How to Increase Preventive Screening Rates in Practice: Toolbox and Guide

How to Increase Preventive Screening
Rates in Practice:
An Action Plan for Implementing
A Primary Care Clinician’s Evidence-Based
Toolbox and Guide
We gratefully acknowledge the contributions of the
following individuals:
Dr. Terri Ades, DNP, FNP-BC, AOCN
Durado Brooks, MD, MPH
Edwin Diaz
Mary Doroshenk, MA
Ted Gansler, MD
Cynthia Gelb
Carmen Guerra, MD
Djenaba Joseph, MD, MPH
Debbie Kirkland
Dorothy Lane, MD, MPH
Barbara Cebuhar
Mona Sarfaty, MD, MPH
Robert Smith, PhD
Michelle Tropper, MPH
Gregory Walker, MBA
Richard Wender, MD
Claire Weschler, MSEd
Colorectal Cancer
• The third most common cancer in U.S. and the second deadliest
– 141,000 new cases expected this year
– More than 49,000 deaths nationwide
• 1.1 million Americans living with colorectal cancer
• Death rates have fallen steadily over the past 20 years
Trends in Colorectal Cancer Mortality Rates by Race/Ethnicity and Sex, 1975‐2007
Trends in CRC
Research suggests that observed declines in CRC incidence and mortality rates are due in large part to:
• Screening and polyp removal, preventing progression of polyps to invasive cancers
– NEJM study Feb 2012 showed polyp removal associated with 53% lower risk of CRC death
• CRC treatment advances
• Screening  detecting cancers at earlier, more treatable stages
Benefits of Screening
Survival Rates by Disease Stage*
5-yr
Survival
100
90
80
70
60
50
40
30
20
10
0
89.8%
67.7%
10.3%
Lo cal
Reg io n al
Distan t
St age of Det ect ion
*1996 - 2003
Question:
Do PCP’s screen their patients for CRC?
Answer:
Yes, 98% already do.
But often done in a haphazard, uncoordinated fashion
Results in some at‐risk patients getting screened, others overlooked
(Klabunde, et. al., Prev Med 2003)
“Action Plan” Toolkit Version
 Eight page guide introduces clinicians and staff to concepts and tools provided in the full Toolkit
 Contains links to the full Toolkit, tools and resources
 Not colorectal‐specific; practical, action‐oriented assistance that can be used in the office to improve screening rates for multiple cancer sites (colorectal, breast and cervical)
Available at http://nccrt.org/about/providereducation/crc-clinician-guide/
Communication
Make a Recommendation
Essential #1
Essential #1
Determine the screening messages you and
your staff will share with patients.
Explore how your practice will assess a
patient’s risk status and receptivity to
screening.
Tools for Your Practice
Essential #1: Make a Recommendation
• CRC Screening Options and Patient Readiness
• Risk Assessment
Why Not Colonoscopy for All?
• Screening rates are disappointingly low
• Patient preference – Many individuals don’t want an invasive test or a test that requires a bowel prep
– Some may not have access to the invasive tests due to lack of coverage or local resources • Greater patient requirements for successful completion of tests that detect both polyps and cancers
– Endoscopic and radiologic exams require a bowel prep and an office or facility visit
• Evidence does not support “best test” or “gold standard”
– Colonoscopy misses 5 – 10% of significant lesions in expert settings
– Questions about efficacy in proximal colon
– Higher potential for patient injury than other tests
– Test performance is highly operator dependent
High Quality Stool Testing
•
•
•
•
CRC screening by FOBT should be performed with high‐sensitivity FOBT ‐ either FIT or a highly sensitive gFOBT (such as Hemoccult SENSA). – Older, less sensitive guiaic tests (such as Hemoccult II) should not be used for CRC screening.
Tests should be repeated yearly
In‐office FOBT is essentially worthless as a screening tool for CRC and must be strongly discouraged.
All positive screening tests should be evaluated by colonoscopy
Sample Tools for Your Practice
Develop a Screening Policy
Essential #2
Create a standard course of action for
screenings, document it, and share it.
Essential #2
Compile a list of screening resources and
determine the screening capacity available in your
community.
Tools for Your Practice
Essential #2: Develop a Screening Policy
• Screening Policy and Office Visits
• CRC Patient Education Materials
Sample Screening Algorithm
Sample Tools for Your Practice
Assess Risk: Personal & Family History
Average risk =
No family history of CRC or adenomatous
polyp
< 50 years
Increased or high risk based on family
history
Increased or high risk based on personal
history
> 50 years
Adenoma
Do not screen
CRC
Screen
IBD
Surveillance
Colonoscopy
High Risk:
Germline Syndrome
HNPCC or FAP
Adenoma or cancer
If positive, diagnosis by
colonoscopy
Screening colonoscopy, genetic testing,
and other cancer screening as
appropriate
Options
Tests That Find Polyps and Cancer
Flexible sigmoidoscopy every 5 years, or
Colonoscopy every 10 years
Double-contrast barium enema every 5 years, or
CT colonography (virtual colonoscopy) every 5 years
Tests That Primarily Find Cancer
Yearly fecal occult blood test (gFOBT) *, or
Yearly fecal immunochemical test (FIT) *, or
Stool DNA test (SDNA), interval uncertain
Screen with colonoscopy 10 years
before youngest relative or age 40
*The
multiple stool take-home test should be used. One test done by the doctor in the office is not adequate for testing.
The tests that are designed to find both early cancer and polyps are preferred if these tests are available and the patient is willing to have one of
these more invasive tests.
*This version of stage theory was adapted from the work of RE Myers.
Patient Education
Get Tested For Colon
Cancer: Here's How."
7-minute video discusses and
demonstrates options for
colorectal cancer screening,
including potential benefits and
limitations of each method.
Available as DVD, or you can
refer patients to the URL to view
from their personal computer.
Be Persistent with Reminders
Essential #3
Essential #3
Determine how your practice will notify patient
and physician when screening and follow up is
due.
Ensure that your system
tracks test results and uses
reminder prompts for patients
and providers.
Tools for Your Practice
Essential #3: Be Persistent
• Reminder Systems
• Tracking Information
Office Wall Chart  Screening guidelines for Breast, Cervical, Colon, Prostate and other cancers
 General lifestyle/prevention  Tobacco cessation
 Healthy diet
 Weight, etc
 English and Spanish
Reminder Fold‐Over Postcard
©2009 American Cancer Society, Inc. No.0052.19
©2009 American Cancer Society, Inc. No.0052.19
Measure Practice Progress
Essential #4
Essential #4
Discuss how your screening system is working
during regular staff meetings, and make
adjustments as needed.
Have staff conduct a screening audit, or contact a
local company that can perform such a service.
Saving Lives Through Preventive
Cancer Screening
ADJUST
PLAN
STUDY
ACT
Tools for Your Practice
Essential #4: Measure Progress
• Staff Feedback
• Practice Performance
Click on education
drop down box
Then select Maintenance of
Certification
Communication
Saving Lives Through Preventive
Cancer Screening
Implement practice changes to achieve the Four Essentials.
Take steps to identify and screen every age-appropriate
patient.
Involve your staff, and put office systems in place .
Follow a continuous improvement model to develop and test
changes to your screening system.
Additional tools and resources to assist practices with increasing colorectal cancer screening can be found in the full version of the Toolkit. Available at www.nccrt.org and www.cancer.org/colonmd