1. 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

2. 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

3. 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

4. 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 for enrollees age 50 and older

5. 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

6. 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

7. 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 , non-HMO, African American or White
randomly selected Medicare enrollees in NC and SC intervention and control counties

8. 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

9. 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

10. 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%

11. Understanding of Risk of Colorectal Cancer

12. Physician Recommendation for Colorectal Cancer Test

13. Ever Had Any Colorectal Cancer Test

14. Had Test According to Guidelines

15. Potential Barriers to Colorectal Cancer Testing

16. 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

17. 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)

18. Where do Medicare consumers get most useful health information ?

19. 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

20. 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

21. 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

22. 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)

23. CDC patient fact sheet

25. 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

26. Birthday card sent to NC beneficiaries

27. 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

28. Revised CIS Postcard - Positive

30. 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

31. 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

32. Patient Assessment
used as part of a reminder system

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

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

35. Post Card for Physicians to send to Patients

36. For more information, contact:
Anna Schenck
Medical Review of NC 5625 Dillard Drive Cary, NC
Check out Medicare Statistics on our website: or