Research Brief Report Increasing Colorectal Cancer Screening at Community-Based Primary Care Clinics in San Francisco Rani Marx, PhD, MPH; Winnie M. Tse, BA; Lisa Golden, MD; Elizabeth C. Johnson, MD rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Context: Adult colorectal cancer screening (CRCS) can lower disease incidence and mortality. However, widespread implementation is inconsistent, especially in the public sector. While specific interventions to increase CRCS have been identified, firsthand accounts of CRCS improvement efforts using multiple techniques in public sector settings are lacking. Objective: A program evaluation was conducted to assess the effect of implementing a culture of continuous quality improvement (QI) on CRCS practices and prevalence. A multipronged incremental effort over more than a decade to increase CRCS at the San Francisco Department of Public Health is described. Setting: Community-based primary care clinics. Participants: Departmental activities and 5 clinics providing full-scope primary care to CRCS-eligible adults who participated in departmental activities and outreach interventions were assessed. Main Outcome Measures: Departmental and clinic-specific CRCS activities and prevalence. Results: Efforts included departmental prioritization; data-driven QI incorporating routine data sharing (monthly reports and data walls); departmental and clinic-specific QI committees; panel management (a team approach to generation of eligibility lists prior to scheduled visits, routinely offering screening during appointments or mailing test kits for patients without appointments); and departmental mail and phone outreach events. Screening ranged from 36.6% to 54.4% in 2010; in 2013, it ranged from 43.6% to 70.2%. Increases occurred consistently over that time in 3 of the 5 clinics and ranged from 1.1% to 14.5%; decreases occurred during 2 intervals in 2 clinics and ranged from 2.3% to 4.3%. Conclusion: CRCS J Public Health Management Practice, 2015, 00(00), 1–6 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
prevalence can be markedly improved in the public sector with a data-driven panel management approach supported by departmental and clinic-specific QI committees and group outreach events. Continued prioritization of and focus on CRCS is required to ensure long-term success. Even small increases will result in avoidable morbidity and mortality associated with this highly preventable disease. KEY WORDS: ambulatory care, colorectal neoplasms, community health services, early detection of cancer, early intervention (education), primary health care, program evaluation, public health practice, quality of health care, screening
Author Affiliations: Primary Care (Dr Marx and Ms Tse) and Ambulatory Care (Dr Golden), San Francisco Health Network, San Francisco Department of Public Health, San Francisco, California; and Department of Family and Community Medicine, University of California San Francisco (Drs Golden and Johnson). This research received no grants from any funding agency in the public, commercial, or nonprofit sectors for work at the clinics the authors’ evaluated. The authors thank the local management teams and staff who conducted screening at the primary care clinics. They also thank Dirk Schwarzhoff, for assistance with CRCS data; Alina Ayzenberg-Cote, Andrea Scobi, and Stella Chan for technical assistance with the outreach events and data collection and analysis; Lynne Drouin and Amy Petersen for developing training materials, conducting training and staff engagement activities, and implementing data walls; and the UCSF Center for Excellence in Primary Care for their assistance with outreach trainings. The views expressed in this article do not necessarily reflect the official policies of the City and County of San Francisco, nor does mention of the San Francisco Department of Public Health imply its endorsement. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). The authors declare no conflicts of interest. Correspondence: Rani Marx, PhD, MPH, San Francisco Health Network, San Francisco Department of Public Health, 25 Van Ness Ave, Ste 200, San Francisco, CA 94102 ([email protected]). DOI: 10.1097/PHH.0000000000000275
1 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2 ❘ Journal of Public Health Management and Practice Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States.1 Although annual screening lowers incidence and associated mortality2 and has been recommended for adults aged 50 to 75 years since 2008, implementation is inconsistent.3 Approximately 65% of eligible persons were screened in 2012; prevalence is lower among the uninsured, poor, less educated, and those with lower access to care or lacking a regular provider,4,5 characteristics common among patients in the public sector. Interventions found to increase screening prevalence have included mailed letters and/or automated phone calls along with mailed test kits6-10 or test kits provided at the clinic;11 follow-up or reminder letters and phone calls, telephone assistance, and nurse navigation;7,12 and offering colorectal cancer screening (CRCS) with influenza vaccination13 in 3 randomized controlled trials and 2 comparative studies in the public sector and 3 randomized controlled trials in managed care settings. Both a Health Resources and Services Administration toolkit14 and an overview of strategies for increasing CRCS in community clinics15 are available. However, firsthand accounts of CRCS improvement efforts using multiple techniques in public sector settings are lacking. We describe a multipronged incremental effort spanning more than a decade to increase CRCS prevalence at 5 San Francisco Department of Public Health (SFDPH) community-based primary care clinics. Our goal was to evaluate the effect of implementing a culture of continuous quality improvement (QI) on CRCS practices and prevalence.
