1. Increasing Colorectal Cancer Screening through an Academic Detailing Intervention ACCN Research Roundtable October 8, 2008 Mark Dignan, Nancy Schoenberg, Kevin Pearce, Brent Shelton, Cheri Tolle Supported by the National Cancer Institute # CA113932

2. Colorectal cancer in Kentucky SEERIncidenceMortality US53.1(52.8-53.4) 19.6 (19.5-19.8) Kentucky 58.7 (56.4-61.1) 24.2 (22.7-25.7)

3. Colorectal cancer in Kentucky (SEER)

4. Appalachian Kentucky Compared with the rest of the United States, Appalachia is  medically underserved  economically distressed  disproportionately burdened with cancer

5. Education & Employment Education (%) Perry Co. KY High School or higher 58.380.4 Bachelor’s or higher 8.924.4 Unemployment (%) 5.13.7 Poverty (%) 26.112.7

6. To increase colorectal cancer screening provided by primary care practices in Appalachian Kentucky Project Goal

7. Methods Phase 1:Formative Research Phase 2:Intervention Trial

8. Phase I: Formative Research  Provider survey to establish contact with practices and identify general characteristics  Focus groups to obtain qualitative information and fill gaps in survey data

9. Phase II: Intervention Trial Participants: Primary care practices in Appalachian Kentucky  Family Medicine  General Internal Medicine  General Practice Outcome: Increase Screening (FOBT, FS, DCBE, Colonoscopy )

10. Academic Detailing Intervention 1.Academic detailing involves providing education where physicians are instructed through personal contact with an individual or group focused on a specific topic 2.Well-known as a method for pharmaceutical sales, this approach has been found to be a novel and effective way to reach busy physicians to provide medical education.

11. Objectives guiding Implementation Implement an educational intervention through academic detailing Evaluate the effectiveness of the intervention at 6 and 18 month post intervention data collection. 6 – month data to assess efficacy 18- month data to assess sustainability

12. Intervention Planning Need for partnerships Identification of primary care practices Desire for a community-based approach to intervention delivery Project management issues Travel and logistics Communication with practices Area Health Education Centers

13. Why Area Health Education Centers? Regional agencies in Kentucky Provide structure for continuing medical education Provide for opportunities for health professional training outside academic institutions They have capacity for outreach to rural health care providers Education is key to their mission Research participation is a new activity for them

14. Study Areas – Three AHEC Regions

15. Recruitment and Baseline Assessment RandomizationIntervention 6-Month Post- Intervention Data Collection 18-Month Post Intervention Data Collection 66 Practices Group 1 (n=33) InterventionOO Randomize Group 2 (n=33) DelayedOO Research Design

16. Procedures 1.An academic detailer in each AHEC region recruited primary care practices. 2.A physician in each practice completed a provider interview. 3.The academic detailer delivered the intervention – the intervention modules focused on Efficacy of colorectal cancer screening Reimbursement Patient counseling Practice management. 4.Project staff conducted medical record reviews in each practice

17. Evaluation Plan – Process and Q/C  Process  Monitoring data collection and intervention delivery  Quality control  Post intervention assessment of veracity of reports

18. Evaluation Plan - Outcomes  Outcomes  Quantitative – Proportion of patients ‘screened’ in practices  Qualitative – Key informant interviews to assess intervention and project experience  Health care providers  Office staff  Intervention staff

19. Results To Date Recruitment – All 66 practices recruited Implementation – Intervention delivered in all 33 practices Screening data Baseline – All practices complete 6-month – 28 practices complete 19

20. Results - FOBT FOBT Recommendation BaselineFollow-up Intervention17.4 (330/1900)20.7 (135/653) Delay19.5 (392/2006)19.5 (270/1386) FOBT Results Documented BaselineFollow-up Intervention16.1 (305/1900)15.6 (102/653) Delay9.0 (181/2006)15.7 (218/1386)

21. Results – Flex Sig Flex Sig Recommendation BaselineFollow-up Intervention0.3 (6/1900)0.2 (1/653) Delay0.5 (10/2006)0.3 (4/1386) Flex Sig Results Documented BaselineFollow-up Intervention0.4 (7/1900)0.2 (1/653) Delay0.3 (5/2006)0.4 (5/1386)

22. Results - Colonoscopy Colonoscopy Recommendation BaselineFollow-up Intervention42.7 (811/1900)48.9 (319/653) Delay44.7 (897/2006)48.5 (672/1386) Colonoscopy Results Documented BaselineFollow-up Intervention28.8 (547/1900)40.3 (263/653) Delay30.5 (612/2006)33.9 (470/1386)

