1. 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

2. 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

3. 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

4. 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

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

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

7. 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

8. Colorectal Cancer HEDIS & UDS Screening Rate
Denominator =
N of 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)

9. Colorectal Cancer HEDIS & UDS Screening Rate
Example
Denominator = 1,000
- 1,100 pts ages 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%

10. 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

11. 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%

12. 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%

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

15. 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

16. 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

17. 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%

19. 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

20. 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

21. 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%

22. 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

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

24. 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

25. 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

26. 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

27. 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

28. 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

29. For Further Information

30. Acknowledgements These studies are supported by:
CDC -- NU58DP (Kim). Cook County CARES: Cancer Alliance to Reignite and Enhance Screening.
CDC -- NU51PS (Kim). Community-based Programs to Increase Hepatitis B Testing and Linkage to Care in Foreign-born Populations.

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

32. Thank you
Questions?
Comments?