommendation <ul><li>Although many physicians recommend CRCS for their patients, few screen every...
Impact of Physician Recommendation <ul><li>Physician recommendation is strongly associated with patient intent to undergo ...
Physician Recommendation <ul><li>Requires an opportunistic/global approach </li></ul><ul><ul><li>Don’t limit efforts to “c...
Essential 2: An Office Policy <ul><li>An office policy is vital because it provides a systematic approach </li></ul><ul><l...
Essential 2: An Office Policy <ul><li>Policy takes into account  </li></ul><ul><ul><li>patient risk level: average, increa...
Office Policy: Determining Patient Risk <ul><li>Have you or any members of your family had CRC? </li></ul><ul><li>Have you...
Office Policy: Determining Patient Risk <ul><li>Average risk  </li></ul><ul><ul><li>No personal history or first degree re...
Office Policy: Determining Patient Risk <ul><li>Increased Risk </li></ul><ul><ul><li>Has a personal or family history of c...
Office Policy: Determining Patient Risk <ul><li>High Risk  ( hereditary colorectal cancer syndromes) </li></ul><ul><ul><li...
Office Policy: Determining Patient Risk <ul><li>High Risk </li></ul><ul><ul><li>Suspect in someone with </li></ul></ul><ul...
Recommendations at a Glance  Using Risk Stratification Specialty referral,  colonoscopy, +/- genetic test Any age <ul><li>...
Office Policy: Determining Patient Risk Assess Risk: Personal and Family Average Risk = no personal or family hx of CRC or...
Insurance Coverage <ul><li>Currently, there is no federal legislation that requires insurers to cover preventive health sc...
Insurance Coverage <ul><li>States that have enacted legislation that requires insurers to cover all CRCS options </li></ul...
Local Medical Resources <ul><li>The screening options available to the patients in your community </li></ul><ul><ul><li>FO...
Patient Preference <ul><li>Video decision aid for colorectal cancer screening (CHOICE) developed by UNC-Chapel Hill invest...
Example of Office Policy: FOBT  Give FOBT kit to all patients over 50 at average risk Patient returns FOBT kit in 1 month ...
Office Policy <ul><li>Once an office policy is created, the office staff must be engaged to actualize it </li></ul><ul><ul...
Office Policy <ul><li>Physicians fall into the pattern that they alone must change in order to improve practice patterns <...
Office Policy: Sample Script <ul><li>“ Dr. Smith would like for you to be tested for CRCS.  You have two choices: </li></u...
Essential 3: An Office Reminder System <ul><li>Reminder systems are “Cues to Action” </li></ul><ul><li>Reminder systems ca...
Essential 3: An Office Reminder System <ul><li>Reminders for patients </li></ul><ul><ul><li>Passive </li></ul></ul><ul><ul...
Patient Reminder Letters
Patient Reminder Postcard
Telephone Scripts
www.MyHealthTestReminder.com
Patient Cues to Action <ul><li>Patient educational material  </li></ul><ul><ul><li>ACS posters, brochures, videos can be o...
American Cancer Society Patient Education Tools <ul><li>This free brochure encourages your patients to talk with you about...
American Cancer Society Patient Education Tools <ul><li>Available at www.cancer.org/colonmd </li></ul>This free kit includ...
Reminders for Physicians <ul><li>Behavioral </li></ul><ul><ul><li>Chart stickers </li></ul></ul><ul><ul><li>Problem lists ...
Preventive Service Schedule http://www.ahrq.gov/ppip/timelinead.pdf
Flow Sheets http://www.nyc.gov/html/doh/downloads/pdf/csi/hyperkit-clin-ptvcare-flowsht.pdf http://www.aafp.org/fpm/200102...
Sample Paper Tracking Template (“Tickler”)   Comment Test result and notification date Date reminder written/Telephone con...
Electronic Medical Records <ul><li>Vista-Office Electronic Health Record (VOE) project.  More information can be obtained ...
Electronic Tracking Systems <ul><li>COMORBID DISEASE MANAGEMENT DATABASE from MI Quality Improvement Organization:  http:/...
Audit and Feedback <ul><li>Chart audit  </li></ul><ul><ul><li>Review a prerequisite number of charts to document whether a...
Chart Audits Template
Staff Involvement <ul><li>Key Point…..the Doctor Can’t Do It All </li></ul><ul><li>The time that patients spend with non-p...
Essential 4: Effective Communication <ul><li>Stage-based communication   </li></ul><ul><ul><li>Based on the Transtheoretic...
Education Examine patient barriers Practical how-to information Readdress screening at a later time Select a screening opt...
Summary <ul><li>Every eligible patient should receive a recommendation for CRCS </li></ul><ul><li>This is most likely to o...
Conclusion <ul><li>The barrier to reducing the number of deaths from colorectal cancer is not a lack of scientific data bu...
Acknowledgement <ul><li>Funding support </li></ul><ul><ul><li>National Cancer Institute grant number K22CA133186 </li></ul...
