Colorectal cancer screening:overview & background

January 8,2007

David A. Haggstrom, MD, MAS

LEADERS SYMPOSIUM“Strategic Planning to Inform a Funded Project onhow to Achieve Workflow Integration in Developing and Implementing CDS for CRC Screening”

Outline

I. CRC screening practice guidelines

II. Competing clinical demands for CRC screening

III. Applied research for screeningA. Clinical decision support

A. Facilitators & barriers

B. Practice-based interventions

Colorectal cancer screeningClinical practice guidelines Target population: men & women 50 years of

age & older at average risk for colorectal cancer

Caveat (VA/DoD): providers should discuss screening with patients ages 80 & older, taking into account estimated life expectancy & presence of co-morbid disease

Colorectal cancer screeningClinical practice guidelines (USPSTF)Test Interval

Fecal occult blood testing (FOBT)3 cards done at home

Annually

Flexible sigmoidoscopy Every 5 years

Colonoscopy Every 10 years

Double-contrast barium enema Every 5 years

Competing clinical demands Most clinical practice guidelines (CPGs) did not

address their applicability for older patients with

multiple comorbidities Most didn’t discuss

burden, short- & long-term goals give guidance for incorporating patient preferences into

treatment plans (Boyd, Wu, JAMA, 2005)

To fully satisfy all USPSTF recommendations 7.4 hrs/working day is needed for the provision of

preventive services by physicians

(Yarnall et al., AJPH, 2003)

Computer reminders – Regenstrief InstituteClinical focus: FOBT, mammography, & Pap testing

Study design: 6-mo. RCTPopulation: 31 GIM faculty & 145 residents at Indiana UniversityIntervention: “directed reminders” vs. routine reminders

1) done/order today 3) patient refused2) NA to patient 4) next visit

Primary outcome: compliance with reminder “directed reminders” overall (46% vs. 38%, p = 0.002) FOBT (61% vs. 49%, p = 0.0007)

Secondary outcomes: 21% of time: NA to patient - due to inadequate data in pt’s EMR 10% of time: patient refused

Conclusions:• Requiring MDs to respond to computer-generated reminders

improved their compliance• However, 100% compliance with cancer screening reminders will

be unattainable due to clinical appropriateness & patient refusal

(Litzelman, Tierney, JGIM, 1993)

Electronic health record – Partners HealthCareBarriers to use 24% of physicians “never/sometimes” used

any EHR functionality during patient visit Barriers to EHR use:

Loss of eye contact with patients (62%) Falling behind schedule (52%) Computers being too slow (49%) Inability to type quickly enough (32%) Using computer in front of patient is rude (31%) Preferring to write long prose notes (28%)

(Linder, AMIA Annu Symp Proc, 2006)

Computer reminders - VAFacilitators to adherence

In VA, overall adherence rate to 15 CRs: 86% (67% - 97%) Variation by clinic, individual clinician, & individual CR

Positive influence upon reminder completion rate: full utilization of support staff in completion process receiving frequent individual feedback on completion

No influence: provider demographics provider attitudes towards reminders

(Mayo-Smith, Abha Agrawal, 2004 & 2006)

Computer reminders - VABarriers to reminders

HIV clinical reminders Design: ethnographic observations & semi-

structured interviews Barriers to effective use:

Workload Time to remove inapplicable reminders False alarms Reduced eye contact Use of paper forms rather than software

(Patterson, Doebbeling, Asch et al., J Biomed Inform, 2005)

Colorectal cancer screeningPrimary care-based interventions

• Practice-individualized facilitation of implementation of tools:• Group randomized clinical trial• 77 community family practices

• Intervention:• 1-day practice assessment - nurse facilitator observed practice MDs & staff• 1.5 hour meeting with practice day after• frequent visits thereafter (unknown dose effect)

• Outcomes at 12 months• Summary scores of preventive service delivery rates:

• Intervention: 42% vs. 31%• Control: 37% vs. 35% (p=0.015)

• Screening services, (p=0.048), not immunization services• Sustained after 24 months

(STEP-UP - Study to Enhance Prevention by Understanding Practice)

(Stange, Goodwin, Am J Prev Med, 2001 & 2003)

CRC screening in primary care practices Most CRC screening interventions focus on either

patients or individual clinicians without examining the office context

Methods: chart review (795 pts eligible for CRC screening) practice surveys (22 family medicine practices)

Factors associated with higher CRC screening: Using nursing or health educator staff to provide

behavioral counseling Reminder system use

(Hudson & Crabtree, Can Det Prev, 2007)

Conclusions1. Generally positive, but sometimes mixed, results

for clinical, computer reminders Direct observation & qualitative methods provide

opportunity to understand potential pathways for effectiveness of clinical reminders

2. Computer reminders Need not only to incorporate evidence base, but address

patient preferences & comorbidities

3. Prior positive experience with practice change Computer reminder often key component Team-based approach also important, particularly to

help address competing time demands

Questions or comments?

Systems engineering framework1. Identify system of interest

2. Choose appropriate performance measure

3. Select best modeling tool

4. Study model properties & behavior under variety of scenarios

5. Make design & operation decisions for implementation

previous applications in hemodialysis, radiation therapy, & patient flow modeling

(Kopach-Konrad, Doebbeling et al., JGIM, 2007)