Using survey data to plan a program to increase colorectal cancer

screening the Medicare population

Anna P. Schenck, PhD, MSPHCarrie Klabunde, PhDRenee Taylor, MPH

Nelson Gunter, MD, MPH

American Public Health Association 2002 Meeting

Collaborators

Carolina Medical ReviewSharon Eubanks, RN

Aunyika Tocharoen, PhD

Nelson Gunter, MD, MPH

Medical Review of NCRenee Taylor, MPH

Louise Henderson, MSPH

Sue Hunter, MPH

Leslie Hill

Lee Hurley

Robin Brown

Anna Schenck, PhDCenters for Medicare &

Medicaid ServicesJim Coan

Catherine Gordon National Cancer InstituteCarrie Klabunde, PhD

Who we are

Medical Review of North Carolina and Carolina Medical Review (in South Carolina) are Quality Improvement Organizations

Contract with Centers for Medicare & Medicaid Services to assure quality of care for Medicare consumers in each state

Background Colorectal cancer is the second most deadly

cancer in the US

Early detection and treatment are the best

defenses against colorectal cancer

Use of screening tests is low

Medicare introduced screening benefit in 1998

for enrollees age 50 and older

Medicare Coverage of Screening Tests

FOBT• yearly

Sigmoidoscopy• every 48 months

Colonoscopy• every 24 months for high risk • every 10 years for average risk (as of 7/1/2001)

Barium Enema• as alternative to sigmoidoscopy or colonoscopy

Project Overview

Center for Medicare & Medicaid Services awarded 2-year project to NC and SC• calculate national and state screening rates • develop and pilot interventions

NCI interest resulted in collaboration• focus groups• baseline and evaluation telephone survey

Baseline Survey Design

• each state selected intervention and comparison counties– SC (mixture of rural and urban)– NC (primarily urban)

Methodology• telephone survey conducted before the intervention• age 50 - 80, non-HMO, African American or White• randomly selected Medicare enrollees in NC and

SC intervention and control counties

What did we want to know? Beliefs, knowledge and attitudes

• risk factors• screening• Medicare coverage

Behaviors• which screening tests are being done• are guidelines being followed

Barriers• why are some not screened

Response

2004 completed interviews• NC = 1003• SC = 1001

Overall response rate 69%• NC = 67%• SC = 70%

Differential response among subgroups indicated a need for weighted analyses

Characteristics of Sample Sex

• Male = 43% Race

• White = 77%• African American = 23%

Education• Less than High School = 25%• High School or Equivalent = 36%• Post High School = 32%

Understanding of Risk of Colorectal Cancer

50

35

19

0

20

40

60

80

100

% r

esp

on

din

g co

rrec

tly

age increases risk equal risk amongsexes

both facts

Physician Recommendation for Colorectal Cancer Test

57

37 36

74

0

20

40

60

80

100

% w

ith

MD

rec

omm

end

atio

n

FOBT Sigmoidoscopy Colonoscopy Any Test

Ever Had Any Colorectal Cancer Test

56

37 35

72

0

20

40

60

80

100

% e

ver

had

tes

t

FOBT Sigmoidoscopy Colonoscopy Any Test

Had Test According to Guidelines

2025

33

55

0

20

40

60

80

100

% w

ith

tes

t in

rec

omm

end

ed i

nte

rval

FOBT Sigmoidoscopy Colonoscopy Any Test

Potential Barriers to Colorectal Cancer Testing

25 22

52

0

20

40

60

80

100

perc

ent

do not need toworry

do not agreetreatment helps

survival

do not knowMedicare pays

Use of other preventive services

Women• those who had

mammogram in past year were more likely to have had colorectal cancer test

• those who had pap smear in last 3 years were more likely to have had a colorectal cancer test

Men• those who had PSA

test in last year were more likely to have had a colorectal cancer test

Reasons for no test

Among those who had not had the test according to guidelines, two reasons most often listed:

• “I didn’t think it was needed” 12% - 18% (depending on test)

• “My doctor didn’t order the test” 77% - 82% (depending on the test)

Where do Medicare consumers get most useful health information ?