● Methods The SFDPH provides outpatient primary care at 11 community-based and 4 hospital-based clinics. We conducted a program evaluation in the 5 community clinics that provide full-scope primary care to CRCSeligible adults and participated in departmental CRCS activities and outreach interventions. The excluded clinics serve populations that are CRCS ineligible or specialized or relied on other approaches to enhance CRCS. Qualitative data on CRCS activities were gathered from discussions and semistructured interviews with administrators and clinical staff, as well as reviewing reports, meeting agendas, and protocols on departmental CRCS activities (2000-2013). We obtained cliniclevel CRCS prevalence data from our patient registry (i2iTracks) summarized in routine reports (2010-2013). We calculated CRCS prevalence for active panel patients16 who were eligible and due for a fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
according to HEDIS criteria:17 aged 50 to 75 years and not up to date on 1 or more of the following: an FOBT or FIT in the past year, a colonoscopy in the past 10 years, a flexible sigmoidoscopy in the past 5 years; patients with a colorectal cancer diagnosis or total colectomy are excluded. Only FOBT was available prior to June 2012; thereafter, FIT became available. Only FIT was used after November 2012. CRCS prevalence data became routinely available in 2010; it is restricted to cross-sectional aggregate data that preclude patient-level analyses and thus did not require institutional review board clearance. Since all 5 clinics received the same interventions, we could not examine the association of program components and outcomes.
● Results Prior to 2011 In early 2000, a departmental Primary Care Quality Improvement Committee (PCQI) was established with 1 representative (including medical directors, frontline physicians, and nurse managers) from each clinic. PCQI focused on forms, follow-up letters, referrals, and patient satisfaction; CRCS was not a focus (Figure; see Supplemental Digital Content Tables 1 and 2, available at: http://links.lww.com/JPHMP/A158 and http: //links.lww.com/JPHMP/A159, respectively). From 2003 to 2005, the department participated in regional chronic disease collaboratives and adopted panel management. In 2005, a patient registry was implemented permitting prospective identification of and clinic-level reports on patients with gaps in preventive and chronic disease care, independent of the information technology department. In 2006, clinic QI committees (usually the clinic medical director and multidisciplinary staff) were established as a liaison to PCQI to bring best practices to the clinic, review reports, and conduct ongoing QI. In 2008, staffing changes led to team-based care including in-reach activities (ie, identifying patients due for screening and offering preventive and chronic disease services during the clinic visit). In March 2009, data wall development began. The data wall, displayed on a bulletin board in the clinics’ public space and updated quarterly, depicts patient sociodemographics, charts showing clinic and aggregate measures selected by PCQI (with improvement goals and benchmarks indicated), and other measures selected by individual clinics. Development of monthly unblinded clinic-level CRCS prevalence reports began in September 2009. Beginning in January 2010, reports were routinely posted on a registry accessible to all clinic administrators
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Increasing Colorectal Cancer Screening in Public Clinics
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FIGURE ● CRCS Improvement Process and Prevalence at 5 San Francisco Department of Public Health Primary Care Clinicsa qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Abbreviation: CRCS, colorectal cancer screening; EMR, electronic medical record; FIT, fecal immunochemical test; PCQI, Primary Care Quality Improvement Committee. a For CRCS interventions, solid lines represent continuous activity, dashed lines represent rollout, and bullets indicate 1-time events.
and PCQI representatives; PCQI representatives began sharing the data with their clinic QI committees. Some clinic administrators generated and shared their own CRCS provider-level data. From July 2009 to 2010, the SFDPH Medicaid managed care plan offered incentive payments for a relative increase in prevalence to clinics selecting CRCS as an improvement measure. From September 2009 to February 2010, the University of California San Francisco conducted a trial at 4 of the clinics (all except C) of standing orders to offer eligible patients FOBT along with influenza vaccination randomized by week within clinic.13
2011 Data-driven QI became a departmental focus, targeting improved screening prevalence for specific diseases.
PCQI introduced 4 to 6 annual measures and goals for all primary care clinics; these were also reported to the SFDPH’s public hospital quality council. CRCS was selected as a priority measure due to high disease and low screening prevalence and was the topic of multiple PCQI meetings where CRCS run charts were posted, and problems and progress were discussed. Starting in 2011 and continuing through 2013, the Medicaid managed care plan required CRCS prevalence reporting and offered clinics incentive payments for reaching established thresholds or relative increase in prevalence. Data walls were installed at all the clinics from May to October 2011. Clinics were expected to review and discuss data wall measures in staff meetings. In August, the department adapted an instrument measuring primary care medical home implementation18 and surveyed clinic QI representatives and usually at least 1 clinic management team
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
4 ❘ Journal of Public Health Management and Practice member. Both CRCS in-reach and outreach activities were assessed.
2012 Limited CRCS improvement in 2011 spurred a departmental outreach intervention. At group events, the Center for Excellence in Primary Care at the University of California San Francisco and the PCQI team trained staff about the importance of CRCS, using the registry to generate patient eligibility lists (previously eligibility was determined immediately before or during a patient’s clinic visit), how to discuss CRCS with patients using scripts and role-plays, followed by handson group postcard mail-outs in February and September and phone outreach in March and October. Approximately 500 patients were targeted for postcard and 500 for phone outreach events at each clinic. Patients due for CRCS who had contact information available and previous CRCS were prioritized.19 Since none of the clinics had 500 eligible patients with prior screening and contact information, the balance included randomly selected patients with contact information but no previous screening. Clinics were expected to make additional calls and follow-up on eligible patients after outreach events. A clinic workflow evaluation and intervention focused on improving access was conducted by Coleman Associates20 at 2 clinics (A and D) from October to December.
