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Abstract: Colorectal cancer screening (CRCS) is the only way to detect colorectal cancer in its earlier stages when morbidity and mortality are low. The literature has shown provider-directed recommendations with office system-directed interventions are the best way to increase CRCS rates.
Colorectal cancer (CRC) is the third leading cause of death for men and women in the United States, yet it is also preventable or amenable to early diagnosis when screening is implemented.1 Despite numerous national campaigns aimed at increasing public awareness, colorectal cancer screening (CRCS) remains underutilized.1,2
Several national organizations have developed evidence-based CRCS guidelines to educate the public and providers about the various tests available to screen for CRC.3,4 Furthermore, there is some confusion about the variety, specificity, and sensitivity of these tests, resulting in low CRCS rates.5-8 In addition, providers have cited many barriers to adhering to CRCS guidelines, including patient comorbidities, patient refusal, provider forgetfulness, lack of time, other health priorities during office visits, and lack of reminders and tracking systems.9,10
Though the number of CRC deaths has continued to decline since 1998, approximately 51,370 people died from CRC in 2010.11 More than half of CRC deaths can be prevented with CRCS because precancerous polyps can be identified with screening and removed before cancer develops.12 Among adults ages 50 or older, the national CRCS adherence rate via sigmoidoscopy or colonoscopy is 62.2%.13The American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008 recommendations state that CRCS should begin at age 50 for both men and women of average-risk, and at age 45 for Black men and women.4
In 2008, the U.S. Preventive Services Task Force (USPSTF) revised CRCS guideline recommendations as reported by the National Cancer Institute (NCI) according to the potential benefits, potential harms, effectiveness, and most current research for each test. USPSTF recommended that all people ages 50 to 75 should undergo high-sensitivity fecal occult blood testing (FOBT) annually; flexible sigmoidoscopy every 5 years with high sensitivity FOBT every 3 years; or colonoscopy every 10 years (see U.S. Preventive Services Task Force colorectal cancer screening recommendations).3
Risk factors for developing CRC include being 50 years old or older, a diet high in saturated fat and low in fiber, obesity, excessive alcohol consumption, cigarette smoking, physical inactivity, and family history of CRC.1,4 Prior to 1989, the incidence of CRC was higher in White males. Since then, the incidence rates have increased in Blacks of both genders compared to Whites of both genders.1 While primary prevention focuses on making healthier diet and lifestyle choices, secondary prevention aims to reduce morbidity and mortality. CRCS is the key to secondary prevention because it allows for removing precancerous polyps or diagnosing CRC earlier.
The most significant predictor of a person following through with CRCS is provider recommendation.14-17 Yet, during office visits, providers often miss the opportunity to recommend or perform cancer screening.18,19 Therefore, it is important to assess what provider-directed interventions in the primary care setting facilitate adherence to CRCS guidelines, and determine what direction future CRCS research should take.
The USPSTF identified three pathways to increase provider delivery for CRCS: provider assessment and feedback, provider incentives, and provider recommendation and recall systems (provider reminders). Provider assessment and feedback interventions assess performance based on the recommendation/completion of screening tests on a regular basis. Provider incentives include direct (monetary) and indirect (continuing medical education credits) rewards for recommendation/completion of screening tests. Provider reminders include colored flags in patient charts, flow charts, checklists, and e-mail or electronic medical record (EMR) reminders that alert the provider to a patient's need for cancer screening. These three pathways were used to narrow the scope for the literature review.
This literature review encompasses a comprehensive assessment of current literature related to provider-directed interventions used to increase CRCS rates using at least one of the provider pathways identified by the USPSTF. Databases searched included CINAHL, MEDLINE, PubMed, Cochrane Library, and Cochrane Central Register of Controlled Trials (supplemented with hand searches) for English-language articles published in the United States between 2000 and 2011. Key words used were provider, interventions, and colorectal cancerscreening. This search resulted in seven studies and two systematic reviews. The systematic reviews were analyzed for individual studies to be included in this review, resulting in five additional articles. Several studies were found in multiple databases and counted only once.
