D EPARTMENT of F AMILY M EDICINE CRC Screening: Projects in Department of Family Medicine,...

DEPARTMENT of FAMILY MEDICINE

CRC Screening: Projects in Department of Family Medicine, University of Iowa

Barcey T. Levy, PhD, MDCancer Summit

October 17, 2008


Background

Colorectal cancer is the 2nd leading cause of cancer-related death.

75 – 90% of cases can be prevented or cured if caught early.

Practice guidelines consistently confirm average risk patients should begin CRC screening at 50 years with repeat at intervals appropriate to the test.

75% of those diagnosed with CRC have no symptoms or family history.

Over half of Americans age 50+ have not been screened for CRC.


Projects

Agency for Healthcare Research and Quality sponsored study to examine CRC screening among rural Iowans. Factors predicting screening Doctor’s reasons for not screening specific

patients IDPH study to encourage uninsured or

underinsured individuals to be screened Newly funded ACS funded study


Iowa Research Network


AHRQ Study Design

Mixed-methods 57 of 240 IRENE (Iowa Research Network)

physicians expressed interest in a study to examine CRC screening in their practice.

A stratified random sample of 16 family physicians in separate practices were enrolled.

Within each practice, a random sample of 60 patients per physician aged 55 – 80 years invited by mail.


InstrumentsQuantitative Patient: 8-page mailed survey about past CRC screening and

attitudes toward screenings.

Medical record review: Documentation of past CRC screening recommendations, tests completed, reasons for test, and medical conditions.

Physician: 3-page mailed survey about attitudes toward CRC screening, systems to facilitate screening, and which tests they personally perform.

Qualitative Physicians dictated their reasons for screening or not screening

3 patients in each category for CRC, as well as their general approach to screening.


Main Outcome: CRC Testing

Any of the following: Take home hemoccult x 3 at least 5 times

< 5.5 years. (Guidelines specify annual testing.)

Flexible sigmoidoscopy < 5.5 years. Colonoscopy < 10.5 years. Barium enema < 5.5 years.

Consistent with ACS/American Gastroenterological Association/USPSTF guidelines


Qualitative Analysis

To assess physicians’ reasons for not screening or for screening specific patients for CRC


Results (Quantitative)

511 patients returned survey and had medical record review conducted in 16 practices (53% of original sample).

Response rate of 30% to 80% for patients of a given physician (18 to 48 patients per physician).


Iowa IRENE CRC Practices


Patient Demographics (n=511)

Mean age of 68.1 yrs 99% white 93% lived in rural counties 81% married 80% total household income below $60,000 62% government insurance 26% working full-time 23% college graduate or higher


Physician Characteristics (n=16)

Age: 53 years (range 43 – 69 years) Length of time in practice: 21.6 years Partners: 5.5 Town size/median population: 6,112 All are board-certified family physicians


Patient Self-report

Has your doctor ever recommended a CRC test? 76% said yes.

Did you complete the recommended test? 70% said they had.

Has your doctor recommended a CRC screening test? 55% said yes.


Chart Review

46% overall were up to date with CRC Screening. 41% had colonoscopy < 10.5 years. 5% had flexible sigmoidoscopy < 5.5 years. 6% had barium enema < 5.5 years. 1% had annual hemoccult x 3 for 5.5 years.

Of those up to date: 39% received asymptomatic screening 61% received diagnostic testing


Patients with CRC tests: current and true screening

0%

10%

20%

30%

40%

50%

60%

70%

80%

Pe

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..

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Overall

Physician

Proportion Current (ACS guidelines) Proportion Screened (no symptoms)


Physician Predictors: Univariate ORs

Variable OR (95% CI) p-value

Patient recalls MD recommendation* 6.4 (4.2, 9.6) <.001

MD documented CRC discussion* 14.1 (8.5, 23.3) <.001

* Not considered in multivariate model


Physician recommendation is VERY important

Among patients who received asymptomatic testing, 90% recalled their physician recommending this, compared with only 37% of those not up to date with testing.


