Increasing Screening for Colorectal Cancer and Hepatitis B Virus in the Health Center Setting Michael T. Quinn, PhD University of Chicago Department of Medicine Center for Asian Health Equity

Objectives Review colorectal cancer and HepB risk Review screening recommendations/benefits Discuss evidence-based interventions for increasing colorectal cancer and HepB screening Share some “lessons learned” from ongoing colorectal cancer and HepB screening studies

Colorectal Cancer Colorectal cancer 3rd most diagnosed cancer 140,000 new cases each year 3rd leading cause of cancer deaths in US Over 50,000 colorectal cancer deaths annually

Colorectal Cancer Risk Factors Age > 50 Hx of Inflammatory Bowel Disease or Crohn’s Disease Family Hx of Colorectal Cancer or Polyps Obesity Alcohol Smoking

Colorectal Cancer Screening Over 50% of new colorectal cases preventable with routine screening Early detection can lead to 65% survival rate after 5 years

Colorectal Cancer Screening Screening recommended ages 50-75 Fecal Occult Blood Testing annually Flexible Sigmoidoscopy every 5 years Colonoscopy every 10 years

This process takes about 15 years Normal Adenoma Carcinoma The transition from normal mucosa to polyp to invasive cancer is usually a lengthy process (7 – 12 years in many cases). This prolonged dwell time provides a unique opportunity for cancer prevention through polyp detection and removal. This process takes about 15 years

Colorectal Cancer HEDIS & UDS Screening Rate Denominator = N of 50-75 y/o pts with medical visit during measurement period (e.g., defined 12 mos) - Excluding pts with hx of colorectal cancer or colectomy Numerator = N of pts with appropriate screening for colorectal cancer (FOBT, Flex Sigmoidoscopy, Colonoscopy)

Colorectal Cancer HEDIS & UDS Screening Rate Example Denominator = 1,000 - 1,100 pts ages 50-75 y/o seen in year 2016 - Exclude 100 pts with hx of colorectal cancer or colectomy Numerator = 300 200 pts complete FOBT/FIT test in 2016 100 pts completed colonoscopy within 9 yrs prior to 2016 Screening Rate = 30%

Colorectal Cancer HEDIS & UDS Screening Rate Limitations Requires medical record review of 10 years Fails to account for those pts with positive sigmoidoscopy or FOBT/FIT who have not followed up with diagnostic colonoscopy

Colorectal Cancer Screening Poll What is your health center’s approximate colorectal cancer screening rate? Don’t Know 20% - 40% 41% - 60% 61% - 80% 81% - 100%

Colorectal Cancer Screening Rates 2015 Program HEDIS Screening Rate HRSA Health Center Program 38.4% NCQA Commercial HMOs 62.8% NCQA Medicare HMOs 67.4% Healthy People 2020 Goal = 70.5%

Colorectal Cancer Screening Rates Chinese = 53.5% Koreans = 29.5% NHIS 2010

Colorectal Cancer Screening NYC Intervention Public Education and Outreach, including targeting underserved groups Professional Education and Outreach DOH “Detailing Initiative” Patient Navigator Programs Direct Endoscope Referral Initiative Colonoscopy Quality Metrics Initiative

Hepatitis B Contagious liver disease Untreated, can lead to cirrhosis, liver cancer Estimate 800,000 to 2.2 million cases in US Estimate 19,000 new cases each year Estimate 3,000 HepB-related deaths annually

Hepatitis B Major risk factor is country of origin US estimated prevalence rate = 0.3% - 0.5% Eastern Europe, Mideast, Brazil = 2% - 7% China, South Asia, Africa = > 8%

Hepatitis B Other risk factors: US-born children not vaccinated as infants, whose parents were from high prevalence countries Persons HIV positive IV drug users Household partners of HepB infected persons Men who have sex with men Hemodialysis patients USPSTF recommends screening high risk groups

HepB Screening Poll Which HepB high risk groups are commonly seen at your health center? Asian Immigrants African Immigrants HIV-positive persons MSM Hemodialysis patients

HepB Screening Poll Don’t Know 20% - 40% 41% - 60% 61% - 80% With your most common HepB high risk group, what is your health center’s approximate screening rate? Don’t Know 20% - 40% 41% - 60% 61% - 80% 81% - 100%

Hepatitis B Screening Rate More difficult to compute (UDS = N screened) Denominator often unknown Pt selection for screening = clinical judgment Mayo clinic primary care study Identified 4,000 Asian American pts Only 31% had screening for HepB Of those screened, 8.5% were HBsAg Positive Loo et al., Arch Intern Med, 2012

Evidence-Based Interventions to Increase Screening Rates Feedback MD Prompts Patient Prompts Communication Training

Evidence-Based Interventions: Feedback Compute and Distribute: System-wide screening rates, by Insurance status Race/ethnicity Country of origin Language spoken Provider-specific screening rates Blinded Non-Blinded

Evidence-Based Interventions: MD Prompts Use EHR to Identify Pts for Screening, by Risk Factor: Passive Prompt EHR pop-up Active Prompt MA generates screening list for day’s patients

Evidence-Based Interventions: Patient Prompts Use EHR to Identify Pts for Screening, by Risk Factor: Passive Prompt Health Center letter reminder Active Prompt MA generates screening list for day’s patients Prompts patient when rooming

Evidence-Based Interventions: Communication Training Patients’ health literacy and cultural, normative, and efficacy beliefs about cancer and screening can be barriers Theory-based communication training can improve screening uptake 5 A’s Behavior Change Model Shared Decision-Making Model Brief Motivational Interviewing Model Stages of Change Model

Evidence-Based Interventions: Systems Requirements Personnel Program Director Data Manager Patient Navigation Established Procedures to Identify At Risk Patients Age Country of Origin Behavioral Risk Low Cost Screening FOBT/FIT Linkage to Available Follow-up Diagnostic Colonoscopy Specialty Care

For Further Information

Acknowledgements These studies are supported by: CDC -- NU58DP006079-01-00 (Kim). Cook County CARES: Cancer Alliance to Reignite and Enhance Screening. CDC -- NU51PS004616-02-01 (Kim). Community-based Programs to Increase Hepatitis B Testing and Linkage to Care in Foreign-born Populations.

Collaborators Karen Kim, MD, MS Matt Johnson, MPH Fornessa Randal, MCRP Chieko Maene, MS Sachin Shah, MD University of Chicago

Thank you Questions? Comments? mquinn@medicine.bsd.uchicago.edu