Internet1%

Family or friends

5%

Media5%

Health pamphlets or

books17%

Doctor or health

professional72%

What the survey told us about consumers

Plenty of room for improvement Lack of knowledge about risk factors and

coverage Those who use other preventive services were

more likely to have been tested Written information such as health pamphlets and

booklets may be useful with this population Media are less influential with this population

What the survey told us about physicians

Patients expect their doctor to order the test

Doctors may need to convince some

patients of the importance of screening

Physician recommendation strong influence

of whether the patient gets a test

Intervention Implications

Consumer interventions need to address:• belief in importance and efficacy of screening

• lack of knowledge about risk factors and Medicare coverage

• use of other preventive services

Provider interventions needed to address:• physician recommendation

• tools to convince patients

Consumer Intervention: CDC Screen for Life Mailing

CDC Screen for Life information was sent to beneficiaries selected in two ways:• randomly selected • selected from persons with regular preventive

service use Total of 16,400 packets were mailed

• 3,000 to randomly selected (NC only)• 5,600 to those with regular preventive service use• 7,800 to targeted aged groups (SC only)

CDC patient fact sheet

Consumer Intervention: Birthday Card

Beneficiaries in intervention counties who turned 65 were sent this card on their birthday

Total of 3,514 cards were sent NC only

Birthday card sent to NC

beneficiaries

Consumer Intervention: NCI Cancer Information Service

Postcards Beneficiaries randomly selected First card did not generate many calls so the

card was redesigned. NC sent 2 versions of a revised card while SC continued to send original cards

Total of 15,300 cards mailed over 6 months period in both NC and SC

Revised CIS Postcard - Positive

Physician Interventions

Provider teleconferences• 2 teleconferences

– promotion of the new screening benefit and project– how to increase screening in the office and get paid

for it

Mailing of physician postcards (SC only) Distribution of FOBT kits through

physician offices (SC only) Provider Toolkit

Screen for Life Toolkit

Promoted through mailings, web-site, regional meetings, fast-fax through NC Medical Society

Ordered via fax-back forms, mail-in forms, web-site

Contained screening guidelines, billing instructions, state testing data and office-based tools

Total of 380 toolkits were distributed• approximately 20% of MDs in target area

Patient Assessment used as part of a reminder system

Patient Health Maintenance FormAs your health care providers, we would like to review some important parts of your health history. Please answerthe following questions. Only answer the questions in the sections that apply to you. If you have filled out thisform in the past 6 months, you do not need to do so again; you may stop here.

Name _________________________________________ Date_____________ Date of birth _____________

Have you ever had the pneumococcal vaccine (pneumonia shot)? Yes___ No___ Don’t know___Have you had your cholesterol checked in the past 3 years? Yes___ No___ Don’t know___

Have you had the flu shot this year? Yes___ No___ Don’t know___Have you had your stool checked for blood (FOBT) in the past year? Yes___ No___ Don’t know___Have you had a flexible sigmoidoscopy in the past 5 years? Yes___ No___ Don’t know___Have you had a colonoscopy in the past 10 years? Yes___ No___ Don’t know___

Have you had a mammogram in the past year? Yes___ No___ Don’t know___

Have you had a pap smear in the past year? Yes___ No___ Don’t know___Have you had a breast exam by a health professional in the past year? Yes___ No___ Don’t know___

Have you had a rectal/prostate exam in the past year? Yes___ No___ Don’t know___Have you had a blood test for prostate (PSA) checked in the past year? Yes___ No___ Don’t know___

Have you had an eye exam by an eye professional in the past year? Yes___ No___ Don’t know___Have you had your feet examined in the past year? Yes___ No___ Don’t know___Have you had your urine checked in the past year? (microalbumin) Yes___ No___ Don’t know___Have you had your cholesterol and lipids checked in the past year? Yes___ No___ Don’t know___Has your blood been checked for longer term sugar control in the past 6 months (HbA1c)? Yes___ No___ Don’t know___

Do you use tobacco? Yes___ No___Have you seen a dentist in the past year? Yes___ No___Are there other issues you would like to discuss with your provider? Yes___ No___

If so, please list.

Medical Review of North Carolina, Inc., Health Maintenance Tool, 2001. This material was prepared by Medical Review of North Carolina, Inc., under a contract with the Centers forMedicare and Medicaid Services, formerly the Health Care Financing Administration. The contents presented do not necessarily reflect CMS policy. 6SOW-NC-CRC-01-01

Clinician comments:

Patients 65 years and older

Patients 50 years and older

Women 40 years and older

All women

Men 50 years and older

Patients with diabetes

All patients

Chart Sticker from Physician Tool Kitused as part of a reminder system

Stage-of-change based patient education brochures (used with video)

Post Card for Physicians to send to Patients

For more information, contact:

Anna Schenck

Medical Review of NC5625 Dillard DriveCary, NC 27511

919 851-2955ncpro.aschenck@sdps.org

Check out Medicare Statistics on our website: www.mrnc.org/ncmed

or www.mrnc.org/crcreport