Finding Best Practices in Chronic Disease Prevention

Sally Honeycutt, MPH, CHESEvaluation Team Lead

Emory Cancer Prevention & Control Research Network (CPCRN)

These highlighted evaluation projects are supported by the Emory CPCRN, which is part of the Prevention Research Centers Program. It is supported by the Centers for Disease Control and Prevention and the National Cancer Institute (Cooperative agreement # 1U48DP0010909-01-1)

Project Goal

Generate practice-based evidence to address gaps in the research literature for cancer prevention and control by identifying and evaluating promising cancer prevention programs developed and conducted by organizations in southwest Georgia

Project Activities

Environmental Scan

Evaluability Assessment

Evaluations

Dissemination

Environmental Scan

• Community Advisory Board (CAB) recommended scan & referred programs

• Selection committee- Emory CPCRN- CAB- Southern GA Evaluation Association

• Identified 8 potential programs- 4 invited to apply- 2 selected for next stage

Evaluability Assessment (EA)• Pre-evaluation activity • Determine whether or not program is ready for

outcome evaluation • Emory CPCRN EA Objectives

- Describe and assess the program model- Determine the program’s capacity to produce needed

evaluation data- Assess stakeholder interest in evaluation & intended use- Determine feasibility of outcome evaluation

EA Components

Expert Review & Recommendations

Site Visit

Document Review Literature

Review

EA Data Collection & Analysis• Site visits

– Work with program staff to identify appropriate participants & format

– Langdale: 8 participants from 4 organizations– Cancer Coalition: 18 participants from 7 organizations

• Discussions/interviews recorded and transcribed verbatim

• Used matrix organized by EA questions to abstract and summarize relevant information

Evaluability Assessment Findings

The Langdale Company and TLC Benefits

Descriptive Case Study

The Langdale Company• Started 1894 as a family owned timber

company• Headquarters: Valdosta, GA

(subsidiaries in rural areas)• Diversified enterprise, subsidiaries in

forest products, automotive, banking, hospitality, land development, etc.

• About 800 employees

What is Unique about Langdale?Health Plan/Health Delivery Approach:• Not only self-insured, but self-administered • Necessitates preventive approach to care• Partner with organizations to provide:

- Comprehensive Medical Management- Case Management- Disease Management- Compliance/Health Advocacy support

Case Study Question & MethodsHow does an employer-owned and operated health benefits plan utilize the Chronic Care Model1 (CCM) to deliver quality chronic disease care to employees and their dependents?• Qualitative Data collection

– Individual interviews (n=6)

– Group discussions (n=2)

– Semi-structured interview guide with questions modified from Assessment of Chronic Illness Care (ACIC)

• Qualitative analysis to identify themes/concepts related to each CCM element

1 Wagner, E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness. [Review]. Milbank Q, 74(4), 511-544.

Preliminary Findings

CCM Element Degree of Fit with Langdale Approach

Clinical Information Systems

Fully developed clinical information system for chronic illness care and care coordination

The Community Fully developed system of linkages between Langdale’s employee benefits program and the community

Self-Management Support

Reasonably good to full support for self-management care within Langdale’s benefit programs

The Health System Reasonably good to full support for chronic illness care throughout the organization

Delivery System Design

In applicable areas, reasonably good to fully developed delivery system design around chronic illness care

Decision Support Less applicable to the employee benefits setting

Implications for Practice

• The CCM (and particular constructs) may help provide a framework for a worksite or employee benefits program to organize the delivery of quality chronic disease care.

• Future research should assess more broadly how worksites and employee benefits can be integrated into the CCM.

Community Cancer Screening Program

• Community Cancer Screening Program™ (CCSP) Goal:

To reduce and ultimately eliminate cancer screening disparities among low-income, uninsured and under-insured patients of local community health centers and other primary care practices

Promoting Colorectal Cancer Screening

• Goal: increase appropriate use of colonoscopy– 304 colonoscopies in 2010

• Patient Navigation Model– Establish and maintain clinical systems to identify and enroll

patients into CCSP– One-on-one education to encourage adherence to referrals for

screening– Address health care system and patient barriers to screening

CCSP: Evidence-based strategiesThe Community Guide to Preventive Services: Intervention Categories Recommended for Colorectal Cancer Screening2

Intervention Category Evidence for Method Used by CCSP

Provider Assessment & Feedback Sufficient: FOBT

Provider Reminder & Recall Systems Strong: FOBTSufficient: Sigmoidoscopy

Client Reminders Strong: FOBT

Small Media Strong: FOBT

One-on-One Education Sufficient: FOBT

Reducing Structural Barriers Strong: FOBT

2 www.thecommunityguide.org/cancer/

Outcome Evaluation of the CCSP

Evaluation Goals

• To explore differences in CRC screening rates at 4 intervention clinics as compared to 9 comparison clinics

• To explore the degree of patient navigator effectiveness towards improving colonoscopy screening rates

Research Design

EligiblePopulation

Non-RandomizedAssignment

CCSP4 clinics

No CCSP9 clinics

Colonoscopy No Colonoscopy

Colonoscopy No Colonoscopy

• Quasi-experimental design– 2 conditions– No randomization to condition

• 18-month study period– Nov. 1, 2009-Apr. 30, 2011

Eligibility Criteria

• Seen by a clinic primary health care provider at least once during the 18-month study period