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  • 5.42% Mortality is decreasing due to reduced exposure to risk factors, increased screening and improved treatment
  • Surveillance Epidemiology and End Results (NCI) Age-adjusted incidence rates
  • Survival statistics are the strongest support for screening 5% diagnosed at unknown stage – overall 5 yr survival 35.8
  • 90% of cases occur after age 50 Family history: one first degree relative &lt;50y.o. or two first degree relatives at any age with CRC= 3-4 fold increase; one first degree relative any age or two second degree: 2-3 fold increase risk Obesity, smoking (by 30-40%) increase chances of dying from CRC Diabetes increases risk of developing CRC by 30%
  • Average time from onset of polyp to the development of CRC (“dwell time”) is approximately 10 years
  • July, 2002 The USPSTF found good evidence that periodic fecal occult blood testing (FOBT) reduces mortality from colorectal cancer and fair evidence that sigmoidoscopy alone or in combination with FOBT reduces mortality. The USPSTF did not find direct evidence that screening colonoscopy is effective in reducing colorectal cancer mortality; efficacy of colonoscopy is supported by its integral role in trials of FOBT, extrapolation from sigmoidoscopy studies, limited case-control evidence, and the ability of colonoscopy to inspect the proximal colon. Double-contrast barium enema offers an alternative means of whole-bowel examination, but it is less sensitive than colonoscopy, and there is no direct evidence that it is effective in reducing mortality rates. The USPSTF found insufficient evidence that newer screening technologies (for example, computed tomographic colography) are effective in improving health outcomes.
  • Colonoscopy should be performed if test are abnormal
  • Where to the guidelines differ? The USPSTF did not prioritize screening tests, or state a preference for the benefits of CRC prevention through the detection and removal of adenomas, however they do acknowledge the greater advantage of endoscopic tests over stool tests. Their guidelines state, ““Direct visualization techniques offer substantial benefit over fecal tests, with greater sensitivity, when considered as a single test.” The USPSTF recommends against routine screening in adults ages 76-85, and recommends against any screening in adults over age 85. Note that the recommendation against screening in adults aged 76-85 is against “routine screening.” This recommendation does not say that say that adults in this age group definitively should not be screened, only that routine screening in this population my not produce benefits that exceed harms. Recent research has shown that the highest rate of serious complications during and after colonoscopy occur in older adults. In contrast, ACS-USMSTF-ACR guidelines simply state that as long as an adult is in good health, they should continue screening in order to be protected against diagnosis of an advanced stage colorectal cancer. At a point where an adult’s health is poor, and they have limited longevity, screening is not advised. Thus, there is considerable overlap in the intent of these two recommendations. Both sets of guidelines take into account that not every 75 year old is the same. Many people in this age group are healthy and have a life expectancy of 20 or years or more, and can clearly benefit from continued colorectal cancer screening. In addition to the individual’s underlying health status, screening history should also be taken into account. A 76 year old who has had normal screening tests for colorectal cancer on a regular basis for a number of years may reasonably consider, in consultation with their physician, to discontinue screening. On the other hand, screening a relatively healthy 76 year old that has never been screened for colorectal cancer may lead to significant benefit.
  • 50% of endoscopists were not following postpolypectomy surveillance guidelines Risk stratification to efficiently use resources so that post-polypectomy surveillance does not drain resources from screening and diagnosis
  • A multifaceted approaches are more effective than a single faceted ones
  • 74-90% of patients who have not had CRCS report they would schedule CRCS if their physician recommended the test Lack of physician recommendation of CRCS is strongly associated with NOT undergoing CRCS Harewood GC et al.; Guerra CE, et al.; Klabunde CN et al. Conversely, physician recommendation of CRCS is one of the most important facilitators of adherence to CRCS Subramanian S, et al.; Teng EJ, et al.; Zapka JG et al.; Myers RE, et al.; Mandelson MT, et al; Bejes C, et al; Holt WS Jr, et al.
  • CRCS was ordered in 47.2% of intervention and 36.8% of the control (auto safety video) (delta 20.8, CI 8.6-32.9%) CRCS was completed in 36.8% of intervention and 22.6% of control (delta 14.2, CI 3.0-25.4%) 11 min video covering susceptibility to CRC, available screening options, significance of positive test, 4 vignettes of pts discussing their experience with CRCS, and assessment of stage of readiness by asking participant to choose a color coded brochure based on their stage of readiness
  • Answer yes to any of these places patient at either increased or high risk
  • HNPCC is an autosomal dominant inherited cancer syndrome that accounts for 1-5% of CRC cases. It is caused by a germline mutation in 1 of 5 mismatch repair genes. Mean age of CRC development is 44 yrs. Tumors tend to be right sided and poorly differentiated, demonstrate microsatellite instability
  • National society of genetic counselors
  • Tests do not include recently added tests to the guidelines
  • 11 min video covering susceptibility to CRC, available screening options, significance of positive test, 4 vignettes of pts discussing their experience with CRCS, and assessment of stage of readiness by asking participant to choose a color coded brochure based on their stage of readiness CRCS was ordered in 47.2% of intervention and 36.8% of the control (auto safety video) (delta 20.8, CI 8.6-32.9%) CRCS was completed in 36.8% of intervention and 22.6% of control (delta 14.2, CI 3.0-25.4%)
  • Using FOBT as main screening modality
