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Identifying optimal approaches to scale up colorectal cancer screening: An overview of CDCs learning laboratory Florence K.L. Tangka, PhD Senior Health Economist 11 th Annual Conference on the Science of Dissemination and Implementation in

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Florence K.L. Tangka, PhD Senior Health Economist

Identifying optimal approaches to scale up colorectal cancer screening: An overview of CDC’s learning laboratory

11th Annual Conference on the Science of Dissemination and Implementation in Health December 3, 2018

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Acknowledgements

  • Florence K.L. Tangka1, Sujha Subramanian2, Sonja Hoover2, Christen Lara3, Casey

Eastman4, Becky Glaze5, Mary Ellen Conn6, Amy DeGroff1, Faye L. Wong1, Lisa C. Richardson1.Identifying Optimal Approaches to Scale Up Colorectal Cancer Screening: An Overview of the Centers for Disease Control and Prevention (CDC)’s Learning Laboratory. Cancer Causes and Control (In Press)

1Centers for Disease Control and Prevention 2RTI International 3Colorado Department of Public Health & Environment 4Washington State Department of Health 5HealthPoint 6West Virginia University

  • CDC’s Colorectal Cancer Control Program Evaluation Working Group (CRCCP)
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Agenda

  • Background
  • Colorectal Cancer
  • CDC’s Colorectal Cancer Control Program (CRCCP)
  • CRCCP Evaluation & CDC’s CRCCP Learning Laboratory
  • Findings
  • Data Use and Dissemination of Findings
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Background: Colorectal Cancer & CDC’s Colorectal Cancer Control Program

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  • 2nd leading cause of cancer death in the US
  • Screening for colorectal cancer (CRC) is beneficial
  • Can find abnormal growth in the colon or rectum
  • Can find cancer at a curable stage
  • USPSFT recommends screening average-risk adult age

50-75

  • In 2016, only 67.3% of adults were up-to-date with CRC

screening

  • Unlikely screened groups include: men, Hispanics,

American Indians, Alaska Natives, people aged 50 to 64 years, city dwellers, and those with lower education and income levels

  • Lower screening rates directly contribute to higher

death rates from CRC.

Colorectal Cancer

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Colorectal Cancer Control Program (CRCCP)

  • Implementing evidence-based

interventions described in the Guide to Community Preventive Services (the Community Guide) and

  • ther supporting strategies in

partnership with health systems.

  • Providing screening and follow-up

services for a limited number of program-eligible people.

1: The Guide to Community Preventive Services, https://www.thecommunityguide.org/topic/cancer

Purpose: to increase colorectal cancer screening rates among low-income, high-need populations by:

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The CRCCP has evolved over time.

2005 -2009

CRCCP Demonstration Project

  • 5 grantees

(state, county, city, and university)

  • Focus:

Delivery of colorectal cancer (CRC) screening and diagnostic services

  • Results:

Viable strategy1

2009-2015

CRCCP DP09-903 & 14-1414

  • 29 grantees

(states, tribes, and territories)

  • Focus:
  • 1. Delivery of CRC screening and

diagnostic services

  • 2. CRC screening promotion for

underserved populations

  • Results:

Limited reach2

2015-2020

CRCCP DP15-1502

  • 30 grantees

(states, universities, and tribe)

  • Focus:

1. Health systems change3 2. Delivery of CRC screening and diagnostic services (6 grantees

  • nly)

1 Cancer, Supplement 119(15), August 1, 2013; 2Monograph in development; 3Satsangi A, DeGroff A.

Planning a National-level Outcome Evaluation of the Colorectal Cancer Control Program. J Ga Public Health Assoc 2016: Supplement to Vol 6(2). https://doi.org/10.21633/jgpha.6.2s16

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The CRCCP consists of two distinct components:

Component 1

All 30 Grantees

Partner with health systems to implement evidence-based interventions (EBIs) and supportive activities (SAs).

EBIs:

  • Patient reminders
  • Provider reminders
  • Provider assessment & feedback
  • Reducing structural barriers

SAs:

  • Small media
  • Patient navigation/community health

workers

  • Provider education
  • Health IT

Component 2

6 Grantees Only

Provide high quality CRC screening, diagnostics, patient navigation, and other support services to eligible patients.

Patient eligibility criteria:

  • Un- or underinsured
  • <250% of the federal poverty level
  • 50-64 years-old
  • Asymptomatic and average risk
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The CRCCP funded 30 grantees in 2015

CDC DP15-1502 CRCCP Grantees Washington, D.C.

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CRCCP Evaluation & Learning Laboratory

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CRCCP – Key Evaluation Questions

Are colorectal cancer screening rates going up? What is the return

  • n investment?