Predictors of CRC testing up to date (multivariable)

Variable mult. OR (95% CI) mult. p-value

Government insurance 1.6 (1.2, 2.3) .004

> 1 annual exam visit 2.4 (1.4, 4.1) .002

Family history of CRC 3.1 (1.6, 5.8) <.001

Number of medical conditions 1.2 (1.1, 1.3) <.001

Importance to patient 2.6 (1.5, 4.5) .001

Satisfied with dr’s discussions of screening importance 3.3 (2.2, 4.8) <.001

Physician able to do FS 2.3 (1.6, 3.4) <.001

Physician feels they follow ACS screening guidelines 1.7 (1.2, 2.5) .005


Qualitative Study

15/16 physicians (94%) telephoned in responses to a structured set of questions

Three patients of each physician from the larger study were randomly chosen who were not up to date with CRC guidelines

We asked physicians to tell us whether screening was discussed with the patient and what factors led to this patient not being screened for CRC


Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines

(based on 40 patients)When CRC screening was not discussed: 20 patients Lack of opportunity to discuss screening

• Patients came in only for acute visits or problems• Patients came in sporadically or saw other providers for health

maintenance care• No tracking system• Not enough time during appointments

Physician forgetfulness Assessment that cost or lack of insurance would be prohibitive to

patient Patient had life issues or other health problems that distracted from

screening Expected patient refusal or lack of interest


Physicians’ Reasons for Specific Patients Not Being Up to Date with CRC Guidelines

When CRC screening was discussed, but patient declined: 20 patients

Cost of screening tests Lack of interest in screening Patient autonomy Patients had life issues or other health problems Fear of screening test procedure No symptoms or family history of CRC


Example Quotes: Factors Preventing Screening Discussions

Patient’s focus on illness and symptoms

“[The patient] has always been a very acute care oriented patient and probably has only come to see me on maybe 3 occasions over the past 15 years. Hence, again, his inconsistent seeking of health care has led to failure to screen for colorectal cancer.”

Lack of tracking system led to forgetfulness:

“She generally presents for acute care, and honestly with…the intermittent few times I see her, I forgot to even bring up colorectal cancer screening. And so, I would put her down as an office system issue with no reminder tracking system.”

Lack of time:

“I think the reason that he wasn’t screened, and probably several other [patients], was just a matter of time in not getting everything done.”


Example Quotes: Physician’s Assessment that Patient Would Decline

“Anyway, the bottom line is he doesn’t have any insurance and he doesn’t have any money, and he’s a truck driver kinda just barely scraping by.”

“So, basically, we’re distracted and he’s distracted by other [health ] problems. I don’t believe I’ve ever really pushed getting colon cancer screening.”


Example Quotes: Factors Leading to Specific Patients Declining Screening:

Cost“[She] won’t do it because she doesn’t have the finances and doesn’t have insurance [that] will pay for the procedure.”

Patient Lack of Interest“I think basically he’s just your proverbial older rural Iowa retired farmer guy who kind of likes to leave things well enough alone…and so I’m not too surprised if he doesn’t do everything that I tell him to do.”

Confounding Factors“Her husband had recently died. She had a depressive reaction associated with it and did not think it was necessary to do the screening.”

Patient Fears“She was not screened and…is resistant to have the colonoscopy due to the fear of the procedure.”

Low Perceived Risk“[He] has not been screened because he has no interest in…having a colonoscopy done unless he was having some symptoms that would require it.”


Discussion

Less than half of patients were up to date with CRC screening by current guidelines.

Of those up to date, over half (61%) received diagnostic testing (testing in response to symptoms).

Physicians can substantially influence patients. Only 55% patients recalled their doctor

recommended screening. Colonoscopy was the most prevalent method of

screening. Physician-specific rates of pts being screened

appropriately varied widely (5% to 75%)


Physician-identified Factors That Influence CRC Screening

For half of patients not up to date, discussion about screening did not take place.