  • Learn from working with national board of medical examiners
  • Once the office policy is designed, physician must Depict and present it: Algorithm Communicate it to the staff Engage the staff in implementing it Allow staff to ask questions about the policy
  • Physicians do not consistently recommend CRCS
  • Blood donation reminder Cholesterol test reminder Colon cancer screening reminder Diabetes test reminder Mammogram reminder Pap test reminder
  • Office staff can pull the charts of patients before their visits and identify and flag the charts of patients who should be screened with a reminder or sticker Patients who are at increased risk of CRCS, should have this fact listed on the problem list Age appropriate screening schedules can be obtained from professional, govt and insurance based industries Comorbid Disease Management Database by Mississippi Quality Improvement Organization Patient Electronic Care System by Texas Association of Community Health Centers
  • Based on USPSTF recommendations; available for adults and children; published 2006
  • , established by the American Academy of Family Physicians, is currently working with the major technology companies to promote and facilitate the use of health information technology by primary care physicians. According to the Center for Health Information Technology, the price of such systems should be reduced by 15-50%. Passive Reminders Physician must click on icon to pull up a screen containing health maintenance reminders Active Reminders Automatically appear in patients due for screening Intrusiveness ranges from pop-ups to inability to close the chart unless screening is addressed
  • An electronic patient registry is a database of all the patients in a physician&apos;s practice who share some characteristic, such as a certain condition or medication regimen. By tracking patients by a disease state like diabetes, physicians can better organize those patients&apos; care. At their most sophisticated level, registries can go much further, producing detailed reports on both individual patients and patient populations. They can provide not only reminders—to check a patient&apos;s hemoglobin A1c level, for example—but also identify patients who aren&apos;t receiving a certain level of care. As a result, patient registries are a key element in collecting and tracking how well you&apos;re meeting treatment goals. There is easy-to-install, user–friendly patient registry software available that is free or at low cost that can be utilized to track preventive screening services. One is COMMAND (Comorbid Disease Management Database) available through the Mississippi Quality Improvement Organization. COMMAND contains more than 130 disease- and test-tracking items. Physicians can add other items as desired. The COMMAND system also includes 21 reminder rules as well as American Cancer Society screening guidelines. Use of COMMAND requires registration at: http://www. iqh .org/index.php3?area=command&amp;topic=101671 . Another is Patient Electronic Care System or PECS2 which was designed by the Texas Association of Community Health Centers, a primary care organization, to support care to patients with chronic diseases or cancer. www. pecsusers .net . It can be downloaded from the Web site, which also offers training for users and instructions for technical support personnel. Registry setup requires knowledge of Microsoft Access. A program overview is online . PECS2 can print out a unique, age-appropriate encounter form for each patient. The encounter can be attached to the chart as the patient comes in to the office and used as a flowsheet. The encounter contains specific information about the patient from prior visits including graphs of key data that would otherwise be time consuming to dig out of the chart. Based on established, pre-programmed guidelines, reminders of missing preventive tests are highlighted in red. Physicians may type data directly into the system during the patient encounter or write on the encounter form in the space provided for updates.
  • . Evidence from meta-analysis indicates that audit and feedback is an effective strategy to increase screening rates. However, there is evidence that this type of feedback is more effective if it is specific to a clinician. After a requisite number of charts are reviewed, the results are tallied. The time interval for repeat audits depends on the size of the practice, the patient population, the staffing level and the type of intervention that is put into place. A baseline audit, a follow-up audit, and an additional audit after a year has gone by will provide insight about the effectiveness and endurance of changes (s) in practice. While chart audits are time consuming, collecting this information is not complicated and is essential for maintaining quality of practice. Furthermore, audits now generate continuing medical education credit toward the physician’s Recognition Award as part of the American Medical Association initiative to provide credits for performance improvement activities. Finally, the American Academy of Family Physicians has established a practice-based performance measurement project, “metric” which offers CME credits for completing practice based performance measurement projects and the American Board of Internal Medicine has similar modules that soon will incorporate colorectal cancer screening audits into their maintenance of certification programs. When feedback is provided, it is helpful to cite national or local benchmarks for preventive services. This helps providers understand the practice’s results in the context of national trends and goals. National benchmarks are available on-line from the National Committee for Quality Assurance (NCQA) at: http://www.ncqa.org/Communications/SOHC2006/SOHC_2006.pdf . [insert sample chart audit template page 131] and goals and measures with which to track them have been set forth by national collaboratives such as the Bureau of Primary care in the federal Health Resources Services Administration at: http:// www.healthdisparities.net/hdc/html/home.aspx .
  • The only thing the staff cannot do is the actual procedure and write the orders for the procedure.