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CDC’s CRCCP Learning Laboratory

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CDC’s Division of Cancer Prevention and Control

  • F. Tangka (applied research) and A. DeGroff (program services)

Health Systems, Medical Centers, and Clinics Implementation and Evaluation in the Real-World Setting Coordinating Center

Research Tools and Methods Implementation Procedures Manuals Intervention Case Studies Webinars and Presentations Peer-Reviewed Journal Publications

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CRCCP Learning Laboratory Grantees and Health System Partner Participants

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Interventions at a Glance

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Center for Colon Cancer Research University of South Carolina

Patient and Provider Incentives Navigation for FIT & Colonoscopy FIT Mailings and Processes

Health Information Technology - Azara Integrated Cancer Screening Programs

Multicomponent Interventions

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Findings

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Among clinics enrolled in the first year of CRCCP , CRC screening rates increased by 8.3 percentage points from baseline to PY2

Baseline n=346; PY1 n= 336; PY2 n= 319

Source: Clinic data submission, Component 1 only, 29 reporting, thru April 2018. Screening rate % reflects weighted mean rate.

Mean Baseline Screening Rate Mean PY1 Annual Screening Rate Mean PY2 Annual Screening Rate

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The reach of the CRCCP grantees is significant

Source: Clinic data submission, April 2018, Component 1 only, all 30 reporting (Includes clinics recruited in PY1, 2, and through March of PY3)

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And continues to grow as new clinics are recruited.

# of clinics

413 541

py1 py2 py3

643

# of patients, aged 50 to 75

997,425 708,520

Source: Clinic data submission, April 2018, Component 1 only, all 30 reporting (Includes clinics recruited in PY1, 2, and through March of PY3)

py1 py2 py3

1,114,136

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Grantees are primarily working with FQHCs

Source: Clinic data submission, April 2018, Component 1 only, all 30 reporting (Includes clinics recruited in PY1, 2, and through March of PY3)

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A closer look at CRCCP clinics 643

CRCCP Clinics

are Federally- Qualified Health Centers (FQHCs) serve high percentages of uninsured patients (>20%) use FOBT/FIT tests as the primary CRC screening test type

Source: Clinic data submission, April 2018, Component 1 only, all 30 reporting (Includes clinics recruited in PY1, 2, and through April of PY3)

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Year 1 analyses identified four factors associated with greater increases in clinic-level CRC screening rates

CRC screening champion CRC screening policy Free CRC fecal tests Implemented 3-4 EBIs

DeGroff A, Sharma K, Satsangi A, Kenney K, Joseph D, Ross K, Leadbetter S, Helsel W, Kammerer W, Firth R, Rockwell T, Short W, Tangka F, Wong F, Richardson L. Increasing Colorectal Cancer Screening in Health Care Systems Using Evidence-Based Interventions. Preventing Chronic Diseases 2018 August 9; Volume 15:E100

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Some Results from Economic Evaluation of CRCCP

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Published in Cancer

  • Tangka FKL, Subramanian S, DeGroff AS, Wong FL, Richardson LC. Identifying optimal approaches to

implement colorectal cancer screening through participation in a learning laboratory. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31679. [Epub ahead of print]

  • Kemper KE, Glaze BL, Eastman CL, Waldron RC, Hoover S, Flagg T, Tangka FKL, Subramanian S. Effectiveness

and cost of multilayered colorectal cancer screening promotion interventions at federally qualified health centers in Washington state. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31693. [Epub ahead of print]

  • Kim KE, Randal F, Johnson M, Quinn M, Maene C, Hoover S, Richmond-Reese V

, Tangka FKL, Joseph DA, Subramanian S. Economic assessment of patient navigation to colonoscopy-based colorectal cancer screening in the real-world setting at the University of Chicago Medical Center. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31690. [Epub ahead of print]

  • Lara CL, Means KL, Morwood KD, Lighthall WR, Hoover S, Tangka FKL, French C, Gayle KD, DeGroff A,

Subramanian S. Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectiveness. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31691. [Epub ahead of print]

  • Dacus HLM, Wagner VL, Collins EA, Matson JM, Gates M, Hoover S, Tangka FKL, Larkins T, Subramanian S.

Evaluation of patient-focused interventions to promote colorectal cancer screening among New York state Medicaid managed care patients. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31692. [Epub ahead of print]

  • Subramanian S, Hoover S, Tangka FKL, DeGroff A, Soloe CS, Arena LC, Schlueter DF, Joseph DA, Wong FL. A

conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31686. [Epub

ahead of print]

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Washington Department of Health &

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Process Measures & Costs for FIT Mailings

FIT Kit Mailings (July 2015-June 2016) Number of FIT kits mailed 5,178 Number of FIT kits returned 1,607 Rate of FIT kits returned (%) 31 Patient Reminders Number of reminders mailed 4,009 Number of automated calls 8,454 Costs Implementation phase cost /// implementation cost per kit returned ($) 30,148 /// 18.76 Total cost /// total cost per kit returned ($) 63,978 /// 39.81

