CRC Screening: Projects in Department of Family Medicine, University of Iowa

1. CRC Screening: Projects in Department of Family Medicine, University of Iowa Barcey T. Levy, PhD, MD Cancer Summit October 17, 2008

2. Background • Colorectal cancer is the 2nd leading cause of cancer-related death. • 75 – 90% of cases can be prevented or cured if caught early. • Practice guidelines consistently confirm average risk patients should begin CRC screening at 50 years with repeat at intervals appropriate to the test. • 75% of those diagnosed with CRC have no symptoms or family history. • Over half of Americans age 50+ have not been screened for CRC.

3. Projects • Agency for Healthcare Research and Quality sponsored study to examine CRC screening among rural Iowans. • Factors predicting screening • Doctor’s reasons for not screening specific patients • IDPH study to encourage uninsured or underinsured individuals to be screened • Newly funded ACS funded study

4. Iowa Research Network

5. AHRQ Study Design • Mixed-methods • 57 of 240 IRENE (Iowa Research Network) physicians expressed interest in a study to examine CRC screening in their practice. • A stratified random sample of 16 family physicians in separate practices were enrolled. • Within each practice, a random sample of 60 patients per physician aged 55 – 80 years invited by mail.

6. Instruments Quantitative • Patient: 8-page mailed survey about past CRC screening and attitudes toward screenings. • Medical record review: Documentation of past CRC screening recommendations, tests completed, reasons for test, and medical conditions. • Physician: 3-page mailed survey about attitudes toward CRC screening, systems to facilitate screening, and which tests they personally perform. Qualitative • Physicians dictated their reasons for screening or not screening 3 patients in each category for CRC, as well as their general approach to screening.

7. Main Outcome: CRC Testing Any of the following: • Take home hemoccult x 3 at least 5 times < 5.5 years. (Guidelines specify annual testing.) • Flexible sigmoidoscopy < 5.5 years. • Colonoscopy < 10.5 years. • Barium enema < 5.5 years. Consistent with ACS/American Gastroenterological Association/USPSTF guidelines

8. Qualitative Analysis To assess physicians’ reasons for not screening or for screening specific patients for CRC

9. Results (Quantitative) • 511 patients returned survey and had medical record review conducted in 16 practices (53% of original sample). • Response rate of 30% to 80% for patients of a given physician (18 to 48 patients per physician).

10. Iowa IRENE CRC Practices

11. Patient Demographics (n=511) • Mean age of 68.1 yrs • 99% white • 93% lived in rural counties • 81% married • 80% total household income below $60,000 • 62% government insurance • 26% working full-time • 23% college graduate or higher

12. Physician Characteristics (n=16) • Age: 53 years (range 43 – 69 years) • Length of time in practice: 21.6 years • Partners: 5.5 • Town size/median population: 6,112 • All are board-certified family physicians

13. Patient Self-report Has your doctor ever recommended a CRC test? • 76% said yes. Did you complete the recommended test? • 70% said they had. Has your doctor recommended a CRC screening test? • 55% said yes.

14. Chart Review 46% overall were up to date with CRC Screening. • 41% had colonoscopy < 10.5 years. • 5% had flexible sigmoidoscopy <5.5 years. • 6% had barium enema < 5.5 years. • 1% had annual hemoccult x 3 for 5.5 years. Of those up to date: • 39% received asymptomatic screening • 61% received diagnostic testing

15. Patients with CRC tests: current and true screening

16. Physician Predictors: Univariate ORs * Not considered in multivariate model

17. Physician recommendation is VERY important Among patients who received asymptomatic testing, 90% recalled their physician recommending this, compared with only 37% of those not up to date with testing.

18. Predictors of CRC testing up to date (multivariable) Variable mult. OR (95% CI) mult. p-value Government insurance 1.6 (1.2, 2.3) .004 > 1 annual exam visit 2.4 (1.4, 4.1) .002 Family history of CRC 3.1 (1.6, 5.8) <.001 Number of medical conditions 1.2 (1.1, 1.3) <.001 Importance to patient 2.6 (1.5, 4.5) .001 Satisfied with dr’s discussions of screening importance 3.3 (2.2, 4.8) <.001 Physician able to do FS 2.3 (1.6, 3.4) <.001 Physician feels they follow ACS screening guidelines 1.7 (1.2, 2.5) .005

19. Qualitative Study • 15/16 physicians (94%) telephoned in responses to a structured set of questions • Three patients of each physician from the larger study were randomly chosen who were not up to date with CRC guidelines • We asked physicians to tell us whether screening was discussed with the patient and what factors led to this patient not being screened for CRC

20. Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines(based on 40 patients) When CRC screening was not discussed: 20 patients • Lack of opportunity to discuss screening • Patients came in only for acute visits or problems • Patients came in sporadically or saw other providers for health maintenance care • No tracking system • Not enough time during appointments • Physician forgetfulness • Assessment that cost or lack of insurance would be prohibitive to patient • Patient had life issues or other health problems that distracted from screening • Expected patient refusal or lack of interest

21. Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines When CRC screening was discussed, but patient declined: 20 patients • Cost of screening tests • Lack of interest in screening • Patient autonomy • Patients had life issues or other health problems • Fear of screening test procedure • No symptoms or family history of CRC

22. Example Quotes: Factors Preventing Screening Discussions Patient’s focus on illness and symptoms “[The patient] has always been a very acute care oriented patient and probably has only come to see me on maybe 3 occasions over the past 15 years. Hence, again, his inconsistent seeking of health care has led to failure to screen for colorectal cancer.” Lack of tracking system led to forgetfulness: “She generally presents for acute care, and honestly with…the intermittent few times I see her, I forgot to even bring up colorectal cancer screening. And so, I would put her down as an office system issue with no reminder tracking system.” Lack of time: “I think the reason that he wasn’t screened, and probably several other [patients], was just a matter of time in not getting everything done.”

