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)
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