  • Theory based communication is more effective generic communication
  • Stage-based communication Transtheoretical Model (Prochaska &amp; DiClemente) Individuals who are candidates for making a health behavior change do so in different stages of readiness Stage-based communication theory suggests that individuals cycle in and out of stages Therefore, individuals who previously refused screening, may re-contemplate and ultimately consider screening Physicians should readdress CRCS even in patients who previously refused
  • PowerPoint presentation

    1. 1. How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician’s 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
    2. 2. Overview <ul><li>Colorectal cancer (CRC) incidence and survival </li></ul><ul><li>Risk factors for CRC </li></ul><ul><li>Pathogenesis </li></ul><ul><li>CRC screening and surveillance guidelines </li></ul><ul><li>CRC screening rates in the U.S. </li></ul><ul><li>Increasing Colorectal Cancer Screening Rates in Practice </li></ul><ul><ul><li>Essential 1: Importance and Barriers of Physician Recommendation </li></ul></ul><ul><ul><li>Essential 2: An Office Policy </li></ul></ul><ul><ul><li>Essential 3: A Reminder System </li></ul></ul><ul><ul><li>Essential 4: An Effective Communication System </li></ul></ul><ul><li>Summary </li></ul>
    3. 3. Colorectal Cancer <ul><li>Colorectal cancer (CRC) is 2 nd leading cause of cancer deaths in U.S. </li></ul><ul><li>In 2008, an estimate 148,810 cases and 49,960 deaths are expected </li></ul><ul><li>Jemal A, Siegel R, Ward E, et al. Cancer statistics, 2008. CA Cancer J Clin 2008;58:71-a–96 </li></ul>
    4. 4. Colorectal Cancer <ul><li>Average lifetime risk of CRC approaches 6% (1 in 18) </li></ul><ul><li>Incidence is decreasing </li></ul><ul><ul><li>66.3 cases/100,000 in 1985 </li></ul></ul><ul><ul><li>49.5 cases/100,000 in 2003 </li></ul></ul><ul><li>Mortality is decreasing </li></ul>
    5. 5. Incidence by Race/Ethnicity and Sex Source: SEER. http://seer.cancer.gov/csr/1975_2004/, based on November 2006 SEER data submission, posted to the SEER web site, 2007. 39.6 42.1 American Indian/Alaska Native 35.3 49.7 Asian/Pacific Islander 44.0 60.4 White 44.6 60.8 All races/ethnicities 32.9 47.5 Hispanic Americans 55.0 72.6 African-American Female (Cases/ 100,000) Male (Cases/ 100,000) Race/Ethnicity
    6. 6. Survival 19 36 39 Proportion diagnosed (%) Metastatic Submucosa or Muscularis/ Regional Lymph Node Mucosa Extent of Disease 10 IV 68 II/III 90 I 5-year survival (%) Duke Stage
    7. 7. Survival by Race/Ethnicity <ul><li>The overall 5-year relative survival rate for 1996-2003 from 17 SEER geographic areas was 64.0% </li></ul><ul><li>Five-year relative survival rates by race and sex were: </li></ul><ul><ul><li>64.9% for white men </li></ul></ul><ul><ul><li>64.9% for white women </li></ul></ul><ul><ul><li>55.2% for black men </li></ul></ul><ul><ul><li>54.7% for black women </li></ul></ul>
    8. 8. Risk Factors <ul><li>Age </li></ul><ul><li>A personal history of colorectal cancer or polyps </li></ul><ul><li>A family history of colorectal cancer or polyps </li></ul><ul><li>A personal history of inflammatory bowel disease </li></ul><ul><li>Ashkenazi Jewish ethnicity </li></ul><ul><li>African American race </li></ul><ul><li>Diet from animal sources </li></ul><ul><li>Physical inactivity </li></ul><ul><li>Obesity </li></ul><ul><li>Smoking </li></ul><ul><li>Alcohol intake </li></ul><ul><li>Diabetes </li></ul>
    9. 9. Pathogenesis <ul><li>Most CRCs develop from adenomatous polyps </li></ul><ul><li>However, only 10% of adenomas progress to cancer </li></ul><ul><li>“ Dwell time” is approximately 10 years </li></ul><ul><li>Prolonged dwell time allows for screening and intervention </li></ul>
    10. 10.   U.S. Preventive Services Task Force Guidelines 2008 <ul><li>The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older for colorectal cancer </li></ul><ul><li>Grade A recommendation </li></ul><ul><li>http://www. ahrq . gov /clinic/3rduspstf/colorectal/ colorr . htm </li></ul>
    11. 12. 2008 ACS/USMSTF/ACR CRC Screening Guidelines <ul><li>Uniform guidelines from American Cancer Society, American College of Radiology and the U.S. Multisociety Task Force on Colorectal Cancer </li></ul><ul><ul><li>American Gastroenterological Association </li></ul></ul><ul><ul><li>American College of Gastroenterology </li></ul></ul><ul><ul><li>American Society of Gastrointestinal Endoscopists </li></ul></ul><ul><ul><li>American College of Physicians </li></ul></ul><ul><li>Originally published in 1997, updated in 2003 and 2008 </li></ul>
    12. 13. 2008 ACS/USMSTF/ACR CRC Screening Guidelines Stool DNA test (sDNA), with high sensitivity for cancer, interval uncertain Annual fecal immunochemical test (FIT) with high test sensitivity for cancer or Annual guaiac-based fecal occult blood test (gFOBT) with high test sensitivity for cancer or Tests That Primarily Detect Cancer CT colonography (CTC) every 5 years Double contrast barium enema (DCBE) every 5 years*, or Colonoscopy every 10 years, or Flexible sigmoidoscopy (FSIG) every 5 years, or Tests That Detect Adenomatous Polyps and Cancer