2013 PCQI monthly meetings shifted to notifying, tracking, and providing referrals to patients with positive CRCS tests; CRCS and other QI measure prevalence was reviewed. CRCS remained a QI and data wall measure but was not singled out for special attention. There were no departmental CRCS interventions.
CRCS prevalence At the end of 2010, CRCS prevalence ranged from 36.3% to 54.4%. One year later, prevalence increased at 3 clinics by 1.1% to 4.8% but decreased at 2 clinics by 2.3% and 2.9%. All medical providers, nursing staff, medical assistants, and health workers understood and could apply SFDPH and national CRCS guidelines and policies (E was missing data), were well along the continuum of implementing in-reach activities, but did not necessarily have support staff consistently review and address care gaps according to the departmental survey. Outreach was variable, ranging from one clinic (B) where support staff consistently followed scheduled outreach protocols to a clinic that did so inconsistently (E).
At the end of 2012, after group outreach concluded, CRCS increased at all clinics compared with a year prior: increases ranged from 4.8% to 14.5%. At the end of 2013, the year following the group outreach interventions, CRCS increased at 3 clinics by 3.1% to 8.6% but decreased at 2 clinics by 2.9% and 4.3% compared with the previous year. Comparing the end of 2010 to the end of 2013, CRCS increased by 7.3% to 20.8% at the 5 clinics.
● Discussion We improved CRCS with sustained efforts at 5 SFDPH community-based primary care clinics. Ours is one of the few real-world assessments of multipronged incremental efforts to increase CRCS in a health department through continuous QI. Screening prevalence was similar to or greater than that achieved after randomized interventions in 2 managed care settings7,8 and the FOBT/influenza trial in our clinics.13 Only one clinic (C) reached the 2012 HEDIS Medicare standard of 62.1% by the end of 2013. Our experience supports the finding that a focus on panel management and use of support staff to conduct specific prevention activities and continuous QI is an effective means of increasing preventive screenings.21-23 It was not possible to analyze factors responsible for the variation across clinics in CRCS prevalence over time. Factors that might contribute include patient demographics, staff to patient ratios, other priorities, continued influenza vaccination with FOBT/FIT,24 and clinic management practices. The proportion of CRCS accounted for by FOBT/FIT alone, the proportion of CRCS-naive patients targeted for outreach, staff time spent at the training and outreach events, date of data wall installation, participation in the external workflow intervention, and implementation of a new electronic medical record do not appear to have influenced CRCS (results not shown). FIT does not appear to account for the majority of CRCS improvement since increases were greatest for 4 clinics after the first intervention when only FOBT was available. Significant challenges to maintaining and increasing CRCS remain. Although many aspects of CRCS have been systematically incorporated into clinic workflow, decreased prevalence at 2 clinics the year after departmental outreach recommends holding regular events and continued departmental focus. Low CRCS prevalence represents a missed opportunity since it can be fairly low cost, cost-effective, and cost beneficial (ie, savings exceed costs) compared with other prevention.25-27 Cost analyses of incremental CRCS improvement efforts such as ours
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Increasing Colorectal Cancer Screening in Public Clinics
are called for when making decisions about program priorities.
Limitations The small number of clinics, lack of patient-level data, and lack of a control group precluded more conclusive identification of factors associated with improvements. While it is possible that CRCS prevalence patterns were due to chance, this seems unlikely, given the temporal association of CRCS improvement and departmental interventions. We could not assess the proportion of colorectal cancer avoided. Our experience may not generalize to other settings. We cannot differentiate patients screened via departmental outreach, nor evaluate prevalence by screening method. However, the majority of CRCS prevalence at the end of 2011 and 2012 was accounted for by FOBT/FIT alone, the method used for outreach.
● Conclusion CRCS prevalence can be markedly improved in the public sector with a data-driven panel management approach supported by departmental and clinic-specific QI committees and group outreach events. Even small increases will result in avoidable morbidity and mortality associated with this highly preventable disease. REFERENCES 1. United States Cancer Statistics: 1999-2010 Incidence and Mortality Web-Based Report. Atlanta, GA: US Cancer Statistics Working Group, US Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2013. http://www.cdc.gov/cancer/npcr/ about uscs.htm. Accessed May 19, 2014. 2. Whitlock EP, Lin J, Liles E, et al. Screening for Colorectal Cancer: An Updated Systematic Review. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-05124-EF-1. Evidence Synthesis No. 65, Part 1. http://www.ncbi.nlm.nih.gov/books/NBK35179. Accessed May 19, 2014. 3. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Rockville, MD: US Preventive Services Task Force; 2008. AHRQ Publication No. 08-05124-EF-3. http://www.uspreventiveservicestaskforce. org/uspstf08/colocancer/colors.htm. Accessed May 19, 2014. 4. Klabunde CN, Djenaba JA, King JB, White A, Plescia M. Vital signs: colorectal cancer screening test use—United States, 2012. MMWR Morb Mortal Wkly Rep. 2013;62:881888. http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6244a4.htm?s cid=mm6244a4 w. Accessed May 19, 2014.
