1. Colorectal Cancer Screening in Appalachia PA: a pilot intervention project William Curry, MD, MS Dept of Family & Community Medicine M.S.Hershey Medical Center 7 MAY 2008

2. Colorectal Cancer Screening in Appalachia PA: a pilot intervention project Mark Dignan, PhD Gene Lengerich, PhD Alan Adelman, MD, MS Brenda Kluhsman, MS Marie Graybill, BSN

3. Colorectal Cancer Second leading cause of cancer deaths –150,000 new cases annually –57,000 annual deaths In Pennsylvania –8,200 new cases annually –Rates decreasing except in black males 75/100,000 black males, 49/100,000 white females –3,000 annual deaths 26/100,000 males, 18/100,000 females

4. Pennsylvania Counties Participating Practices Hershey Medical Center

5. Burden of Disease Union County –130 cases per year 20% more cases in males than expected –32 deaths per year 18/100,000 males, 12/100,000 females Northumberland County –190 cases per year 20% more cases in males than expected –163 deaths per year 30/100,000 males, 19/100,000 females

6. Burden of Disease Centre County –271 cases per year 7% fewer cases in males than expected –93 deaths per year 20/100,000 males, 14/100,000 females Snyder –137 cases per year 32% more cases in females than expected –38 deaths per year 19/100,000 males, 17/100,000 females

7. Colorectal Cancer Screening Screening of population is less than optimal –53% in US –49% in PA 44% in Appalachian PA Only 32% of colorectal cancers are found at local stage in rural Appalachia.

8. ACS CRC Screening Guidelines Fecal occult blood test (FOBT)* or fecal immunochemical test (FIT)* every year** *For FOBT or FIT, the take-home multiple sample method should be used. **Colonoscopy should be done if the FOBT or FIT shows blood in the stool

9. ACS CRC Screening Guidelines Flexible sigmoidoscopy every 5 years** **Colonoscopy should be done if sigmoidoscopy results show a polyp

10. ACS CRC Screening Guidelines an FOBT* or FIT* every year plus flexible sigmoidoscopy every 5 years** (Of these first 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5 years is preferable.) **Colonoscopy should be done if the FOBT or FIT shows blood in the stool or sigmoidoscopy results show a polyp

11. ACS CRC Screening Guidelines Double-contrast barium enema every 5 years** **Colonoscopy should be done if DCBE shows a polyp

12. ACS CRC Screening Guidelines Colonoscopy every 10 years ** **If possible, polyps should be removed during the colonoscopy.

13. ACS CRC Screening Guidelines Other alternatives –Stool DNA –CT Colonography (virtual colonoscopy)

14. Colorectal Cancer Screening Factors influencing cancer screening –Patient/population factors –Physician factors –Medical environment factors

15. Colorectal Cancer Screening Interventions –Audit & Feedback –CME –Provider reminders Despite these efforts, CRC screening rates remain lower than breast, cervical and prostate cancer screenings.Despite these efforts, CRC screening rates remain lower than breast, cervical and prostate cancer screenings.

16. Colorectal Cancer Screening Academic Detailing –One-on-One interaction between provider and trained educator Interactive information presentation –Evidence for Academic Detailing? Reduced inappropriate and over-prescribing Tobacco cessation Improved rural diabetes care Increased mammography use Decreased inappropriate PSA ordering

17. Colorectal Cancer Screening Academic Detailing –One study that showed improved follow-up of positive FOBT 1 –Mixed evidence about effectiveness with CRC screening Physician recommendation is an important factor in patient willingness to be screened

18. Colorectal Cancer Screening Study design –4 practices

19. Colorectal Cancer Screening Study Design –Baseline Provider Survey Screening practices Follow-up practices Referral patterns –Practice Assessment Key informant interviews Assess current screening practices

20. Colorectal Cancer Screening Study Design –Medical Record Abstraction Patients 50 and older Seen in practice in the previous 2 months Estimate number of patients offered screening and who had screening completed –Exclusion criteria »History of colon cancer, polyps »Symptoms of colon cancer »Acute visit

21. Colorectal Cancer Screening Study Design –Academic Detailing Visit 1 – Lunch and Learn Visit 2 & 3 – Tailored intervention based on practice assessment and Visit 1 Visit 4 – Follow-up and final physician assessment –Post-intervention Provider survey –Post-intervention medical record abstraction

22. Colorectal Cancer Screening Study Design –Post-intervention Key-informant interviews Qualitative assessment

23. Colorectal Cancer Screening Data Collection with caBIG –Working with Univ of Minnesota, capturing chart abstraction via web to NCI database caBIG™ Goal: To create a virtual web of interconnected data, individuals, and organizations redefining how research is conducted, care is provided, and patients/ participants interact with the biomedical research enterprise –CDEs - Completed –Output is an Excel datafile to research team

29. Results Four practices –Initial 3 visits completed –Initial provider surveys collected –Record review 280 patient records abstracted –105 entered into CaBIG »64 completed –Initial Datafile returned from CaBIG –45% screening rate (preliminary) Patient factors Physician/system factors

30. Lunch and Learn Lessons Providers and staff engaged Each practice has different outlook –Wall Charts –Handouts –Engaging staff Story telling Want information on their performance

31. Acknowledgements National Cancer Institute ACTION Health The four practice sites Research Team

32. References 1.Myers RE, Turner B, Weinberg D, et al. Impact of a physician-oriented intervention on follow-up in colorectal cancer screening Preventive Medicine, 2004 ;38(4):375- 381 2.Soumerai SB, McLaughlin TJ, Gurwitz JH, Guadagnoli E, Hauptman PJ, Borbas C, et al. Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial. JAMA 1998;279(17):1358-63.Effect of local medical opinion leaders on quality of care for acute myocardial infarction: a randomized controlled trial.

33. References 3.Centers for Medicare and Medicaid Services. Colon Cancer Screening. 2008. Available at: http://www.cms.hhs.gov/ColorectalCancerScreening. Accessed January 31, 2008. http://www.cms.hhs.gov/ColorectalCancerScreening 4.American Cancer Society. Detailed Guide: Colon and Rectum Cancer. 2008. Available at: http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=10. http://www.cancer.org/docroot/CRI/CRI_2_3x.asp?dt=10

34. Colorectal Cancer Screening Questions?