The Effect of Key Organizational Attributes on Cancer Screening Rates Eric Shaw, Bijal Balasubramanian, Alicja Piasecki, Pamela Ohman-Strickland, Jeanne Ferrante, A John Orzano, Benjamin Crabtree University of Medicine & Dentistry of New Jersey – Robert Wood Johnson Medical School, Somerset, NJ Funded by: The National Cancer Institute R01 NCI CA11287 (PI: Crabtree)

Background Most assessments of cancer screening deficiencies have focused on patient factors (eg., payment sources, knowledge deficits, preferences/attitudes) physician factors (eg., verbal recommendations for screening, training, beliefs about test performance) Effect of organizational factors of primary care practices remains understudied

Recent advancements in understanding organizational factors: Interventions that focus on changing organizational care processes have the largest effects on prevention performance Stone, EG et al. Interventions that Increase Use of Adult Immunization and Cancer Screening Services: A Meta- Analysis. Ann Intern Med 2002; 136:641-651. Smaller practice size, greater autonomy over care delivery, and more clinical support influenced CRC screening Yano, EM et al. Practice Care Practice Organization Influences Colorectal Cancer Screening Performance. HSR 2007; 42:1130-1149 Gap in research on community-based primary care practice organizational factors and multiple cancer screening tests

Purpose of this Paper To evaluate the association between key organizational attributes of primary care practices and screening for breast, cervical, colorectal, and prostate cancer

Theoretical Lens Cohen D et al. A Practice Change Model for Quality Improvement in Primary Care Practice. J Health Mgmt 2004; 49:3:155-168.

Methods Design: Cross sectional analysis using data from patient surveys, chart audit, and practice surveys from SCOPE Participants: Consecutive sample of ~30 patients, aged > 50, from 24 NJ family medicine practices Outcome Measures: Mammography (women ≥ 50 yrs, yearly) Pap smear (women 50-70 yrs, every 3 years) Prostate cancer screening (men 50-70 yrs, yearly) Colorectal cancer screening (men and women ≥ 50 yrs) FOBT (1 yr), flex sig (5 yr), colonoscopy (10 yr), or BE (5 yr)

Key Organizational Attributes Factor analysis of practice surveys resulted in 5 stable factors* Communication Teamwork Access to information Practice busyness/chaos History of change * Followed strategy used by: Ohman-Strickland PA, et al. Measuring Organizational Attributes of Primary Care Practices: Development of a New Instrument. HSR; 2007:1-17.

Analysis Hierarchical logistical regression adjusting for patient age, gender, race/ethnicity, comorbidity, presence of EMR Adjusts for the correlation of patients clustered within practices

Demographics Most practices were single specialty (family medicine) group practices owned by clinicians Mean patient age was 64 years (SD = 10) 61% female 69% white, 18% black, 9% Hispanic, 4% other 11 of 24 practices had EMRs

Results Cancer Screening Teamwork History of Change - mammography OR = 1.8 p = .04 - CRC screening OR = 1.9, p = .05 History of Change OR = 4.2, p = .008

Teamwork Communication Access to info History of change

Results Resources for Change Cancer Screening - Communication - History of change Cancer Screening - Access to info Level of chaos

Discussion Teamwork and history of change were important for increased CA screening rates Unpack dynamic interplay among practices’ “resources for change” Next steps: test this model using other datasets While patient and physician factors must not be ignored, interventions aimed at improving cancer screening rates should consider practice-level factors