• Age 50-64• Sliding fee scale eligible

Blue stars = CCSP Intervention ClinicsGreen stars = Comparison Clinics

Setting: All 13 FQHCs in region

FQHC: Federally Qualified Health Center

Southwest GA Federally Qualified Health Centers

• Four FQHC Systems– 13 total clinics

• Provider/Patient Ratio– Mean: 0.0039– Range: 0.0015-0.0087

• % Uninsured Patients– 0-25%: 6 clinics– 25-50%: 7 clinics

# Patients seen (2010)

# Clinics

< 1,000 1

1,001 – 2,000 5

2,001 – 3,000 2

3,001 – 4,000 4

> 4,000 1

Sample Size

• Intervention– 4 clinics– Serve 3,009 patients– 1,267 eligible patients– Take 25%– 350 charts to review

• Comparison– 9 clinics– Serve 11,001 patients– 2,506 eligible patients– Take 25%– 625 charts to review

975 patients

Data Collection Methods

• Data source: Patient medical charts (EMR & paper)• Time period: Aug. 2011 – Mar. 2012• Randomly select charts from list of eligible patients

provided by clinic• Trained abstractors collect data in clinics• Rigorous quality control methods

– 10% of records double-abstracted– 100% double-abstraction for primary outcomes (Colonoscopy

referral & exam)

Data Abstraction Form• Used to abstract data

from patient charts• Provides a standard way

to collect data• Captures

– Demographics– CRC history– CRC screening

• Colonoscopy• Sigmoidoscopy• Blood Stool Test

Data Analysis

• Analysis to date– Descriptive statistics– Identify potential confounders– Preliminary assessment of differences between

intervention and comparison clinics

• Pending analysis– Controlling for clustering within clinics– Screening rates by clinic– Relationship between navigator contacts and colonoscopy

Preliminary FindingsEvaluation Goal: To determine whether the colorectal cancer screening component of the Coalition’s CCSP is associated with increased rates of colonoscopy screening.

• n=809 patients at normal colorectal cancer (CRC) risk• Patient Demographics

– 66% female– Mean age 56 years (range 50-64)– 61% Black; 36% White

Preliminary FindingsAre rates of colonoscopy screening among uninsured/ underinsured patients age 50-64 at the four intervention clinics significantly higher than at the nine comparison clinics?

Note. Statistics not yet adjusted for clustering within clinics˄ Among patients due for colonoscopy during study† Among all eligible patient* p < .0001

Outcome Intervention Comparison Total c2

Had colonoscopy referral during study

No 108 (42.0%) 388 (76.1%) 496 (64.7%)86.738*

Yes 149 (58.0%) 122 (23.9%) 271 (35.3%)Had a colonoscopy exam during study

No 167 (65.0%) 477 (93.5%) 644 (84.0%)103.439*

Yes 90 (35.0%) 33 (6.5%) 123 (16.0%) Total ˄ 257 510 767 Compliant on any test No 166 (57.4%) 464 (89.2%) 630 (77.9%)

108.962*Yes 123 (42.6%) 56 (10.8%) 179 (22.1%)

Total† 289 520 809

Preliminary Findings

What is the degree of CCSP effectiveness towards improving colonoscopy screening behavior?

Note. Statistics not yet adjusted for clustering within clinics˄ Controlling for Race (Black)† Controlling for Race (Black) and Age (50-59 and 60-64)* p < .0001

Outcome Wald (c2) Odds Ratio

Had colonoscopy referral during study (among due) 75.447* 4.260˄Had colonoscopy exam during study (among due) 79.669* 7.708†Compliant on any test 89.448* 6.013†

Limitations

• Non-random assignment– Possibility program implemented in higher capacity clinics

• Variable quality of chart data– Intervention clinics: all EMRs– Comparison clinics: mix of paper and EMR– CCSP designed to improve quality of medical info in charts

• Contamination– Patients from comparison clinics referred to intervention

clinics for colonoscopy

AcknowledgmentsCCSP Staff, Stakeholders & Local TeamCancer Coalition of South GA: Denise Ballard, MEd

Diane Fletcher, RNRhonda GreenJames Hotz, MD

Medical College of GA: Alex BruederShavonda ThomasJennifer Yam

SW GA Family Medical Residency: Teri Stapleton, MD TSTC Health IT program: Aisha Viquez

Langdale Staff, Stakeholders & Local TeamThe Langdale Company: Barbara Barrett

Mark WilsonLowndes County Partnership for Health: Alan Powell

John SparksTLC Benefits Solutions, Inc.: Kate Waagner Doctor’s Direct Health Care: Tina Wise, RN

* Evaluability assessment or evaluation project leader † Expert Review Committee Member

Emory University CPCRNKimberly Jacob Arriola, PhD, MPH*†

Lucja Bundy, MEd, MAMichelle Carvalho, MPHCam Escoffery, PhD, MPH†

April Hermstad, MPHSally Honeycutt, MPH Michelle Kegler, DrPH, MPH†

Joseph Lipscomb, PhD†

Natasha Ludwig-Barron, MPHGillian Schauer, MPH*Iris Smith, PhD, MPH†

Deanne Swan, PhD*†

Amanda Wyatt, MPHVera (Jingqi) Yang, MPH

Questions?

• Ask now, or…• Look for our posters at

the National Cancer Conference in August!