    13. 14. Guidelines Article and CME Quiz <ul><li>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 2008;58:130-160 </li></ul><ul><li>This article is available online at http:// CAonline . AmCancerSoc .org </li></ul><ul><li>Free CME credit for successfully completing the online quiz http://CME. AmCancerSoc .org </li></ul>
    14. 15. Comparison of Recommendations No specific prioritization of tests, though recommendations acknowledge that direct visualization techniques offer substantial benefit over fecal tests Tests are grouped into those that (1) primarily are effective at detecting cancer, and (2) those that are effective at detecting cancer and adenomatous polyps. Group 2 is preferred over group 1 due to the greater potential for prevention. Prioritization of tests No specific recommendations for age to begin testing or type of testing Detailed recommendations based on personal risk and family history Screening in high risk adults Begin screening at age 50. Routine screening between ages 76-85 is not recommended. Screening after age 85 is not recommended. Begin and age 50, and end screening at a point where curative therapy would not be offered due to life-limiting co-morbidity Age to begin and end screening in average risk adults Age to begin and end screening, and test prioritization USPSTF ACS/USMSTF/ACR Recommendation
    15. 16. 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; 56:143-159 Recommended Follow-up Polyp Characteristic 10 years Hyperplastic polyp 3 months Malignant polyp with favorable criteria 3-6 months if removed piecemeal 5 years once completely removed Large (>2cm) sessile polyp 3 years (shorter interval if >10 adenomas) > 2 adenomas, > 1 cm, high grade dysplasia, or villous 5-10 years (consider family history, findings of prior colonoscopy and patient preference) 1 or 2 tubular adenomas, <1 cm
    16. 17. Important Points About CRCS <ul><li>The digital exam is not a recommended CRCS strategy </li></ul><ul><li>A single office FOBT is not adequate screening </li></ul><ul><li>A positive FOBT should never be repeated; it should always be followed up by colonoscopy </li></ul><ul><li>FOBT is not adequate surveillance for patients with a history of adenomas </li></ul><ul><li>Success of screening stool tests depends on participation in a screening program </li></ul><ul><li>FOBTs, FITs and sDNA tests vary in sensitivity and specificity and guidelines recommend high sensitivity </li></ul><ul><ul><li>FOBT: e.g. Hemoccult SENSA </li></ul></ul><ul><ul><li>FIT: e.g. immoCARE-C and FOB advanced have higher sensitivity and specificity </li></ul></ul><ul><ul><li>sDNA: e.g. EXACT Sciences </li></ul></ul>
    17. 18. CRC Screening Rates in the U.S. <ul><li>60.8% of adults over 50 years of age have had FOBT within the previous year of lower endosocopy within the previous 10 years </li></ul><ul><ul><li>BRFSS, 2006 </li></ul></ul><ul><li>~90% of patients who have not had CRCS report that a doctor’s recommendation would motivate them to undergo CRCS </li></ul>
    18. 19. Barriers to Recommending CRCS <ul><li>All eligible patients do not consistently receive a provider recommendation for CRCS </li></ul><ul><li>Barriers are at all levels: patient, physician, system </li></ul><ul><li>Interventions are needed to address the multiple barriers to address patient, physician and system level barriers </li></ul><ul><ul><li>Guerra, CE et al. Barriers to Physician Recommendation of Colorectal Cancer Screening. J Gen Intern Med. 2007;22(12):1681-8. </li></ul></ul>
    19. 20. How to Increase Colorectal Cancer Screening Rates in Practice: A PCC Evidence-based Toolbox and Guide <ul><ul><li>Educational guide and compendium of tools to increase primary care providers’ recommendation of colorectal cancer screening </li></ul></ul><ul><ul><li>Written by </li></ul></ul><ul><ul><ul><li>Mona Sarfaty, M.D., Research Assistant Professor, Dept of Health Policy, Thomas Jefferson University </li></ul></ul></ul><ul><ul><li>Edited by </li></ul></ul><ul><ul><ul><li>Karen Peterson, Ph.D., Cancer Research and Prevention Foundation </li></ul></ul></ul><ul><ul><ul><li>Richard Wender, M.D., Professor and Chair, Dept of Family and Community Medicine, Thomas Jefferson University </li></ul></ul></ul><ul><ul><li>Published </li></ul></ul><ul><ul><ul><li>The National Colorectal Cancer Roundtable </li></ul></ul></ul><ul><ul><li>Funded by </li></ul></ul><ul><ul><ul><li>American Cancer Society and Centers for Disease Control and Prevention </li></ul></ul></ul><ul><ul><li>Available at: http://www. nccrt .org/Documents/General/ IncreaseColorectalCancerScreeningRates . pdf </li></ul></ul>
    20. 22. The Toolbox Article and CME Quiz <ul><li>Sarfaty M, Wender R. How to increase colorectal cancer screening rates in practice. Ca Cancer J Clin 2007;57:354-366 </li></ul><ul><li>This article is available online at http:// CAonline . AmCancerSoc .org </li></ul><ul><li>Free CME credit for successfully completing the online quiz http://CME. AmCancerSoc .org </li></ul>
    21. 24. Toolbox <ul><li>Your recommendation </li></ul><ul><li>Office policy </li></ul><ul><li>Reminder system </li></ul><ul><li>Communication strategies </li></ul>