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5. Holden DJ, Harris R, Porterfield DS, et al. Enhancing the Use and Quality of Colorectal Cancer Screening. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Evidence Reports/Technology Assessments, No. 190. http: //www.ncbi.nlm.nih.gov/books/NBK44526. Accessed May 19, 2014. 6. Gupta S, Halm EA, Rockey DC, et al. Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial. JAMA Intern Med. 2013;173(18):1725-1732. 7. Green BB, Wang CY, Anderson ML, et al. An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial. Ann Intern Med. 2013;158(5, pt 1):301-311. 8. Mosen DM, Feldstein AC, Perrin N, et al. Automated telephone calls improved completion of fecal occult blood testing. Med Care. 2010;48(7):604-610. 9. Hendren S, Winters P, Humiston S, et al. Randomized, controlled trial of a multimodal intervention to improve cancer screening rates in a safety-net primary care practice. J Gen Intern Med. 2014;29(1):41-49. 10. Coronado GD, Vollmer WM, Petrik A, et al. Strategies and opportunities to STOP colon cancer in priority populations: pragmatic pilot study design and outcomes. BMC Cancer. 2014;14:55. 11. Lee JK, Groessl EJ, Ganiats TG, Ho SB. Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening. BMC Gastroenterol. 2011;11:93. 12. Davis T, Arnold C, Rademaker A, et al. Improving colon cancer screening in community clinics. Cancer. 2013;119(21):38793886. 13. Potter MB, Walsh JM, Yu TM, Gildengorin G, Green LW, McPhee SJ. The effectiveness of the FLU-FOBT program in primary care, a randomized trial. Am J Prev Med. 2011;41(1): 9-16. 14. HRSA Clinical Quality & Performance Measures Supplemental Technical Assistance. Clinical Quality Measures: Colorectal Cancer Screening. Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration. http://www.hrsa.gov/quality/toolbox/measures/ colorectalcancer/index.html. Accessed May 19, 2014. 15. Sarfaty M, Doroshenk M, Hotz J, et al. Strategies for expanding colorectal cancer screening at community health centers. CA Cancer J Clin. 2013;63:221-231. http://onlinelibrary.wiley. com/doi/10.3322/caac.21191/pdf. Accessed November 28, 2014. 16. Marx R, Drennan MJ, Johnson EC, Solnit SA, Hirozawa AM, Katz MH. Creating a medical home in the San Francisco Department of Public Health: establishing patient panels. J Public Health Manag Pract. 2009;15(4):337-344. 17. Colorectal Cancer Screening: Percentage of Members 50 to 75 Years of Age Who Had Appropriate Screening for Colorectal Cancer. Washington, DC: US Department of Health and Human Services, Agency for Healthcare Research and Quality, National Quality Measures Clearinghouse; 2013. http://www.qualitymeasures.ahrq.gov/content.aspx?id =47144. Accessed May 19, 2014. 18. Patient-Centered Medical Home Assessment. Seattle, WA: MacColl Center for Health Care Innovation, Group
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6 ❘ Journal of Public Health Management and Practice
19.
20.
21.
22. 23.
Health Research Institute, Improving Chronic Illness Care. http://www.improvingchroniccare.org/index.php?p= PCMH-A&s=317. Accessed May 19, 2014. Janda M, Hughes KL, Auster JF, Leggett BA, Newman BM. Repeat participation in colorectal cancer screening utilizing fecal occult blood testing: a community-based project in a rural setting. J Gastroenterol Hepatol. 2010(10):1661-1667. Patient Visit Redesign, It’s About Time. Boulder, CO: Coleman Associates. http://www.patientvisitredesign.com/ coleman-associates/our-services. Accessed May 19, 2014. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136(9): 641-651. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366(21):1955-1957. Chen EH, Bodenheimer T. Improving population health through team-based panel management: comment on “Electronic Medical Record Reminders and Panel Management to
24.
25.
26.
27.
Improve Primary Care of Elderly Patients.” Arch Intern Med. 2011;171(17):1558-1559. Walsh JM, Gildengorin G, Green LW, Jenkins J, Potter MB. The FLU-FOBT program in community clinics: durable benefits of a randomized controlled trial. Health Educ Res. 2012;27(5):886-894. Woolf SH. The price paid for not preventing diseases. In: Yong PL, Saunders RS, Olsen LA, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: National Academies Press; 2010:220225. http://www.ncbi.nlm.nih.gov/books/NBK53914. Accessed May 19, 2014. Maciosek MV, Solberg LI, Coffield AB, Edwards NM, Goodman MJ. Colorectal cancer screening: health impact and cost effectiveness. Am J Prev Med. 2006;31(1):80-89. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006;31(1):52-61.
