Increasing Colorectal Cancer Screening Increasing Colorectal Cancer Screening through an Academic Detailing through an Academic Detailing
InterventionIntervention
ACCN Research Roundtable October 8, 2008
Mark Dignan, Nancy Schoenberg, Kevin Pearce, Brent Shelton, Cheri Tolle
Supported by the National Cancer Institute # CA113932
Colorectal cancer in Kentucky
SEER IncidenceIncidence MortalityMortality
US US 53.153.1
(52.8-53.4) (52.8-53.4)
19.619.6(19.5-19.8) (19.5-19.8)
Kentucky Kentucky 58.758.7(56.4-61.1) (56.4-61.1)
24.224.2(22.7-25.7) (22.7-25.7)
Colorectal cancer in Kentucky (SEER)
0
10
20
30
40
50
60
Incidence Mortaltiy
US
Kentucky
Appalachian KentuckyAppalachian Kentucky
Compared with the rest of the United States, Appalachia is medically underserved economically distressed disproportionately burdened with cancer
Education & EmploymentEducation & EmploymentEducation (%)Education (%) Perry Co.Perry Co. KYKY
High School or higherHigh School or higher 58.358.3 80.480.4
Bachelor’s or higherBachelor’s or higher 8.98.9 24.424.4
Unemployment (%)Unemployment (%) 5.15.1 3.73.7
Poverty (%)Poverty (%) 26.126.1 12.712.7
To increase colorectal cancer screening provided by primary care practices in
Appalachian Kentucky
Project GoalProject Goal
MethodsMethods
Phase 1: Formative Research
Phase 2: Intervention Trial
Phase I: Formative Research Provider survey to establish contact with
practices and identify general characteristics
Focus groups to obtain qualitative information and fill gaps in survey data
Phase II: Intervention Trial
Participants: Primary care practices inAppalachian Kentucky
Family Medicine General Internal Medicine General Practice
Outcome: Increase Screening (FOBT, FS,
DCBE, Colonoscopy)
Academic Detailing Intervention
1. Academic detailing involves providing education where physicians are instructed through personal contact with an individual or group focused on a specific topic
2. Well-known as a method for pharmaceutical sales, this approach has been found to be a novel and effective way to reach busy physicians to provide medical education.
Objectives guiding Implementation
• Implement an educational intervention through academic detailing
• Evaluate the effectiveness of the intervention at 6 and 18 month post intervention data collection.• 6 – month data to assess efficacy• 18- month data to assess sustainability
Intervention Planning
• Need for partnerships• Identification of primary care practices• Desire for a community-based approach to
intervention delivery• Project management issues
•Travel and logistics•Communication with practices
• Area Health Education Centers
Why Area Health Education Centers?
• Regional agencies in Kentucky• Provide structure for continuing medical education• Provide for opportunities for health professional
training outside academic institutions
• They have capacity for outreach to rural health care providers
• Education is key to their mission• Research participation is a new activity for them
Study Areas – Three AHEC Regions
Recruitment Recruitment and and Baseline Baseline AssessmentAssessment
RandomizatioRandomizationn
InterventioInterventionn
6-Month 6-Month Post-Post-Intervention Intervention Data Data CollectionCollection
18-Month 18-Month PostPostInterventionInterventionData Data CollectionCollection
6666 Practices PracticesGroup 1 Group 1 (n=33)(n=33)
InterventionIntervention OO OO
RandomizeRandomize
Group 2 Group 2 (n=33)(n=33)
DelayedDelayed OO OO
Research DesignResearch Design
ProceduresProcedures
1. An academic detailer in each AHEC region recruited primary care practices.
2. A physician in each practice completed a provider interview.
3. The academic detailer delivered the intervention – the intervention modules focused on
• Efficacy of colorectal cancer screening• Reimbursement• Patient counseling• Practice management.
