Colorectal Cancer Screening in Appalachia PA: a pilot intervention project

1. Colorectal Cancer Screening in Appalachia PA: a pilot intervention project William Curry, MD, MS Dept of Family & Community Medicine M.S.Hershey Medical Center 7 MAY 2008

2. Colorectal Cancer Screening in Appalachia PA: a pilot intervention project Mark Dignan, PhD Gene Lengerich, PhD Alan Adelman, MD, MS Brenda Kluhsman, MS Marie Graybill, BSN

3. Colorectal Cancer • Second leading cause of cancer deaths • 150,000 new cases annually • 57,000 annual deaths • In Pennsylvania • 8,200 new cases annually • Rates decreasing except in black males • 75/100,000 black males, 49/100,000 white females • 3,000 annual deaths • 26/100,000 males, 18/100,000 females

4. Pennsylvania Counties Participating Practices Hershey Medical Center

5. Burden of Disease • Union County • 130 cases per year • 20% more cases in males than expected • 32 deaths per year • 18/100,000 males, 12/100,000 females • Northumberland County • 190 cases per year • 20% more cases in males than expected • 163 deaths per year • 30/100,000 males, 19/100,000 females

6. Burden of Disease • Centre County • 271 cases per year • 7% fewer cases in males than expected • 93 deaths per year • 20/100,000 males, 14/100,000 females • Snyder • 137 cases per year • 32% more cases in females than expected • 38 deaths per year • 19/100,000 males, 17/100,000 females

7. Colorectal Cancer Screening • Screening of population is less than optimal • 53% in US • 49% in PA • 44% in Appalachian PA Only 32% of colorectal cancers are found at local stage in rural Appalachia.

8. ACS CRC Screening Guidelines • Fecal occult blood test (FOBT)* • or fecal immunochemical test (FIT)* every year** *For FOBT or FIT, the take-home multiple sample method should be used. **Colonoscopy should be done if the FOBT or FIT shows blood in the stool

9. ACS CRC Screening Guidelines • Flexible sigmoidoscopy every 5 years** **Colonoscopy should be done if sigmoidoscopy results show a polyp

10. ACS CRC Screening Guidelines • an FOBT* or FIT* every year plus flexible sigmoidoscopy every 5 years** (Of these first 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5 years is preferable.) **Colonoscopy should be done if the FOBT or FIT shows blood in the stool or sigmoidoscopy results show a polyp

11. ACS CRC Screening Guidelines • Double-contrast barium enema every 5 years** **Colonoscopy should be done if DCBE shows a polyp

12. ACS CRC Screening Guidelines • Colonoscopy every 10 years ** **If possible, polyps should be removed during the colonoscopy.

13. ACS CRC Screening Guidelines • Other alternatives • Stool DNA • CT Colonography (virtual colonoscopy)

14. Colorectal Cancer Screening • Interventions • Audit & Feedback • CME • Provider reminders • Despite these efforts, CRC screening rates remain lower than breast, cervical and prostate cancer screenings.

15. Colorectal Cancer Screening • Academic Detailing • One-on-One interaction between provider and trained educator • Interactive information presentation • Evidence for Academic Detailing? • Reduced inappropriate and over-prescribing • Tobacco cessation • Improved rural diabetes care • Increased mammography use • Decreased inappropriate PSA ordering

16. Colorectal Cancer Screening • Academic Detailing • One study that showed improved follow-up of positive FOBT1 • Mixed evidence about effectiveness with CRC screening • Physician recommendation is an important factor in patient willingness to be screened

17. Colorectal Cancer Screening • Study Design • Baseline Provider Survey • Screening practices • Follow-up practices • Referral patterns • Practice Assessment • Key informant interviews • Assess current screening practices

18. Colorectal Cancer Screening • Study Design • Medical Record Abstraction • Patients 50 and older • Seen in practice in the previous 2 months • Estimate number of patients offered screening and who had screening completed • Exclusion criteria • History of colon cancer, polyps • Symptoms of colon cancer • Acute visit

19. Colorectal Cancer Screening • Study Design • Academic Detailing • Visit 1 – Lunch and Learn • Visit 2 & 3 – Tailored intervention based on practice assessment and Visit 1 • Visit 4 – Follow-up and final physician assessment • Post-intervention Provider survey • Post-intervention medical record abstraction

20. Colorectal Cancer Screening • Study Design • Post-intervention Key-informant interviews • Qualitative assessment

21. Colorectal Cancer Screening • Data Collection with caBIG • Working with Univ of Minnesota, capturing chart abstraction via web to NCI database • caBIG™ Goal: To create a virtual web of interconnected data, individuals, and organizations redefining how research is conducted, care is provided, and patients/ participants interact with the biomedical research enterprise • CDEs - Completed • Output is an Excel datafile to research team

27. Results • Four practices • Initial 3 visits completed • Initial provider surveys collected • Record review • 280 patient records abstracted • 105 entered into CaBIG • 64 completed • Initial Datafile returned from CaBIG • 45% screening rate (preliminary) • Patient factors • Physician/system factors

28. Lunch and Learn Lessons • Providers and staff engaged • Each practice has different outlook • Wall Charts • Handouts • Engaging staff • Story telling • Want information on their performance

29. Acknowledgements • National Cancer Institute • ACTION Health • The four practice sites • Research Team

30. References • Myers RE , Turner B , Weinberg D , et al. Impact of a physician-oriented intervention on follow-up in colorectal cancer screening Preventive Medicine, 2004 ;38(4):375-381 • Soumerai SB, McLaughlin TJ, Gurwitz JH, Guadagnoli E, Hauptman PJ, Borbas C, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA 1998;279(17):1358-63.

31. References • Centers for Medicare and Medicaid Services. Colon Cancer Screening. 2008. Available at: http://www.cms.hhs.gov/ColorectalCancerScreening. Accessed January 31, 2008. • American Cancer Society. Detailed Guide: Colon and Rectum Cancer. 2008. Available at: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=10.

32. Colorectal Cancer Screening Questions?