    22. 25. Essential 1: Physician Recommendation <ul><li>Although many physicians recommend CRCS for their patients, few screen every eligible patient </li></ul><ul><li>Why screen for CRCS? </li></ul><ul><ul><li>Screening prevents CRC and reduces mortality </li></ul></ul><ul><ul><li>Insurance reporting requirements (HEDIS ® ) </li></ul></ul><ul><ul><li>P4P </li></ul></ul><ul><ul><li>Malpractice suits involving missed diagnosis of CRC are costly </li></ul></ul><ul><ul><li>CME </li></ul></ul>
    23. 26. Impact of Physician Recommendation <ul><li>Physician recommendation is strongly associated with patient intent to undergo CRCS and completion of CRCS </li></ul>
    24. 27. Physician Recommendation <ul><li>Requires an opportunistic/global approach </li></ul><ul><ul><li>Don’t limit efforts to “check-ups” or “physicals” </li></ul></ul><ul><li>Requires a system that doesn’t depend on the doctor alone </li></ul>
    25. 28. Essential 2: An Office Policy <ul><li>An office policy is vital because it provides a systematic approach </li></ul><ul><li>Only a systematic approach can insure that the physician’s recommendation is delivered to all patients </li></ul>
    26. 29. Essential 2: An Office Policy <ul><li>Policy takes into account </li></ul><ul><ul><li>patient risk level: average, increased, high </li></ul></ul><ul><ul><ul><li>Tools included on how to risk stratify patients </li></ul></ul></ul><ul><ul><li>local medical resources </li></ul></ul><ul><ul><ul><li>Access to CRCS tests in region; FOBT requires no facilities or personnel </li></ul></ul></ul><ul><ul><li>insurance coverage </li></ul></ul><ul><ul><ul><li>Insured? Covered? Deductible? Copay? </li></ul></ul></ul><ul><ul><li>patient preference </li></ul></ul><ul><ul><ul><li>Tools are available for determining patient adherence </li></ul></ul></ul>
    27. 30. Office Policy: Determining Patient Risk <ul><li>Have you or any members of your family had CRC? </li></ul><ul><li>Have you or any members of your family had an adenomatous polyp? </li></ul><ul><li>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) </li></ul><ul><li>Do you have a history of Crohn’s disease or ulcerative colitis (for more than 8 years)? </li></ul><ul><li>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) </li></ul>
    28. 31. Office Policy: Determining Patient Risk <ul><li>Average risk </li></ul><ul><ul><li>No personal history or first degree relatives with colorectal polyps or cancer </li></ul></ul><ul><ul><li>Options for screening </li></ul></ul><ul><ul><ul><li>Flex sig every 5 years </li></ul></ul></ul><ul><ul><ul><li>Colonoscopy every 10 years </li></ul></ul></ul><ul><ul><ul><li>Double contrast barium enema every 5 years </li></ul></ul></ul><ul><ul><ul><li>CT colonography every 5 years </li></ul></ul></ul><ul><ul><ul><li>Guaiac-based FOBT </li></ul></ul></ul><ul><ul><ul><li>FIT </li></ul></ul></ul><ul><ul><ul><li>stool DNA </li></ul></ul></ul>
    29. 32. Office Policy: Determining Patient Risk <ul><li>Increased Risk </li></ul><ul><ul><li>Has a personal or family history of colorectal polyps or CRC </li></ul></ul><ul><ul><li>Or </li></ul></ul><ul><ul><li>Has a personal history of inflammatory bowel disease for more than 8 years </li></ul></ul><ul><li>18-20% of population is at increased risk </li></ul><ul><li>Patients are not given options for screening </li></ul><ul><li>Colonoscopy is the preferred screening test </li></ul><ul><li>Screening should begin earlier (age 40 or younger) </li></ul>
    30. 33. Office Policy: Determining Patient Risk <ul><li>High Risk ( hereditary colorectal cancer syndromes) </li></ul><ul><ul><li>Hereditary non-polyposis colorectal cancer (HNPCC) </li></ul></ul><ul><ul><li>Familial adenomatous polyposis (FAP) </li></ul></ul><ul><ul><li>Attenuated FAP </li></ul></ul>
    31. 34. Office Policy: Determining Patient Risk <ul><li>High Risk </li></ul><ul><ul><li>Suspect in someone with </li></ul></ul><ul><ul><ul><li>A family history of an adenomatous polyp or CRC in relative under age 50 </li></ul></ul></ul><ul><ul><ul><li>Two or more relatives with CRC </li></ul></ul></ul><ul><ul><ul><li>Multiple colorectal adenomas (usually 10 or more) diagnosed over one or more exams </li></ul></ul></ul><ul><ul><li>Refer to local cancer genetic counselor www. nsgc .org </li></ul></ul>
    32. 35. Recommendations at a Glance Using Risk Stratification Specialty referral, colonoscopy, +/- genetic test Any age <ul><li>High Risk </li></ul><ul><ul><li>Familial syndrome or IBD>8 years </li></ul></ul>Colonoscopy Age 40 or 10 years prior to earliest diagnosis in family <ul><li>Increased Risk </li></ul><ul><ul><li>CRC/Adenoma in a 1 º relative </li></ul></ul><ul><li>Options: </li></ul><ul><ul><li>stool tests </li></ul></ul><ul><ul><li>endoscopy </li></ul></ul><ul><ul><li>radiologic studies </li></ul></ul>> Age 50 <ul><li>Average Risk </li></ul><ul><ul><li>No risk factors and No symptoms </li></ul></ul>Recommendation Age to Screen Risk Category
    33. 36. Office Policy: Determining Patient Risk Assess Risk: Personal and Family Average Risk = no personal or family hx of CRC or adenomatous polyp <50 yrs +Personal history Do Not Screen +Family History If + f/u with diagnostic Colonoscopy Adenoma or Cancer Surveillance Colonoscopy begin in childhood Adenoma CRC Or IBD Screen 10 yrs before youngest relative or age 40 Surveillance Colonoscopy Germline Syndrome Increased risk = + family or personal hx of CRC or adenomatous polyp, IBD > 8 yrs High risk = HNPCC related ca, FAP, aFAP > 50 yrs Screen
