American Public Health Association 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

Collaborators Carolina Medical Review Medical Review of NC 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 Centers for Medicare & Medicaid Services Jim Coan Catherine Gordon National Cancer Institute Carrie Klabunde, PhD

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

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

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

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 baseline and evaluation telephone survey

Baseline Survey Design Methodology SC (mixture of rural and urban) 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

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

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

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%

Understanding of Risk of Colorectal Cancer

Physician Recommendation for Colorectal Cancer Test

Ever Had Any Colorectal Cancer Test

Had Test According to Guidelines

Potential Barriers to Colorectal Cancer Testing

Use of other preventive services 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

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)

Where do Medicare consumers get most useful health information ?

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

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

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

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)

CDC patient fact sheet

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

Birthday card sent to NC beneficiaries

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

Revised CIS Postcard - Positive

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

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

Patient Assessment used as part of a reminder system

Chart Sticker from Physician Tool Kit used as part of a reminder system

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

Post Card for Physicians to send to Patients

For more information, contact: Anna Schenck Medical Review of NC 5625 Dillard Drive Cary, NC 27511 919 851-2955 ncpro.aschenck@sdps.org Check out Medicare Statistics on our website: www.mrnc.org/ncmed or www.mrnc.org/crcreport