23. Example Quotes: Physician’s Assessment that Patient Would Decline “Anyway, the bottom line is he doesn’t have any insurance and he doesn’t have any money, and he’s a truck driver kinda just barely scraping by.” “So, basically, we’re distracted and he’s distracted by other [health ] problems. I don’t believe I’ve ever really pushed getting colon cancer screening.”

24. Example Quotes: Factors Leading to Specific Patients Declining Screening: Cost “[She] won’t do it because she doesn’t have the finances and doesn’t have insurance [that] will pay for the procedure.” Patient Lack of Interest “I think basically he’s just your proverbial older rural Iowa retired farmer guy who kind of likes to leave things well enough alone…and so I’m not too surprised if he doesn’t do everything that I tell him to do.” Confounding Factors “Her husband had recently died. She had a depressive reaction associated with it and did not think it was necessary to do the screening.” Patient Fears “She was not screened and…is resistant to have the colonoscopy due to the fear of the procedure.” Low Perceived Risk “[He] has not been screened because he has no interest in…having a colonoscopy done unless he was having some symptoms that would require it.”

25. Discussion • Less than half of patients were up to date with CRC screening by current guidelines. • Of those up to date, over half (61%) received diagnostic testing (testing in response to symptoms). • Physicians can substantially influence patients. • Only 55% patients recalled their doctor recommended screening. • Colonoscopy was the most prevalent method of screening. • Physician-specific rates of pts being screened appropriately varied widely (5% to 75%)

26. Physician-identified Factors That Influence CRC Screening • For half of patients not up to date, discussion about screening did not take place. • Many CRC tests were ordered for patients with symptoms or with increased risk.

27. Implications • Physician discussion and recommendation is key! • Medical insurance should cover health maintenance exams. Medicare does not currently cover health maintenance exams. Discussion of CRC screening options and rationale takes time. • Quality measures should take into account the importance of physician education and adequate discussion for the patient and should reward physicians for incorporating these into practice. • Reported rates should exclude patients who have declined screening after a documented discussion.

28. Interventions to improve CRC screening rates are needed! • Develop successful patient and physician education programs about the importance of screening (before symptoms occur). • Identify effective tracking and reminder systems. • Identify effective elements of physician recommendation and discussion for successful screening.

29. Conclusions • Many factors interfere with CRC screening discussions. • Most patients who were up to date received diagnostic as opposed to asymptomatic testing. • Interventions will likely require health system changes, and education aimed at both the physician and the patient.

30. IDPH contract • Goal was to screen asymptomatic individuals who were uninsured or underinsured • Used a fecal immunochemical test (FIT) kit that required a small sample from a single stool

31. Potential Individuals Eligible for Screening • Electronically identified individuals attending UIHC clinics in Family Medicine/Internal Medicine who were “underinsured” and who had not been screened for CRC in appropriate interval. • Approached people in person or by mail in clinic settings for low-income in Johnson County (Free Medical Clinic and UIHC clinics) • Hung posters about this screening program in various venues in Johnson County

32. Patient Recruitment • 1,882 patients identified by IT as having no or low insurance and mailed information about the study including a cover letter, consent forms, an eligibility form and a return envelope • 112 individuals received a mailing through the Iowa City Free Medical Clinic • 92 approached in person in primary care clinic • 41 approached in family & internal med clinics • Eligible if Iowa resident, no coverage for CRC screening, and no CRC screening in the accepted intervals

33. Patient recruitment and follow-up • 94 half-days spent on face-to-face recruiting • Preparing mailings and clinic packets throughout the 6 months involved ~ 3 hours per day • 1 hour each day to test specimens, send notice to participant of results, log in database, and notify GI clinic • Medical student donated 24 hours calling patients • Follow-up letters and phone calls all took time

34. FIT results • A total of 298 FIT kits have been handed out or mailed, with a total of 235 kits returned (79%). • Of the 235 kits returned, 186 tested negative (79%) and 49 (20%) tested positive. • Each individual with a positive result was telephoned and their result explained to them. The Division of Gastroenterology at the University of Iowa is conducting colonoscopies on those with positive results.

35. Colonoscopy Results • 16 colonoscopies completed to date • 9/16 had at least one biopsy due to polyps • 5 had at least one tubular adenoma • 4 had only hyperplastic polyps • 2 had polyps of both types • One individual had an incomplete colonoscopy due to pronounced narrowing of the colon; f/u barium enema was normal • No complications from any of the colonoscopies • Remaining colonoscopies are in the process of being scheduled

36. How could program be better? • 95% felt that the test was not difficult to complete • “Doesn’t need improving, easier test than colonoscopy” • “Great program, thanks so much” • “The communication could be better” • “It was ok for me as is. The fact that this is a free test to help save lives is highly commendable.” • “Not sure, but I was thankful to be involved with the program, my best friend passed away from colon cancer.”

37. Conclusions from IDPH • Patients in need of screening had a 75% return rate for the FIT kits • People were generally quite satisfied with the program • The positive rate was much higher than anticipated leading to more colonoscopies than originally anticipated. • Still completing colonoscopies.

38. ACS study • Funded 7/1/08 • Will do an intervention study in 15 rural family physician offices to encourage individuals who have never been screened or who are due for screening to be tested for CRC • We will randomize patients within offices to one of four interventions

40. Any questions?