4. Project staff conducted medical record reviews in each practice
Evaluation Plan – Process and Q/CEvaluation Plan – Process and Q/C
Process Monitoring data collection and intervention delivery
Quality control Post intervention assessment of veracity of reports
Evaluation Plan - OutcomesEvaluation Plan - Outcomes
Outcomes Quantitative – Proportion of patients ‘screened’ in
practices Qualitative – Key informant interviews to assess
intervention and project experience Health care providers Office staff Intervention staff
Results To DateResults To Date
• Recruitment – All 66 practices recruited
• Implementation – Intervention delivered in all 33 practices
• Screening data• Baseline – All practices complete• 6-month – 28 practices complete
19
Results - FOBTResults - FOBT
FOBT Recommendation
Baseline Follow-up
Intervention 17.4 (330/1900) 20.7 (135/653)
Delay 19.5 (392/2006) 19.5 (270/1386)
FOBT Results Documented
Baseline Follow-up
Intervention 16.1 (305/1900) 15.6 (102/653)
Delay 9.0 (181/2006) 15.7 (218/1386)
Results – Flex SigResults – Flex Sig
Flex Sig Recommendation
Baseline Follow-up
Intervention 0.3 (6/1900) 0.2 (1/653)
Delay 0.5 (10/2006) 0.3 (4/1386)
Flex Sig Results Documented
Baseline Follow-up
Intervention 0.4 (7/1900) 0.2 (1/653)
Delay 0.3 (5/2006) 0.4 (5/1386)
Results - ColonoscopyResults - Colonoscopy
Colonoscopy Recommendation
Baseline Follow-up
Intervention 42.7 (811/1900) 48.9 (319/653)
Delay 44.7 (897/2006) 48.5 (672/1386)
Colonoscopy Results Documented
Baseline Follow-up
Intervention 28.8 (547/1900) 40.3 (263/653)
Delay 30.5 (612/2006) 33.9 (470/1386)
Results – Barium EnemaResults – Barium Enema
BE Recommended
Baseline Follow-up
Intervention 0.3 (6/1900) 0.2 (1/653)
Delay 0.3 (5/2006) 0.0 (0/1386)
BE Results Documented
Baseline Follow-up
Intervention 0.3 (5/1900) 0.3 (2/653)
Delay 0.3 (5/2006) 0.0 (0/1386)
Results – All Screening modesResults – All Screening modes
Ever Recommended Screening (Any Type)
Baseline Follow-up
Intervention 48.5 (921/1900) 56.2 (367/653)
Delay 50.6 (1015/2006) 52.5 (727/1386)
Appropriate Screening (Meeting Recommendations for Any Type)
Baseline Follow-up
Intervention 29.5 (560/1900) 37.5 (245/653)
Delay 29.2 (585/2006) 34.1 (473/1386)
Screening Recommended and Completed Screening Recommended and Completed by Study Group, BASELINEby Study Group, BASELINE
25
Findings – To date
• Screening rates are low. • Colonoscopy appears to be the screening test that is
recommended most commonly in this population.
• Rates for fecal occult blood testing are low which may indicate a lack of enthusiasm for this method.
• Rates for flexible sigmoidoscopy are so small as to be negligible, suggesting that primary health care providers have largely ceased providing this service.
Next StepsNext Steps
• Complete delayed group intervention delivery• Complete post-intervention data collection• Analyze data and investigate stopping rule• Schedule 18 month follow-up data collection• Develop application to fund dissemination
study
Dissemination study (Effectiveness)Dissemination study (Effectiveness)
Tentative Research Questions
1. Can an academic detailing intervention designed to increase colorectal cancer screening in rural primary care practices be disseminated through the AHEC system?
2. . Are there factors that facilitate or inhibit the diffusion of innovation process through the AHEC system?
Collaborators
Southern AHEC• Dwaine Harris• Shirley Balman
Southeastern AHEC• Michael Gayheart• Gwen Whitaker
Northeastern AHEC• Kayla Rose• Caudill, Jaime
UK Collaborators
Southern AHEC• Dwaine Harris• Shirley Balman
Southeastern AHEC• Michael Gayheart• Gwen Whitaker
Northeastern AHEC• Kayla Rose• Caudill, J aime
UK PRC• Cheri Tolle• Mark Dignan• Nikki Lawhorn
Module One
Colorectal Screening:
Does it Work?
Colorectal Cancer… Preventable. Treatable. Beatable.
Learning Objectives
• Cite incidence and mortality rates for colorectal cancer in Kentucky by Area Development Districts
• Discuss the effectiveness of four colorectal cancer screening methods
• Identify age and frequency guidelines for colorectal cancer screening
Colorectal cancer is the second leading cause of cancer-related death in the US and Kentucky
Colorectal Cancer Incidence Rates by County
Colorectal Cancer Mortality Rates by County
Colorectal Cancer Diagnoses 2004 Area Development Districts
Population at Risk
Total Cases
State of Kentucky
4,141,835 2465
Bluegrass 713,821 384
Cumberland Valley
241,334 159
Lake Cumberland
198,385 136
Big Sandy 158,836 102
FIVCO 136,786 108
Kentucky River
119,307 84
Gateway 78,480 48
Buffalo Trace 56,242 40
Colorectal Cancer Deaths 2004 Area Development Districts
Population at Risk
Total Deaths
State of Kentucky
4,141,835 856
Bluegrass 713,821 127
Cumberland Valley
241,334 51
Lake Cumberland
198,385 31
Big Sandy 158,836 32
FIVCO 136,786 36
Kentucky River
119,307 25
Gateway 78,480 14
Buffalo Trace 56,242 15
Screening for Colorectal Cancer is Effective
Colorectal Cancer Screening Evidence
• Fecal Occult Blood Test (FOBT) • 33% mortality reduction, 20% incidence reduction (annual testing, three cards at home)• Sigmoidoscopy
• 59% mortality reduction within reach of scope
• Colonoscopy• 40-60% incidence reduction
• Double Contrast Barium Enema (DCBE)• Still being evaluated as screening tool
Everyone 50 years and older should receive regular screening for colorectal cancer
High risk individuals may need to begin screening earlier
Colorectal Cancer Screening Guidelines
• FOBT
yearly
• Sigmoidoscopy
5 years
• Colonoscopy
10 years
• DCBE
5 years
Summary
Colorectal cancer is the second leading cause of cancer-related deaths in the US and Kentucky Colorectal cancer incidence rates tend to be higher in eastern Kentucky Current screening methods are FOBT, sigmoidoscopy, colonoscopy, and DCBE All asymptomatic patients age 50 and over should be referred for screening FOBT = annually; Sigmoidoscopy = 5 years; Colonoscopy = 10 years; DCBE = 5 years