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Context: Adult colorectal cancer screening (CRCS) can lower disease incidence and mortality. However, widespread implementation is inconsistent, especially in the public sector. While specific interventions to increase CRCS have been identified, firsthand accounts of CRCS improvement efforts using multiple techniques in public sector settings are lacking. Objective: A program evaluation was conducted to assess the effect of implementing a culture of continuous quality improvement (QI) on CRCS practices and prevalence. A multipronged incremental effort over more than a decade to increase CRCS at the San Francisco Department of Public Health is described. Setting: Community-based primary care clinics. Participants: Departmental activities and 5 clinics providing full-scope primary care to CRCS-eligible adults who participated in departmental activities and outreach interventions were assessed. Main Outcome Measures: Departmental and clinic-specific CRCS activities and prevalence. Results: Efforts included departmental prioritization; data-driven QI incorporating routine data sharing (monthly reports and data walls); departmental and clinic-specific QI committees; panel management (a team approach to generation of eligibility lists prior to scheduled visits, routinely offering screening during appointments or mailing test kits for patients without appointments); and departmental mail and phone outreach events. Screening ranged from 36.6% to 54.4% in 2010; in 2013, it ranged from 43.6% to 70.2%. Increases occurred consistently over that time in 3 of the 5 clinics and ranged from 1.1% to 14.5%; decreases occurred during 2 intervals in 2 clinics and ranged from 2.3% to 4.3%. Conclusion: CRCS J Public Health Management Practice, 2015, 00(00), 1–6 C 2015 Wolters Kluwer Health, Inc. All rights reserved. Copyright
prevalence can be markedly improved in the public sector with a data-driven panel management approach supported by departmental and clinic-specific QI committees and group outreach events. Continued prioritization of and focus on CRCS is required to ensure long-term success. Even small increases will result in avoidable morbidity and mortality associated with this highly preventable disease. KEY WORDS: ambulatory care, colorectal neoplasms, community health services, early detection of cancer, early intervention (education), primary health care, program evaluation, public health practice, quality of health care, screening
Author Affiliations: Primary Care (Dr Marx and Ms Tse) and Ambulatory Care (Dr Golden), San Francisco Health Network, San Francisco Department of Public Health, San Francisco, California; and Department of Family and Community Medicine, University of California San Francisco (Drs Golden and Johnson). This research received no grants from any funding agency in the public, commercial, or nonprofit sectors for work at the clinics the authors’ evaluated. The authors thank the local management teams and staff who conducted screening at the primary care clinics. They also thank Dirk Schwarzhoff, for assistance with CRCS data; Alina Ayzenberg-Cote, Andrea Scobi, and Stella Chan for technical assistance with the outreach events and data collection and analysis; Lynne Drouin and Amy Petersen for developing training materials, conducting training and staff engagement activities, and implementing data walls; and the UCSF Center for Excellence in Primary Care for their assistance with outreach trainings. The views expressed in this article do not necessarily reflect the official policies of the City and County of San Francisco, nor does mention of the San Francisco Department of Public Health imply its endorsement. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.JPHMP.com). The authors declare no conflicts of interest. Correspondence: Rani Marx, PhD, MPH, San Francisco Health Network, San Francisco Department of Public Health, 25 Van Ness Ave, Ste 200, San Francisco, CA 94102 ([email protected]). DOI: 10.1097/PHH.0000000000000275
1 Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
2 ❘ Journal of Public Health Management and Practice Colorectal cancer is the third most common cancer and the third leading cause of cancer deaths in the United States.1 Although annual screening lowers incidence and associated mortality2 and has been recommended for adults aged 50 to 75 years since 2008, implementation is inconsistent.3 Approximately 65% of eligible persons were screened in 2012; prevalence is lower among the uninsured, poor, less educated, and those with lower access to care or lacking a regular provider,4,5 characteristics common among patients in the public sector. Interventions found to increase screening prevalence have included mailed letters and/or automated phone calls along with mailed test kits6-10 or test kits provided at the clinic;11 follow-up or reminder letters and phone calls, telephone assistance, and nurse navigation;7,12 and offering colorectal cancer screening (CRCS) with influenza vaccination13 in 3 randomized controlled trials and 2 comparative studies in the public sector and 3 randomized controlled trials in managed care settings. Both a Health Resources and Services Administration toolkit14 and an overview of strategies for increasing CRCS in community clinics15 are available. However, firsthand accounts of CRCS improvement efforts using multiple techniques in public sector settings are lacking. We describe a multipronged incremental effort spanning more than a decade to increase CRCS prevalence at 5 San Francisco Department of Public Health (SFDPH) community-based primary care clinics. Our goal was to evaluate the effect of implementing a culture of continuous quality improvement (QI) on CRCS practices and prevalence.
