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

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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