Kemper KE, Glaze BL, Eastman CL, Waldron RC, Hoover S, Flagg T, Tangka FKL, Subramanian S. Effectiveness and cost of multilayered colorectal cancer screening promotion interventions at federally qualified health centers in washington state. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31693. [Epub ahead of print]

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Colorado Dept. of Public Health & Environment

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Health System 1 Health System 2

  • 9 clinics
  • Partnered 2012–Ongoing
  • 5 clinics
  • Partnered 2014–Ongoing

Interventions Implemented

  • Provider assessment & feedback
  • Implement CRC policy & workflow
  • Implementation of Azara
  • Patient reminders
  • Reducing structural barriers
  • Use of FIT/FOBT
  • Update EHR with CRC screenings
  • Provider assessment & feedback
  • Implement CRC policy & workflow
  • Provider reminder & recall
  • Patient reminders
  • Reducing structural barriers
  • Use of FIT/FOBT
  • Creating accurate reports

Lara CL, Means KL, Morwood KD, Lighthall WR, Hoover S, Tangka FKL, French C, Gayle KD, DeGroff A, Subramanian S. Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectiveness. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31691. [Epub ahead of print]

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Incremental Cost Per Screen

Health System 1 Baseline 2013-14 (Yr 1) 2014-15 (Yr 2) Screening rate (%) 21.1 22.7 39.2 Number of additional screens 491 2,042 Incremental cost per screen ($) 7.24 27.75 Health System 2 Baseline 2014-15 (Yr 1) 2015-16 (Yr2) 2016-17 (Yr 3) Screening rate (%) 25.7 28.6 34.7 35.4 Number of additional screens 101 246 596 Incremental cost per screen ($) 8.21 66.26 17.41

Lara CL, Means KL, Morwood KD, Lighthall WR, Hoover S, Tangka FKL, French C, Gayle KD, DeGroff A, Subramanian S. Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectiveness. Cancer. 2018 Oct 25. doi: 10.1002/cncr.31691. [Epub ahead of print]

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University of Chicago Patient Navigation (PN) Intervention

Patient Navigation at UCMC:

  • Non-RN PN - phone-based (4 calls)

Patients targeted for navigation:

  • Provider recommended (PCP or GI)
  • Patient self directed through phone tree
  • RN pre-call communication

Implementation Timeline

  • Fall 2015: Cost benefit study completed
  • July 2016: PN hired
  • Sept–Dec 2016: Orientation, training and initial implementation
  • March 2017: Weeklong quality improvement Kaizen process
  • Ongoing: Assessment and evaluation; bi-weekly team meetings

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Kim KE, Randal F, Johnson M, Quinn M, Maene C, Hoover S, Richmond-Reese V, Tangka FKL, Joseph DA, Subramanian S. Economic assessment of patient navigation to colonoscopy-based colorectal cancer screening in the real-world setting at the University of Chicago Medical Center.

  • Cancer. 2018 Oct 25. doi: 10.1002/cncr.31690. [Epub ahead of print]
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Effectiveness and Cost of the Patient Navigation Intervention

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Patient Navigation No Yes Number of patients 2,713 536 Completed colonoscopy 1,990 456 Completion rate 74.3% 85.1% No show rate 15.4% 8.2% Assumed No-Show Rate Navigated Rate Cost per Patient Successfully Navigated Total Cost Implementation Only 0% 85% $148 $88 25% 85% $209 $125 50% 85% $359 $215 75% 85% $1,255 $751

Kim KE, Randal F, Johnson M, Quinn M, Maene C, Hoover S, Richmond-Reese V, Tangka FKL, Joseph DA, Subramanian S. Economic assessment of patient navigation to colonoscopy-based colorectal cancer screening in the real-world setting at the University of Chicago Medical Center.

  • Cancer. 2018 Oct 25. doi: 10.1002/cncr.31690. [Epub ahead of print]
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Dissemination of Results

  • Manuscripts
  • Manuscript Summaries
  • Webinars
  • Program Spotlights
  • Conference presentations
  • Grantee reports
  • CDC News Letters/bulletin

Manuscripts CDC News Letter/Bulletin

CDC Newsletter- Collection of 6 Manuscripts on the Economic Evaluation of CDC's CRCCP at: https://content.govdelivery.com/accounts/USCDC/bulletins/21b3080

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Using evaluation results to:

Improve program implementation Strengthen accountability of CDC to Congress and the public Inform future programmatic planning and policy making

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The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Go to the official federal source of cancer prevention information: www.cdc.gov/cancer

@CDC_Cancer

Follow DCPC Online!

Thank You!

Presented by Florence Tangka Email: FTangka@cdc.gov

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