● Methods The SFDPH provides outpatient primary care at 11 community-based and 4 hospital-based clinics. We conducted a program evaluation in the 5 community clinics that provide full-scope primary care to CRCSeligible adults and participated in departmental CRCS activities and outreach interventions. The excluded clinics serve populations that are CRCS ineligible or specialized or relied on other approaches to enhance CRCS. Qualitative data on CRCS activities were gathered from discussions and semistructured interviews with administrators and clinical staff, as well as reviewing reports, meeting agendas, and protocols on departmental CRCS activities (2000-2013). We obtained cliniclevel CRCS prevalence data from our patient registry (i2iTracks) summarized in routine reports (2010-2013). We calculated CRCS prevalence for active panel patients16 who were eligible and due for a fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
according to HEDIS criteria:17 aged 50 to 75 years and not up to date on 1 or more of the following: an FOBT or FIT in the past year, a colonoscopy in the past 10 years, a flexible sigmoidoscopy in the past 5 years; patients with a colorectal cancer diagnosis or total colectomy are excluded. Only FOBT was available prior to June 2012; thereafter, FIT became available. Only FIT was used after November 2012. CRCS prevalence data became routinely available in 2010; it is restricted to cross-sectional aggregate data that preclude patient-level analyses and thus did not require institutional review board clearance. Since all 5 clinics received the same interventions, we could not examine the association of program components and outcomes.
● Results Prior to 2011 In early 2000, a departmental Primary Care Quality Improvement Committee (PCQI) was established with 1 representative (including medical directors, frontline physicians, and nurse managers) from each clinic. PCQI focused on forms, follow-up letters, referrals, and patient satisfaction; CRCS was not a focus (Figure; see Supplemental Digital Content Tables 1 and 2, available at: http://links.lww.com/JPHMP/A158 and http: //links.lww.com/JPHMP/A159, respectively). From 2003 to 2005, the department participated in regional chronic disease collaboratives and adopted panel management. In 2005, a patient registry was implemented permitting prospective identification of and clinic-level reports on patients with gaps in preventive and chronic disease care, independent of the information technology department. In 2006, clinic QI committees (usually the clinic medical director and multidisciplinary staff) were established as a liaison to PCQI to bring best practices to the clinic, review reports, and conduct ongoing QI. In 2008, staffing changes led to team-based care including in-reach activities (ie, identifying patients due for screening and offering preventive and chronic disease services during the clinic visit). In March 2009, data wall development began. The data wall, displayed on a bulletin board in the clinics’ public space and updated quarterly, depicts patient sociodemographics, charts showing clinic and aggregate measures selected by PCQI (with improvement goals and benchmarks indicated), and other measures selected by individual clinics. Development of monthly unblinded clinic-level CRCS prevalence reports began in September 2009. Beginning in January 2010, reports were routinely posted on a registry accessible to all clinic administrators
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Increasing Colorectal Cancer Screening in Public Clinics
❘ 3
FIGURE ● CRCS Improvement Process and Prevalence at 5 San Francisco Department of Public Health Primary Care Clinicsa qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Abbreviation: CRCS, colorectal cancer screening; EMR, electronic medical record; FIT, fecal immunochemical test; PCQI, Primary Care Quality Improvement Committee. a For CRCS interventions, solid lines represent continuous activity, dashed lines represent rollout, and bullets indicate 1-time events.
and PCQI representatives; PCQI representatives began sharing the data with their clinic QI committees. Some clinic administrators generated and shared their own CRCS provider-level data. From July 2009 to 2010, the SFDPH Medicaid managed care plan offered incentive payments for a relative increase in prevalence to clinics selecting CRCS as an improvement measure. From September 2009 to February 2010, the University of California San Francisco conducted a trial at 4 of the clinics (all except C) of standing orders to offer eligible patients FOBT along with influenza vaccination randomized by week within clinic.13
2011 Data-driven QI became a departmental focus, targeting improved screening prevalence for specific diseases.
PCQI introduced 4 to 6 annual measures and goals for all primary care clinics; these were also reported to the SFDPH’s public hospital quality council. CRCS was selected as a priority measure due to high disease and low screening prevalence and was the topic of multiple PCQI meetings where CRCS run charts were posted, and problems and progress were discussed. Starting in 2011 and continuing through 2013, the Medicaid managed care plan required CRCS prevalence reporting and offered clinics incentive payments for reaching established thresholds or relative increase in prevalence. Data walls were installed at all the clinics from May to October 2011. Clinics were expected to review and discuss data wall measures in staff meetings. In August, the department adapted an instrument measuring primary care medical home implementation18 and surveyed clinic QI representatives and usually at least 1 clinic management team
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
4 ❘ Journal of Public Health Management and Practice member. Both CRCS in-reach and outreach activities were assessed.
2012 Limited CRCS improvement in 2011 spurred a departmental outreach intervention. At group events, the Center for Excellence in Primary Care at the University of California San Francisco and the PCQI team trained staff about the importance of CRCS, using the registry to generate patient eligibility lists (previously eligibility was determined immediately before or during a patient’s clinic visit), how to discuss CRCS with patients using scripts and role-plays, followed by handson group postcard mail-outs in February and September and phone outreach in March and October. Approximately 500 patients were targeted for postcard and 500 for phone outreach events at each clinic. Patients due for CRCS who had contact information available and previous CRCS were prioritized.19 Since none of the clinics had 500 eligible patients with prior screening and contact information, the balance included randomly selected patients with contact information but no previous screening. Clinics were expected to make additional calls and follow-up on eligible patients after outreach events. A clinic workflow evaluation and intervention focused on improving access was conducted by Coleman Associates20 at 2 clinics (A and D) from October to December.