23. Results – Barium Enema BE Recommended BaselineFollow-up Intervention0.3 (6/1900)0.2 (1/653) Delay0.3 (5/2006)0.0 (0/1386) BE Results Documented BaselineFollow-up Intervention0.3 (5/1900)0.3 (2/653) Delay0.3 (5/2006)0.0 (0/1386)

24. Results – All Screening modes Ever Recommended Screening (Any Type) BaselineFollow-up Intervention48.5 (921/1900)56.2 (367/653) Delay50.6 (1015/2006)52.5 (727/1386) Appropriate Screening (Meeting Recommendations for Any Type) BaselineFollow-up Intervention29.5 (560/1900)37.5 (245/653) Delay29.2 (585/2006)34.1 (473/1386)

25. Screening Recommended and Completed by Study Group, BASELINE 25

26. Findings – To date Screening rates are low. Colonoscopy appears to be the screening test that is recommended most commonly in this population. Rates for fecal occult blood testing are low which may indicate a lack of enthusiasm for this method. Rates for flexible sigmoidoscopy are so small as to be negligible, suggesting that primary health care providers have largely ceased providing this service.

27. Next Steps Complete delayed group intervention delivery Complete post-intervention data collection Analyze data and investigate stopping rule Schedule 18 month follow-up data collection Develop application to fund dissemination study

28. Dissemination study (Effectiveness) Tentative Research Questions 1. Can an academic detailing intervention designed to increase colorectal cancer screening in rural primary care practices be disseminated through the AHEC system? 2.. Are there factors that facilitate or inhibit the diffusion of innovation process through the AHEC system?

29. Collaborators Southern AHEC Dwaine Harris Shirley Balman Southeastern AHEC Michael Gayheart Gwen Whitaker Northeastern AHEC Kayla Rose Caudill, Jaime

30. UK Collaborators Southern AHEC Dwaine Harris Shirley Balman Southeastern AHEC Michael Gayheart Gwen Whitaker Northeastern AHEC Kayla Rose Caudill, J aime UK PRC Cheri Tolle Mark Dignan Nikki Lawhorn

31. Module One Colorectal Screening: Does it Work? Colorectal Cancer… Preventable. Treatable. Beatable.

32. Learning Objectives Cite incidence and mortality rates for colorectal cancer in Kentucky by Area Development Districts Discuss the effectiveness of four colorectal cancer screening methods Identify age and frequency guidelines for colorectal cancer screening

33. Colorectal cancer is the second leading cause of cancer-related death in the US and Kentucky

34. Colorectal Cancer Incidence Rates by County

35. Colorectal Cancer Mortality Rates by County

36. Colorectal Cancer Diagnoses 2004 Area Development Districts Population at Risk Total Cases State of Kentucky 4,141,8352465 Bluegrass713,821384 Cumberland Valley 241,334159 Lake Cumberland 198,385136 Big Sandy158,836102 FIVCO136,786108 Kentucky River119,30784 Gateway78,48048 Buffalo Trace56,24240

37. Colorectal Cancer Deaths 2004 Area Development Districts Population at Risk Total Deaths State of Kentucky 4,141,835856 Bluegrass713,821127 Cumberland Valley 241,33451 Lake Cumberland 198,38531 Big Sandy158,83632 FIVCO136,78636 Kentucky River119,30725 Gateway78,48014 Buffalo Trace56,24215

38. Screening for Colorectal Cancer is Effective

39. Colorectal Cancer Screening Evidence Fecal Occult Blood Test (FOBT) 33% mortality reduction, 20% incidence reduction (annual testing, three cards at home) Sigmoidoscopy 59% mortality reduction within reach of scope Colonoscopy 40-60% incidence reduction Double Contrast Barium Enema (DCBE) Still being evaluated as screening tool

40. Everyone 50 years and older should receive regular screening for colorectal cancer High risk individuals may need to begin screening earlier

41. Colorectal Cancer Screening Guidelines FOBT yearly Sigmoidoscopy 5 years Colonoscopy 10 years DCBE 5 years

42. Summary  Colorectal cancer is the second leading cause of cancer-related deaths in the US and Kentucky  Colorectal cancer incidence rates tend to be higher in eastern Kentucky  Current screening methods are FOBT, sigmoidoscopy, colonoscopy, and DCBE  All asymptomatic patients age 50 and over should be referred for screening FOBT = annually; Sigmoidoscopy = 5 years; Colonoscopy = 10 years; DCBE = 5 years