    34. 37. Insurance Coverage <ul><li>Currently, there is no federal legislation that requires insurers to cover preventive health screening </li></ul><ul><li>As of 2009, only 28 states including the District of Columbia required insurance coverage of colorectal cancer screening </li></ul><ul><ul><li>Entertainment Industry Foundation </li></ul></ul>
    35. 38. Insurance Coverage <ul><li>States that have enacted legislation that requires insurers to cover all CRCS options </li></ul><ul><ul><li>New Jersey, Maryland, Washington, DC, and Delaware, Pennsylvania (as of Jan 1, 2009) </li></ul></ul>
    36. 39. Local Medical Resources <ul><li>The screening options available to the patients in your community </li></ul><ul><ul><li>FOBT requires no facilities or personnel other than the patient and staff of the office practice </li></ul></ul><ul><ul><li>However, a positive screen requires a complete diagnostic exam by colonoscopy </li></ul></ul>
    37. 40. Patient Preference <ul><li>Video decision aid for colorectal cancer screening (CHOICE) developed by UNC-Chapel Hill investigators </li></ul><ul><ul><li>Pignone M, et al. Videotape-based decision aid for colon cancer screening. A randomized, controlled trial. Ann Intern Med, 2000;133(10):761-9. </li></ul></ul><ul><ul><ul><li>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%) </li></ul></ul></ul><ul><ul><ul><li>CRCS was completed in 36.8% of intervention and 22.6% of control (difference 14.2%, CI 3.0-25.4%) </li></ul></ul></ul><ul><ul><li>Available in VHS or DVD format for $25 from: </li></ul></ul><ul><ul><ul><li>Jennifer Griffith, Sheps Center for Health Services Research, 725 Martin Luther King Jr. Blvd, CB# 7590, Chapel Hill, NC 27599-7590 </li></ul></ul></ul><ul><li>Most physicians have a preferred screening strategy and will offer alternative strategies if patients refuse the preferred strategy </li></ul>
    38. 41. 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 Send reminder letter/postcard Place patient’s letter/postcard in next year’s ticker Patient returns FOBT w/in 1 month Record results in chart and notify pt of results No Yes Direct Contact Negative Positive Repeat in 1 yr or offer FS or CS Schedule CS
    39. 42. Office Policy <ul><li>Once an office policy is created, the office staff must be engaged to actualize it </li></ul><ul><ul><li>Present office policy to staff and offer them the opportunity to ask questions </li></ul></ul><ul><ul><li>Depict it using an algorithm </li></ul></ul><ul><ul><li>Post it </li></ul></ul><ul><ul><li>Disseminate it </li></ul></ul><ul><ul><li>Staff reminders </li></ul></ul>
    40. 43. Office Policy <ul><li>Physicians fall into the pattern that they alone must change in order to improve practice patterns </li></ul><ul><li>Physicians often fail to recognize that to effect change, the office system must be changed </li></ul><ul><ul><li>By engaging other office members, staff </li></ul></ul><ul><ul><li>By developing reminder systems and cues to action </li></ul></ul>
    41. 44. Office Policy: Sample Script <ul><li>“ Dr. Smith would like for you to be tested for CRCS. You have two choices: </li></ul><ul><li>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 </li></ul><ul><li>You may go directly to colonoscopy.” </li></ul>
    42. 45. Essential 3: An Office Reminder System <ul><li>Reminder systems are “Cues to Action” </li></ul><ul><li>Reminder systems can be directed at patients, clinicians, or both </li></ul><ul><li>Reminder systems can be simple, or complex, with the more complex systems having the greatest benefit </li></ul><ul><li>58% of physicians do not use reminder systems; 37% have a paper reminder system </li></ul>
    43. 46. Essential 3: An Office Reminder System <ul><li>Reminders for patients </li></ul><ul><ul><li>Passive </li></ul></ul><ul><ul><ul><li>Letters </li></ul></ul></ul><ul><ul><ul><li>Postcards </li></ul></ul></ul><ul><ul><ul><li>Prescriptions </li></ul></ul></ul><ul><ul><ul><li>Pamphlets </li></ul></ul></ul><ul><ul><ul><li>DVDs, videos </li></ul></ul></ul><ul><ul><ul><li>Websites </li></ul></ul></ul><ul><ul><ul><li>List of agencies that have available educational material included in Toolbox </li></ul></ul></ul><ul><ul><li>Active </li></ul></ul><ul><ul><ul><li>Telephone scripts </li></ul></ul></ul><ul><ul><ul><li>In-person </li></ul></ul></ul><ul><ul><ul><li>Electronic: For highly motivated patients: myhealthtestreminder.com </li></ul></ul></ul>
    44. 47. Patient Reminder Letters
    45. 48. Patient Reminder Postcard
    46. 49. Telephone Scripts
    47. 50. www.MyHealthTestReminder.com
    48. 51. Patient Cues to Action <ul><li>Patient educational material </li></ul><ul><ul><li>ACS posters, brochures, videos can be ordered for free via the web: cancer.org/colonmd </li></ul></ul>
    49. 52. American Cancer Society Patient Education Tools <ul><li>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. </li></ul>Available at www.cancer.org/colonmd
    50. 53. American Cancer Society Patient Education Tools <ul><li>Available at www.cancer.org/colonmd </li></ul>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.