2013 PCQI monthly meetings shifted to notifying, tracking, and providing referrals to patients with positive CRCS tests; CRCS and other QI measure prevalence was reviewed. CRCS remained a QI and data wall measure but was not singled out for special attention. There were no departmental CRCS interventions.
CRCS prevalence At the end of 2010, CRCS prevalence ranged from 36.3% to 54.4%. One year later, prevalence increased at 3 clinics by 1.1% to 4.8% but decreased at 2 clinics by 2.3% and 2.9%. All medical providers, nursing staff, medical assistants, and health workers understood and could apply SFDPH and national CRCS guidelines and policies (E was missing data), were well along the continuum of implementing in-reach activities, but did not necessarily have support staff consistently review and address care gaps according to the departmental survey. Outreach was variable, ranging from one clinic (B) where support staff consistently followed scheduled outreach protocols to a clinic that did so inconsistently (E).
At the end of 2012, after group outreach concluded, CRCS increased at all clinics compared with a year prior: increases ranged from 4.8% to 14.5%. At the end of 2013, the year following the group outreach interventions, CRCS increased at 3 clinics by 3.1% to 8.6% but decreased at 2 clinics by 2.9% and 4.3% compared with the previous year. Comparing the end of 2010 to the end of 2013, CRCS increased by 7.3% to 20.8% at the 5 clinics.
● Discussion We improved CRCS with sustained efforts at 5 SFDPH community-based primary care clinics. Ours is one of the few real-world assessments of multipronged incremental efforts to increase CRCS in a health department through continuous QI. Screening prevalence was similar to or greater than that achieved after randomized interventions in 2 managed care settings7,8 and the FOBT/influenza trial in our clinics.13 Only one clinic (C) reached the 2012 HEDIS Medicare standard of 62.1% by the end of 2013. Our experience supports the finding that a focus on panel management and use of support staff to conduct specific prevention activities and continuous QI is an effective means of increasing preventive screenings.21-23 It was not possible to analyze factors responsible for the variation across clinics in CRCS prevalence over time. Factors that might contribute include patient demographics, staff to patient ratios, other priorities, continued influenza vaccination with FOBT/FIT,24 and clinic management practices. The proportion of CRCS accounted for by FOBT/FIT alone, the proportion of CRCS-naive patients targeted for outreach, staff time spent at the training and outreach events, date of data wall installation, participation in the external workflow intervention, and implementation of a new electronic medical record do not appear to have influenced CRCS (results not shown). FIT does not appear to account for the majority of CRCS improvement since increases were greatest for 4 clinics after the first intervention when only FOBT was available. Significant challenges to maintaining and increasing CRCS remain. Although many aspects of CRCS have been systematically incorporated into clinic workflow, decreased prevalence at 2 clinics the year after departmental outreach recommends holding regular events and continued departmental focus. Low CRCS prevalence represents a missed opportunity since it can be fairly low cost, cost-effective, and cost beneficial (ie, savings exceed costs) compared with other prevention.25-27 Cost analyses of incremental CRCS improvement efforts such as ours
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Increasing Colorectal Cancer Screening in Public Clinics
are called for when making decisions about program priorities.
Limitations The small number of clinics, lack of patient-level data, and lack of a control group precluded more conclusive identification of factors associated with improvements. While it is possible that CRCS prevalence patterns were due to chance, this seems unlikely, given the temporal association of CRCS improvement and departmental interventions. We could not assess the proportion of colorectal cancer avoided. Our experience may not generalize to other settings. We cannot differentiate patients screened via departmental outreach, nor evaluate prevalence by screening method. However, the majority of CRCS prevalence at the end of 2011 and 2012 was accounted for by FOBT/FIT alone, the method used for outreach.
● Conclusion CRCS prevalence can be markedly improved in the public sector with a data-driven panel management approach supported by departmental and clinic-specific QI committees and group outreach events. Even small increases will result in avoidable morbidity and mortality associated with this highly preventable disease. REFERENCES 1. United States Cancer Statistics: 1999-2010 Incidence and Mortality Web-Based Report. Atlanta, GA: US Cancer Statistics Working Group, US Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2013. http://www.cdc.gov/cancer/npcr/ about uscs.htm. Accessed May 19, 2014. 2. Whitlock EP, Lin J, Liles E, et al. Screening for Colorectal Cancer: An Updated Systematic Review. Rockville, MD: Agency for Healthcare Research and Quality; 2008. AHRQ Publication No. 08-05124-EF-1. Evidence Synthesis No. 65, Part 1. http://www.ncbi.nlm.nih.gov/books/NBK35179. Accessed May 19, 2014. 3. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. Rockville, MD: US Preventive Services Task Force; 2008. AHRQ Publication No. 08-05124-EF-3. http://www.uspreventiveservicestaskforce. org/uspstf08/colocancer/colors.htm. Accessed May 19, 2014. 4. Klabunde CN, Djenaba JA, King JB, White A, Plescia M. Vital signs: colorectal cancer screening test use—United States, 2012. MMWR Morb Mortal Wkly Rep. 2013;62:881888. http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm6244a4.htm?s cid=mm6244a4 w. Accessed May 19, 2014.
