Technical Assistance Webinar
Provider/Client Reminder and Recall Systems to Increase Colon Cancer Screening Presented by: Thomas Rich, MPH Health Systems Manager American Cancer Society
Faculty Disclosure Statement • As a provider accredited by ACCME, ANCC, and ACPE, the IHS Clinical Support Center must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course directors/coordinators, planning committee members, faculty, reviewers and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty will also disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. All those who are in a position to control the content of this educational activity have completed the disclosure process and have indicated that they do not have any significant financial relationships or affiliations with any manufacturers or commercial products to disclose.
Faculty Disclosure Statement Funding for this webinar was made possible by the Centers for • Disease Control and Prevention DP17-1701, Cancer Prevention and Control Programs for State, Territorial, and Tribal Programs awarded to the Inter-Tribal Council of Michigan in support of the Three Fires Cancer Consortium. Webinar contents do not necessarily represent the official views of the Centers for Disease Control and Prevention. No commercial interest support was used to fund this activity. •
Accreditation The Indian health Service (IHS) Clinical Support Center is • accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The IHS Clinical Support Center designates this live activity for a • maximum of 1 ¾ AMA PRA Category 1 Credits™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity. The Indian Health Service Clinical Support Center is accredited • with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is designated 1.75 contact hours for nurses. •
CE Evaluation and Certificate Continuing Education guidelines require that the attendance of • all who participate be properly documented. To obtain a certificate of continuing education, you must be • registered for the course, participate in the webinar in its entirety and submit a completed post-webinar survey. The post-webinar survey will be emailed to you after the • completion of the course. Certificates will be mailed to participants within four weeks by • the Indian Health Service Clinical Support Center.
Learning Objectives/Outcomes By the end of this webinar, participants will be able to: 1. Examine the current colon cancer disparities among the American Indian population of Michigan. 2. Apply current clinical guidelines to screen and detect colon cancer. 3. Implement a system to alert clinicians and inform patients who are due or overdue for screening.
Provider Reminder and Recall Systems Tom Rich MPH, American Cancer Society, NC Region February 21, 2018
Objectives • Recognize the burden of CRC on the NA population. • Understand the importance of developing and following an overall plan. • Calculate current screening rates • Design a clinic screening strategy • Recognize the importance of patient choice • Develop dissemination strategies to improve use of materials (e.g. build into EHR) • Identify and address barriers to screening • Understand the power of a provider recommendation • Assess the effectiveness of the plan
AI/AN Cancer Burden Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/
CRC Screening Among IHS User Population (GPRA) Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/
RESULTS Slide taken from NCCRT presentation: Colorectal Cancer Screening In American Indian & Alaska Native Communities – November 28, 2017, NCCRT, http://nccrt.org/resource-center/
Importance of Developing an Overall Plan
http://nccrt.org/wp-content/uploads/0305.60-Colorectal-Cancer-Manual_FULFILL.pdf
#1: Make a Recommendation Assess a patient’s risk status and receptivity to screening. Determine screening messages you and your staff will share with patients.
# #2: Develop a Screening Policy Create a standard course of action for screenings, document it, and share it. Ensure patient education & follow-up
#3: Be Persistent with Reminders Determine how your practice will notify patient and physician when screening and follow up is due . Ensure that your system tracks test results and uses reminder prompts for patients and providers.
#4: Measure Practice Progress Discuss how your screening system is working during regular staff meetings and make adjustments as needed. Have staff conduct a screening audit.
The Intervention • Reminders inform health care providers it is time for a client’s cancer screening test (called a “reminder”) or that the client is overdue for screening (called a “recall”). • The Community Preventive Services Task Force (CPSTF) recommends provider reminder systems based on strong evidence of their effectiveness in increasing colorectal cancer screening by fecal occult blood test (FOBT) and sufficient evidence of their effectiveness in increasing colorectal cancer screening by flexible sigmoidoscopy.
Considerations •Link to other preventive services. •Clinic may not have the technology or manpower. •Only good for those you see. •Must conform to the community.
USPSTF CRC Screening Guidelines (June 2016)
Where to Start • Patients who appear for regular check-ups; • Patients who come for other preventive services; • Patients who had been screened before; • Patients who receive regular care for chronic conditions; • Patients who come in only when they have a problem; • Patients who are part of your practice, but almost never come in.
Patient Preference • Diverse sample of 323 adults given detailed side-by-side description of FOBT and colonoscopy (DeBourcy et al. 2007) • 53% preferred FOBT • Almost half felt very strongly about their preference • 212 patients at 4 health centers rated different screening options with different attributes (Hawley et al. 2008) • 31% preferred FOBT • 37% preferred colonoscopy • Nationally representative sample of 2068 VA patients given brief descriptions of each screening mode (Powell et al. 2009) • 29% preferred FOBT • 37% preferred colonoscopy
Patient Preference Inadomi, Arch Intern Med 2012
Colonoscopy Limitations Frequently referred to as “gold Also: standard,” but evidence shows: • Greater patient requirements for successful completion • Colonoscopy misses ~10% of • Requires bowel prep and significant lesions in expert facility visit, pre-procedure settings visit, chaperone for post- • More costly on a one-time basis procedure • Access • Higher potential for patient injury than other tests • Limited by insurance status, local resources • Wide variation in quality (when data are captured and available) • Patient preference
Types of Stool Tests Tests that detect blood (Fecal Occult Blood Tests) • Two types (but multiple brands, variable performance) • Guaiac-based FOBT • Immunochemical (FIT) Tests that detect aberrant DNA • One test (Cologuard) available in U.S. • Combines DNA mutation test with FIT • Recently added to USPSTF screening guideline (June 2016) * Stool tests are only appropriate for average risk patients
Clinical Screening Strategy
Key Questions • What are you doing now to make sure eligible patients are being screened for CRC? • Are you using evidence-based interventions to screen patients for CRC? • What has worked and not worked in the past when you have tried to increase CRC screenings? • What has worked and not worked in the past when you tried to increase screening for other diseases such as breast cancer, cervical cancer, or diabetes? Are there lessons learned that could be applied to CRC screening?
Creating a Plan Creating a Plan
Sample Policy/Procedure
Standing Orders Advantages • Easy to implement. Disadvantages • Only reaches patients already contacting the health care system. • No opportunity for patient input.
Chart Reminders Advantages • Inexpensive and efficient (reviewing health maintenance inventories with patients on average requires less than 4 minutes with the patients and quickly becomes part of the physician’s routine). Disadvantages • Only reaches patients with scheduled office visits and chart reminders may be more effective in managed care organizations as compared with fee-for-service practices since cost to the patient may be a barrier to vaccination in a fee-for-service practice.
Barriers
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