Anna P. Schenck, PhD, MSPH Carrie Klabunde, PhD Renee Taylor, MPH Nelson Gunter, MD, MPH

1. Using survey data to plan a program to increase colorectal cancer screening the Medicare population American Public Health Association 2002 Meeting Anna P. Schenck, PhD, MSPH Carrie Klabunde, PhD Renee Taylor, MPH Nelson Gunter, MD, MPH

2. Carolina Medical Review Sharon Eubanks, RN Aunyika Tocharoen, PhD Nelson Gunter, MD, MPH Medical Review of NC Renee Taylor, MPH Louise Henderson, MSPH Sue Hunter, MPH Leslie Hill Lee Hurley Robin Brown Anna Schenck, PhD Collaborators Centers for Medicare & Medicaid Services Jim Coan Catherine Gordon National Cancer Institute Carrie Klabunde, PhD

3. Who we are • Medical Review of North Carolina and Carolina Medical Review (in South Carolina) are Quality Improvement Organizations • Contract with Centers for Medicare & Medicaid Services to assure quality of care for Medicare consumers in each state

4. Background • Colorectal cancer is the second most deadly cancer in the US • Early detection and treatment are the best defenses against colorectal cancer • Use of screening tests is low • Medicare introduced screening benefit in 1998 for enrollees age 50 and older

5. Medicare Coverage of Screening Tests • FOBT • yearly • Sigmoidoscopy • every 48 months • Colonoscopy • every 24 months for high risk • every 10 years for average risk (as of 7/1/2001) • Barium Enema • as alternative to sigmoidoscopy or colonoscopy

6. Project Overview • Center for Medicare & Medicaid Services awarded 2-year project to NC and SC • calculate national and state screening rates • develop and pilot interventions • NCI interest resulted in collaboration • focus groups • baselineand evaluation telephone survey

7. Baseline Survey • Design • each state selected intervention and comparison counties • SC (mixture of rural and urban) • NC (primarily urban) • Methodology • telephone survey conducted before the intervention • age 50 - 80, non-HMO, African American or White • randomly selected Medicare enrollees in NC and SC intervention and control counties

8. What did we want to know? • Beliefs, knowledge and attitudes • risk factors • screening • Medicare coverage • Behaviors • which screening tests are being done • are guidelines being followed • Barriers • why are some not screened

9. Response • 2004 completed interviews • NC = 1003 • SC = 1001 • Overall response rate 69% • NC = 67% • SC = 70% • Differential response among subgroups indicated a need for weighted analyses

10. Characteristics of Sample • Sex • Male = 43% • Race • White = 77% • African American = 23% • Education • Less than High School = 25% • High School or Equivalent = 36% • Post High School = 32%

11. Understanding of Risk of Colorectal Cancer

12. Physician Recommendation for Colorectal Cancer Test

13. Ever Had Any Colorectal Cancer Test

14. Had Test According to Guidelines

15. Potential Barriers to Colorectal Cancer Testing

16. Women those who had mammogram in past year were more likely to have had colorectal cancer test those who had pap smear in last 3 years were more likely to have had a colorectal cancer test Men those who had PSA test in last year were more likely to have had a colorectal cancer test Use of other preventive services

17. Reasons for no test • Among those who had not had the test according to guidelines, two reasons most often listed: • “I didn’t think it was needed”12% - 18% (depending on test) • “My doctor didn’t order the test”77% - 82% (depending on the test)

18. Where do Medicare consumers get most useful health information ?

19. What the survey told us about consumers • Plenty of room for improvement • Lack of knowledge about risk factors and coverage • Those who use other preventive services were more likely to have been tested • Written information such as health pamphlets and booklets may be useful with this population • Media are less influential with this population

20. What the survey told us about physicians • Patients expect their doctor to order the test • Doctors may need to convince some patients of the importance of screening • Physician recommendation strong influence of whether the patient gets a test

21. Intervention Implications • Consumer interventions need to address: • belief in importance and efficacy of screening • lack of knowledge about risk factors and Medicare coverage • use of other preventive services • Provider interventions needed to address: • physician recommendation • tools to convince patients

22. Consumer Intervention: CDC Screen for Life Mailing • CDC Screen for Life information was sent to beneficiaries selected in two ways: • randomly selected • selected from persons with regular preventive service use • Total of 16,400 packets were mailed • 3,000 to randomly selected (NC only) • 5,600 to those with regular preventive service use • 7,800 to targeted aged groups (SC only)

23. CDC patient fact sheet

25. Consumer Intervention: Birthday Card • Beneficiaries in intervention counties who turned 65 were sent this card on their birthday • Total of 3,514 cards were sent • NC only

26. Birthday card sent to NC beneficiaries

27. Consumer Intervention: NCI Cancer Information Service Postcards • Beneficiaries randomly selected • First card did not generate many calls so the card was redesigned. NC sent 2 versions of a revised card while SC continued to send original cards • Total of 15,300 cards mailed over 6 months period in both NC and SC

28. Revised CIS Postcard - Positive

30. Physician Interventions • Provider teleconferences • 2 teleconferences • promotion of the new screening benefit and project • how to increase screening in the office and get paid for it • Mailing of physician postcards (SC only) • Distribution of FOBT kits through physician offices (SC only) • Provider Toolkit

31. Screen for Life Toolkit • Promoted through mailings, web-site, regional meetings, fast-fax through NC Medical Society • Ordered via fax-back forms, mail-in forms, web-site • Contained screening guidelines, billing instructions, state testing data and office-based tools • Total of 380 toolkits were distributed • approximately 20% of MDs in target area

32. Patient Assessment used as part of a reminder system

33. Chart Sticker from Physician Tool Kitused as part of a reminder system

34. Stage-of-change based patient education brochures (used with video)

35. Post Card for Physicians to send to Patients

36. For more information, contact: Anna Schenck Medical Review of NC5625 Dillard DriveCary, NC 27511919 851-2955ncpro.aschenck@sdps.org Check out Medicare Statistics on our website: www.mrnc.org/ncmed or www.mrnc.org/crcreport