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5. Holden DJ, Harris R, Porterfield DS, et al. Enhancing the Use and Quality of Colorectal Cancer Screening. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Evidence Reports/Technology Assessments, No. 190. http: //www.ncbi.nlm.nih.gov/books/NBK44526. Accessed May 19, 2014. 6. Gupta S, Halm EA, Rockey DC, et al. Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial. JAMA Intern Med. 2013;173(18):1725-1732. 7. Green BB, Wang CY, Anderson ML, et al. An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial. Ann Intern Med. 2013;158(5, pt 1):301-311. 8. Mosen DM, Feldstein AC, Perrin N, et al. Automated telephone calls improved completion of fecal occult blood testing. Med Care. 2010;48(7):604-610. 9. Hendren S, Winters P, Humiston S, et al. Randomized, controlled trial of a multimodal intervention to improve cancer screening rates in a safety-net primary care practice. J Gen Intern Med. 2014;29(1):41-49. 10. Coronado GD, Vollmer WM, Petrik A, et al. Strategies and opportunities to STOP colon cancer in priority populations: pragmatic pilot study design and outcomes. BMC Cancer. 2014;14:55. 11. Lee JK, Groessl EJ, Ganiats TG, Ho SB. Cost-effectiveness of a mailed educational reminder to increase colorectal cancer screening. BMC Gastroenterol. 2011;11:93. 12. Davis T, Arnold C, Rademaker A, et al. Improving colon cancer screening in community clinics. Cancer. 2013;119(21):38793886. 13. Potter MB, Walsh JM, Yu TM, Gildengorin G, Green LW, McPhee SJ. The effectiveness of the FLU-FOBT program in primary care, a randomized trial. Am J Prev Med. 2011;41(1): 9-16. 14. HRSA Clinical Quality & Performance Measures Supplemental Technical Assistance. Clinical Quality Measures: Colorectal Cancer Screening. Rockville, MD: US Department of Health and Human Services, Health Resources and Services Administration. http://www.hrsa.gov/quality/toolbox/measures/ colorectalcancer/index.html. Accessed May 19, 2014. 15. Sarfaty M, Doroshenk M, Hotz J, et al. Strategies for expanding colorectal cancer screening at community health centers. CA Cancer J Clin. 2013;63:221-231. http://onlinelibrary.wiley. com/doi/10.3322/caac.21191/pdf. Accessed November 28, 2014. 16. Marx R, Drennan MJ, Johnson EC, Solnit SA, Hirozawa AM, Katz MH. Creating a medical home in the San Francisco Department of Public Health: establishing patient panels. J Public Health Manag Pract. 2009;15(4):337-344. 17. Colorectal Cancer Screening: Percentage of Members 50 to 75 Years of Age Who Had Appropriate Screening for Colorectal Cancer. Washington, DC: US Department of Health and Human Services, Agency for Healthcare Research and Quality, National Quality Measures Clearinghouse; 2013. http://www.qualitymeasures.ahrq.gov/content.aspx?id =47144. Accessed May 19, 2014. 18. Patient-Centered Medical Home Assessment. Seattle, WA: MacColl Center for Health Care Innovation, Group
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19.
20.
21.
22. 23.
Health Research Institute, Improving Chronic Illness Care. http://www.improvingchroniccare.org/index.php?p= PCMH-A&s=317. Accessed May 19, 2014. Janda M, Hughes KL, Auster JF, Leggett BA, Newman BM. Repeat participation in colorectal cancer screening utilizing fecal occult blood testing: a community-based project in a rural setting. J Gastroenterol Hepatol. 2010(10):1661-1667. Patient Visit Redesign, It’s About Time. Boulder, CO: Coleman Associates. http://www.patientvisitredesign.com/ coleman-associates/our-services. Accessed May 19, 2014. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med. 2002;136(9): 641-651. Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med. 2012;366(21):1955-1957. Chen EH, Bodenheimer T. Improving population health through team-based panel management: comment on “Electronic Medical Record Reminders and Panel Management to
24.
25.
26.
27.
Improve Primary Care of Elderly Patients.” Arch Intern Med. 2011;171(17):1558-1559. Walsh JM, Gildengorin G, Green LW, Jenkins J, Potter MB. The FLU-FOBT program in community clinics: durable benefits of a randomized controlled trial. Health Educ Res. 2012;27(5):886-894. Woolf SH. The price paid for not preventing diseases. In: Yong PL, Saunders RS, Olsen LA, eds. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: National Academies Press; 2010:220225. http://www.ncbi.nlm.nih.gov/books/NBK53914. Accessed May 19, 2014. Maciosek MV, Solberg LI, Coffield AB, Edwards NM, Goodman MJ. Colorectal cancer screening: health impact and cost effectiveness. Am J Prev Med. 2006;31(1):80-89. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006;31(1):52-61.
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