Many CRC tests were ordered for patients with symptoms or with increased risk.


Implications

Physician discussion and recommendation is key! Medical insurance should cover health maintenance

exams. Medicare does not currently cover health maintenance exams. Discussion of CRC screening options and rationale takes time.

Quality measures should take into account the importance of physician education and adequate discussion for the patient and should reward physicians for incorporating these into practice.

Reported rates should exclude patients who have declined screening after a documented discussion.


Interventions to improve CRC screening rates are needed!

Develop successful patient and physician education programs about the importance of screening (before symptoms occur).

Identify effective tracking and reminder systems.

Identify effective elements of physician recommendation and discussion for successful screening.


Conclusions

Many factors interfere with CRC screening discussions.

Most patients who were up to date received diagnostic as opposed to asymptomatic testing.

Interventions will likely require health system changes, and education aimed at both the physician and the patient.


IDPH contract

Goal was to screen asymptomatic individuals who were uninsured or underinsured

Used a fecal immunochemical test (FIT) kit that required a small sample from a single stool


Potential Individuals Eligible for Screening

Electronically identified individuals attending UIHC clinics in Family Medicine/Internal Medicine who were “underinsured” and who had not been screened for CRC in appropriate interval.

Approached people in person or by mail in clinic settings for low-income in Johnson County (Free Medical Clinic and UIHC clinics)

Hung posters about this screening program in various venues in Johnson County


Patient Recruitment 1,882 patients identified by IT as having no or low

insurance and mailed information about the study including a cover letter, consent forms, an eligibility form and a return envelope

112 individuals received a mailing through the Iowa City Free Medical Clinic

92 approached in person in primary care clinic 41 approached in family & internal med clinics Eligible if Iowa resident, no coverage for CRC

screening, and no CRC screening in the accepted intervals


Patient recruitment and follow-up

94 half-days spent on face-to-face recruiting Preparing mailings and clinic packets throughout the

6 months involved ~ 3 hours per day 1 hour each day to test specimens, send notice to

participant of results, log in database, and notify GI clinic

Medical student donated 24 hours calling patients Follow-up letters and phone calls all took time


FIT results

A total of 298 FIT kits have been handed out or mailed, with a total of 235 kits returned (79%).

Of the 235 kits returned, 186 tested negative (79%) and 49 (20%) tested positive.

Each individual with a positive result was telephoned and their result explained to them. The Division of Gastroenterology at the University of Iowa is conducting colonoscopies on those with positive results.


Colonoscopy Results 16 colonoscopies completed to date 9/16 had at least one biopsy due to polyps

5 had at least one tubular adenoma 4 had only hyperplastic polyps 2 had polyps of both types

One individual had an incomplete colonoscopy due to pronounced narrowing of the colon; f/u barium enema was normal

No complications from any of the colonoscopies Remaining colonoscopies are in the process of being

scheduled


How could program be better? 95% felt that the test was not difficult to complete “Doesn’t need improving, easier test than

colonoscopy” “Great program, thanks so much” “The communication could be better” “It was ok for me as is. The fact that this is a free test

to help save lives is highly commendable.” “Not sure, but I was thankful to be involved with the

program, my best friend passed away from colon cancer.”


Conclusions from IDPH

Patients in need of screening had a 75% return rate for the FIT kits

People were generally quite satisfied with the program

The positive rate was much higher than anticipated leading to more colonoscopies than originally anticipated.

Still completing colonoscopies.


ACS study

Funded 7/1/08 Will do an intervention study in 15 rural family

physician offices to encourage individuals who have never been screened or who are due for screening to be tested for CRC

We will randomize patients within offices to one of four interventions


Any questions?

D EPARTMENT of F AMILY M EDICINE CRC Screening: Projects in Department of Family Medicine,...

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