Several studies incorporated patient interventions in addition to provider interventions. These studies were included if interventions were conducted separately and if statistical analyses were reported separately to eliminate the potential for contamination of provider intervention data. After inclusion and exclusion criteria were applied, 11 studies were accepted for final use. Nine studies were randomized control trials (RCTs), one study was a non-randomized RCT, and one study was a time-series analysis.20-30
The types of provider reminders included interoffice letters, electronic computer reminders, and computerized paper attachments to charts.20,25,28 Exclusive use of provider reminders showed mixed results in three studies. Reminders mailed to physicians increased surveillance colonoscopy by 9.2% compared to 4.5% in the control group (P = 0.009).20 The Clinical Reminder and Outcomes System did not produce a significant change in FOBT at baseline or intervention periods.28 Sequist et al. implemented electronic reminders during office visits as a provider intervention method.25 The group given reminders showed no significant change from the control group (41.9% versus 40.2%; P = 0.47), but the more office visits a patient had, the higher the CRCS rates. Patients with three or more office visits experienced increased CRCS rates of 59.5% versus 52.7% (P = 0.07) in the control group. Two studies showed an increase in the detection of adenomas.20,25
Nease et al. deployed ClinfoTracker, a computer reminder system set up according to the USPSTF guidelines.29 All staff members were trained to use ClinfoTracker and two offices without electronic scheduling used reminder forms attached to patient charts. The average baseline CRCS rates was 41.7% and in 9 months, CRCS rates increased to 50.9% (range 33.2 to 66.5%) with an average increase of 9% (range 9 to 24%; P = 0.002).
Academic detailing is used to increase knowledge through some form of education such as providing written documents or a presentation. Shankaran et al. implemented academic detailing and a $100 honorarium was given to participating physicians.26 Outcome measurements at 12 months showed a 7% increase in colonoscopies.
Persell et al. combined reminder systems with assessment and feedback for a time-series analysis.30 A flagging system within the EMR was implemented. Providers received quarterly performance reports over the 2-year study period. The baseline CRCS rate was 53.7% (P = 0.007) and rose to 62% (P < 0.001).
Roetzheim et al. conducted a clustered RCT to determine the efficacy of the Cancer Screening Office Systems (Cancer SOS) intervention to increase FOBT in eight underserved, county-funded primary healthcare clinics.23 Office staff was trained to ensure patient completion of a cancer screening checklist and to use chart stickers that reflected screening status. Every 6 months, office staff received feedback for CRCS rates. Random chart reviews at baseline and at 12 months showed that the intervention increased the odds ratio (OR) for FOBT (OR = 2.5, 95% CI, 1.65 to 4.0, P < 0.0001).
Ruffin and Gorenflo developed an RCT with four arms: a control arm, office intervention arm, patient intervention arm, and a combined office and patient intervention arm.24 The office intervention arm varied slightly between practices, as each office staff determined what steps they wanted to implement to increase screening recommendations. Baseline FOBT rates were 38% among control practices, 35% for office intervention practices, 38% for patient intervention practices, and 31% among practices that used both interventions. After 1 year, all practices showed an increase in FOBT; however, at year 2, FOBT rates dropped in all practices. Despite even the small increase for the combined intervention in year 3, these various interventions made no significant long-term difference in FOBT.
Thompson et al. targeted their intervention toward LPNs.27 The LPN identified FOBT-eligible patients and then completed the Health Promotion Screening Form. Once the provider approved the form, the patient received an FOBT kit upon departure and was given 90 days to return all the cards. Compared to the control group, FOBT increased (15% versus 52%, P < 0.001).
Lane et al. conducted an RCT using three provider interventions to increase endoscopy referral and/or FOBT dispensing/completion in community health centers.21 First, the educator/facilitator made a preintervention visit to build partnerships with the sites. Second, a 1-hour continuing medical education-approved session was offered. Third, a strategic planning session was conducted at each site with all staff members using SWOT (Strengths, Weaknesses, Opportunities, and Threats) analysis. Each site then developed its own action plan to delineate responsibilities with the goal of increasing CRCS. Based on medical record audits, the intervention group had a 16% increase from baseline in CRCS referral/dispensing/completion compared to 4% in the control group (OR = 2.25, range = 1.67 to 3.03, P < 0.001).
