Increasing Colorectal Cancer Screening through an Academic Detailing Intervention

1. Increasing Colorectal Cancer Screening through an Academic Detailing Intervention ACCN Research Roundtable October 8, 2008 Mark Dignan, Nancy Schoenberg, Kevin Pearce, Brent Shelton, Cheri Tolle Supported by the National Cancer Institute # CA113932

2. Colorectal cancer in Kentucky

3. Colorectal cancer in Kentucky (SEER)

4. Appalachian Kentucky Compared with the rest of the United States, Appalachia is • medically underserved • economically distressed • disproportionately burdened with cancer

5. Education & Employment

6. Project Goal To increase colorectal cancer screening provided by primary care practices in Appalachian Kentucky

7. Methods Phase 1: Formative Research Phase 2: Intervention Trial

8. Phase I: Formative Research • Provider surveyto establish contact with practices and identify general characteristics • Focus groupsto obtain qualitative information and fill gaps in survey data

9. Phase II: Intervention Trial Participants: Primary care practices in Appalachian Kentucky • Family Medicine • General Internal Medicine • General Practice Outcome: Increase Screening (FOBT, FS, DCBE, Colonoscopy)

10. Academic Detailing Intervention • Academic detailing involves providing education where physicians are instructed through personal contact with an individual or group focused on a specific topic • Well-known as a method for pharmaceutical sales, this approach has been found to be a novel and effective way to reach busy physicians to provide medical education.

11. Objectives guiding Implementation • Implement an educational intervention through academic detailing • Evaluate the effectiveness of the intervention at 6 and 18 month post intervention data collection. • 6 – month data to assess efficacy • 18- month data to assess sustainability

12. Intervention Planning • Need for partnerships • Identification of primary care practices • Desire for a community-based approach to intervention delivery • Project management issues • Travel and logistics • Communication with practices • Area Health Education Centers

13. Why Area Health Education Centers? • Regional agencies in Kentucky • Provide structure for continuing medical education • Provide for opportunities for health professional training outside academic institutions • They have capacity for outreach to rural health care providers • Education is key to their mission • Research participation is a new activity for them

14. Study Areas – Three AHEC Regions

15. Research Design

16. Procedures • An academic detailer in each AHEC region recruited primary care practices. • A physician in each practice completed a provider interview. • The academic detailer delivered the intervention – the intervention modules focused on • Efficacy of colorectal cancer screening • Reimbursement • Patient counseling • Practice management. • Project staff conducted medical record reviews in each practice

17. Evaluation Plan – Process and Q/C • Process • Monitoring data collection and intervention delivery • Quality control • Post intervention assessment of veracity of reports

18. Evaluation Plan - Outcomes • Outcomes • Quantitative – Proportion of patients ‘screened’ in practices • Qualitative – Key informant interviews to assess intervention and project experience • Health care providers • Office staff • Intervention staff

19. Results To Date • Recruitment – All 66 practices recruited • Implementation – Intervention delivered in all 33 practices • Screening data • Baseline – All practices complete • 6-month – 28 practices complete

20. Results - FOBT

21. Results – Flex Sig

22. Results - Colonoscopy

23. Results – Barium Enema

24. Results – All Screening modes

25. Screening Recommended and Completed by Study Group, BASELINE

26. Findings – To date • Screening rates are low. • Colonoscopy appears to be the screening test that is recommended most commonly in this population. • Rates for fecal occult blood testing are low which may indicate a lack of enthusiasm for this method. • Rates for flexible sigmoidoscopy are so small as to be negligible, suggesting that primary health care providers have largely ceased providing this service.

27. Next Steps • Complete delayed group intervention delivery • Complete post-intervention data collection • Analyze data and investigate stopping rule • Schedule 18 month follow-up data collection • Develop application to fund dissemination study

28. Dissemination study (Effectiveness) Tentative Research Questions 1. Can an academic detailing intervention designed to increase colorectal cancer screening in rural primary care practices be disseminated through the AHEC system? 2. . Are there factors that facilitate or inhibit the diffusion of innovation process through the AHEC system?

29. Collaborators Northeastern AHEC Kayla Rose Caudill, Jaime Southern AHEC • Dwaine Harris • Shirley Balman Southeastern AHEC • Michael Gayheart • Gwen Whitaker

30. UK Collaborators Northeastern AHEC Kayla Rose Caudill, J aime UK PRC Cheri Tolle Mark Dignan Nikki Lawhorn Southern AHEC • Dwaine Harris • Shirley Balman Southeastern AHEC • Michael Gayheart • Gwen Whitaker

31. Module One Colorectal Screening: Does it Work? Colorectal Cancer… Preventable. Treatable. Beatable.

32. Learning Objectives • • Cite incidence and mortality rates for • colorectal cancer in Kentucky by Area • Development Districts • • Discuss the effectiveness of four • colorectal cancer screening methods • • Identify age and frequency guidelines • for colorectal cancer screening

33. Colorectal cancer is the second leadingcause of cancer-related death in the US and Kentucky

34. Colorectal Cancer Incidence Rates by County

35. Colorectal Cancer Mortality Rates by County

36. Colorectal Cancer Diagnoses 2004 Area Development Districts

37. Colorectal Cancer Deaths 2004 Area Development Districts

38. Screening for Colorectal Cancer is Effective

39. Colorectal Cancer Screening Evidence • • Fecal Occult Blood Test (FOBT)• 33% mortality reduction, 20% incidence reduction (annual testing, three cards at home) • • Sigmoidoscopy • • 59% mortality reduction within reach of scope • • Colonoscopy • • 40-60% incidence reduction • • Double Contrast Barium Enema (DCBE) • • Still being evaluated as screening tool

40. Everyone 50 years and older should receive regular screening for colorectal cancer High risk individuals may need to begin screening earlier

41. Colorectal Cancer Screening Guidelines •FOBT yearly •Sigmoidoscopy 5 years •Colonoscopy 10 years •DCBE 5 years

42. Summary • Colorectal cancer is the second leading • cause of cancer-related deaths in the US • and Kentucky • Colorectal cancer incidence rates tend to be • higher in eastern Kentucky • Current screening methods are FOBT, • sigmoidoscopy, colonoscopy, and DCBE • All asymptomatic patients age 50 and over • should be referred for screening • FOBT = annually; Sigmoidoscopy = 5 years; • Colonoscopy = 10 years; DCBE = 5 years