    51. 54. Reminders for Physicians <ul><li>Behavioral </li></ul><ul><ul><li>Chart stickers </li></ul></ul><ul><ul><li>Problem lists </li></ul></ul><ul><ul><li>Screening schedules/flow sheets </li></ul></ul><ul><ul><li>Integrated summary </li></ul></ul><ul><ul><li>Paper tracking templates </li></ul></ul><ul><ul><li>Electronic reminders: EMR (Vista-Office Electronic Health Record ; AC-group/IOM requirements for EMRs) </li></ul></ul><ul><ul><li>Tracking databases: paper and electronic (COMMAND, PECS2) </li></ul></ul><ul><li>Cognitive: Audit and Feedback, Ticklers (provides national benchmarks and targets) </li></ul><ul><li>System: Staff assignments </li></ul>
    52. 55. Preventive Service Schedule http://www.ahrq.gov/ppip/timelinead.pdf
    53. 56. Flow Sheets http://www.nyc.gov/html/doh/downloads/pdf/csi/hyperkit-clin-ptvcare-flowsht.pdf http://www.aafp.org/fpm/20010200/preventivecareflowsheets.pdf
    54. 57. Sample Paper Tracking Template (“Tickler”) Comment Test result and notification date Date reminder written/Telephone contact NeedsFOBT, FS, CS, none CS referral date FS referral date FOBT result FOBT distribution date RiskA/I/H DOB Race/Ethnicity Sex Name MRN Tel #
    55. 58. Electronic Medical Records <ul><li>Vista-Office Electronic Health Record (VOE) project. More information can be obtained at: http://www. worldvista .org/ </li></ul><ul><li>Free, online rating system for electronic medical records by the AC group based on the Institute of Medicine’s requirements for a computerized patient record at: www. acgroup .org/pages/396843/index. htm </li></ul>
    56. 59. Electronic Tracking Systems <ul><li>COMORBID DISEASE MANAGEMENT DATABASE from MI Quality Improvement Organization: http://www. iqh .org/index.php3?area=command&topic=101671 </li></ul><ul><li>PATIENT ELECTRONIC CARE SYSTEM TX Assoc of Community Health Centers: www. pecsusers .net </li></ul>
    57. 60. Audit and Feedback <ul><li>Chart audit </li></ul><ul><ul><li>Review a prerequisite number of charts to document whether a certain elements are found on the chart </li></ul></ul><ul><ul><li>Produces an 18.6% improvement in screening rates </li></ul></ul><ul><ul><li>Can produce feedback for a provider or a practice </li></ul></ul><ul><ul><li>Overcomes physician recall bias or inability to self-assess the proportion of their patients that have been screened </li></ul></ul><ul><li>A repeat audit may be conducted to assess the impact of an intervention </li></ul><ul><ul><li>Time interval for repeat audit varies depending on </li></ul></ul><ul><ul><ul><li>size of the practice </li></ul></ul></ul><ul><ul><ul><li>patient population </li></ul></ul></ul><ul><ul><ul><li>staffing level </li></ul></ul></ul><ul><ul><ul><li>intervention that has been implemented </li></ul></ul></ul>
    58. 61. Chart Audits Template
    59. 62. Staff Involvement <ul><li>Key Point…..the Doctor Can’t Do It All </li></ul><ul><li>The time that patients spend with non-physician staff is underutilized </li></ul><ul><li>Standing orders can empower nurses, PA’s, intake staff, etc. to distribute materials, distribute patient surveys to be completed in the waiting room, stool blood cards, schedule appointments for colonoscopy, etc. </li></ul><ul><li>Involve staff in meetings to discuss progress in achieving office goals for improving the delivery of preventive services </li></ul>
    60. 63. Essential 4: Effective Communication <ul><li>Stage-based communication </li></ul><ul><ul><li>Based on the Transtheoretical Model (Prochaska & DiClemente) </li></ul></ul><ul><li>Individuals who are candidates for making a health behavior change do so in different stages of readiness </li></ul>
    61. 64. Education Examine patient barriers Practical how-to information Readdress screening at a later time Select a screening option and provide motivational information
    62. 65. Summary <ul><li>Every eligible patient should receive a recommendation for CRCS </li></ul><ul><li>This is most likely to occur if </li></ul><ul><ul><li>The provider or the staff provide a personal recommendation to each patient </li></ul></ul><ul><ul><li>There is an office policy to assure that each patient receives a CRCS recommendation from their provider </li></ul></ul><ul><ul><li>There are reminder systems in place targeting providers/staff and patients </li></ul></ul><ul><ul><li>There is effective, stage-based communication </li></ul></ul><ul><li>The Toolbox contains many tools to systematically recommend CRCS to each eligible patient </li></ul><ul><li>Toolbox can be accessed at: cancer.org/colonmd </li></ul>
    63. 66. Conclusion <ul><li>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. </li></ul><ul><ul><li>Daniel K. Podolsky, MD (NEJM, 7/20/00) </li></ul></ul>
    64. 67. Acknowledgement <ul><li>Funding support </li></ul><ul><ul><li>National Cancer Institute grant number K22CA133186 </li></ul></ul><ul><ul><li>Robert Wood Johnson Foundation Amos Medical Faculty Development Award </li></ul></ul><ul><li>American Cancer Society, PA division </li></ul><ul><ul><li>Diana Fox, Director, Strategic Collaborations </li></ul></ul><ul><ul><li>Mauricio Conde, Project Manager, Health Systems </li></ul></ul><ul><li>Toolbox authors, editors, developers including the CDC, ACS and NCCRT </li></ul>
    65. 68. Questions?

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