Over 2 years, Ornstein et al. conducted a group-randomized intervention trial that combined electronic medical record audit and feedback, practice site visits with academic detailing, participatory planning, and best practice dissemination meetings for the interventional group.22 Thirty-two internal and family medicine practices reported quarterly data and received practice and provider feedback regarding the CRCS status of their patients. Site visits were conducted every 6 months to facilitate use of the Practice Partner Research Network (PPRNet) model and share best practice approaches to improve practice performance. After 2 years, a repeat EMR review was conducted to measure practice using the same criteria as the baseline practice data collection. EMR results showed that the intervention practices increased CRCS from 60.7% to 71.2%, compared to an increase among control practices' from 57.7% to 62.8% with the adjusted difference of 4.9% (95% CI, range 3.8% to 6.1%). The percentage of recommendations for CRCS also increased in the intervention practices, with an adjusted difference of 7.9% (95% CI, range 6.3% to 9.5%).
The studies reveal greater opportunities to increase CRCS. Combining two provider-directed interventions showed a positive and synergistic effect to increase CRCS.23,26,30 Combining multiple provider-directed interventions was shown to be very effective, demonstrating a statistically significant increase in CRCS rates.21,22
Among the published work, only Ornstein et al. identified a guiding framework (see PPRNet TRIP QI Model).22 Implementing this model proved to be very successful in increasing CRCS rates in this study. The PPRNet TRIP QI Model was developed from previous research grounded in complexity science theory and microsystems theory to explain office systems improvements when clinical guidelines were implemented.31-33 This model is delivered using practice performance reports from EMR data extracts on a set of quality indicators relevant to primary care. Site visits and network meetings are used to develop a practice-wide learning organization. In conjunction with this model, Nemeth et al. established the concepts for practice development, extending the Institute of Medicine's work on microsystems from large, integrated healthcare delivery systems to small- to medium-sized independent primary care practices.31,34 Four well-defined components-organizational leadership, people, performance/improvement, and information-were used to learn the primary care practice's organizational structure, communication systems, roles and responsibilities of members, and leadership abilities within that specific microsystem.31
The process of change includes: vision with clear goals; team involvement; enhanced communication systems; developed staff knowledge; small, incremental steps; EMR assimilation into practice; and feedback within a culture of improvement.
This model was tested in the nationwide Practice Partner Research Network and has been effective at increasing CRCS rates.22,32 It is expected that this model will continue to provide direction and a framework to increase CRCS in primary care practices.
Several of these reviewed studies included limitations such as time, provider and staff member turnover, failure to implement interventions as planned, changes in financial reimbursement, the Hawthorne effect, and staying updated with advances in EMR technology.24,25,27,29,30,35 A theoretical framework is only mentioned in Ornstein et al.'s work.36 Also, the drawback of using multiple interventions is the inability to determine which intervention was most effective.
Greater attention to CRCS practices for all providers is warranted, especially for nurse practitioners (NPs). Primary care physicians account for less than one-third of all U.S. physicians and this proportion is declining.35 Seven of the studies assessed only physician CRCS practices.20,24,26,29,30,37 The role of NPs in primary care has not been discussed in depth in the literature.38 Most studies were conducted in urban, academic settings.20,25-28,30,37 Future research must include the NP's role, as NPs are working to fill the gap in primary care and rural healthcare.
The process of combining multiple provider-directed interventions with an office team approach in the primary care setting was successful in many of the studies reviewed.10,21,22,38 EMR audit and feedback, academic detailing, participatory planning, and discussion of best practice habits as delineated in the PPRNet TRIP QI Model can provide the roadmap to successfully increasing CRCS rates.22 NPs are in an ideal position to help implement and facilitate use of this model to detect CRC earlier in patients.
The use of multiple provider-directed interventions with an office system team approach is the best way to increase CRCS rates in the primary care practice setting. This analysis endorses the use of the PPRNet TRIP QI Model which includes EMR-based assessment and feedback, academic detailing, reminder systems, and participatory planning for best practice dissemination to increase CRCS rates in primary care practices. More longitudinal research is needed as well as research in the rural setting and research that includes NP practices. NPs are also in an excellent position to implement and guide implementation of the PPRNet TRIP QI Model in their practices to increase CRCS.
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