WT LAN Quality Measurement Reporting Part II

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Improving Colon Cancer Screening Rates

7/31/2013

Presented by Jerri Hiniker, Stratis Health, Matt Flory, American Cancer Society, Beverly Annis, quality improvement instructor, Sue Schneider, Renville County Hospitals and Clinics.

Operator: Good afternoon, ladies and gentlemen, and thank you for waiting. Welcome to the Cancer Screening Tips Conference Call. All lines have been placed on listen-only mode and the floor will be open for your questions and comments following the presentation.

Without further ado, it is my pleasure to turn the floor over to your host, Ms. Jerri Hiniker (ph). Miss Hiniker, the floor is yours.

Jerri Hiniker:Thank you, Russ and welcome, everyone to our webinar this afternoon on improving colon cancer screening rates. I appreciate everyone taking the time out of their afternoon. We have a lot of exciting information to share with you and the presenters today will be Matt Flory, he is the Healthcare Partnership Director for the Midwest Division of the American Cancer Society; Beverly Annis, who is the Community and Quality Improvement Consultant and has worked with Minnesota Community Measurements on their Measurement and Reporting Committee; Sue Schneider, she is a Clinical coder in the Health Information Management Department for Renville County Hospitals and Clinics; and then myself, I'm a Program Manager at Stratis Health.

The webinar today is sponsored by Stratis Health, the American Cancer Society, Minnesota Community Measurement and Aligning Forces for Quality Improvement. And our objective for today are to describe cancer screening measures and procedures, identify tools and resources to help improve screening rates, and help you all develop plans to increase screening rates in your clinics.

I just wanted to share with you that your lines, as you heard, are muted throughout the presentation. We will open up the lines at the end of the webinar, during our discussion portion, where you can ask questions. But I would also encourage everyone to please use the chat function, when we can also answer questions or save those questions for when we have the phone lines open.

So with that, I'm going to turn it over to Matt Flory and he will be talking about screening measures and tests.

Matt Flory:Thanks, Jerri. You can go ahead and move me to the next slide. I wanted to start by grounding our conversation today a little bit in the Minnesota Community Measurement measure for colon-cancer screening. Can I get the next slide, Jerri?

If you were to scroll down, one of the simple things that you see here is that a patient is considered up to date if they received one of three types of tests: a colonoscopy, a sigmoidoscopy, or a stool test. And I just want to ground the conversation in that measure and encourage you to think about the fact that any one of those three is an acceptable test. Next slide, Jerri?

So why not colonoscopy for everyone? Well, there are a couple of reasons. The first is that screening rates, based on just picking one test, like a lot of people do; they're not optimal. The rates are lower than we would like them to be. A colonoscopy doesn't meet with every patient preference. Some people are afraid of the bowel prep; they're afraid of invasive tests or they just aren't interested in it. But there can also be other barriers and limitations; for instance, perhaps there is not an endoscopist within a reasonable driving distance and if you're going undergo sedation you might need somebody to drive you. So even getting to ride to care is not always optimal.

In addition, the bowel prep requires some discomfort for patients and so if we were just to measure colonoscopy or just to recommend colonoscopy; patient compliance isn't always as high. But I also want to underscore the evidence and the guidelines; and this is true of all the consensus guidelines; it just doesn't support the idea that colonoscopy is the best test or the gold standard. There is certainly an argument that can be made, but colonoscopy does miss some lesions. There are some questions about efficacy in the proximal colon. There's a higher potential for patient industry and to some degree the test performance is dependent on whoever does the colonoscopy.

So not only are there other options out there, but these options really are in the consensus guidelines or, or, or. There isn't a preference. And one of the things I want to encourage you to think about today is to provide options to your patients, recognizing that the best test is the test that they get. Next slide.

So I want to talk briefly a little bit about the fecal occult blood test just in case anybody is less familiar with those. The rationale is pretty simple; that if we can detect blood in the stool, chances are we should be looking further to see if there is cancer because cancers tend to bleed. And large polyps also might bleed, although less likely than other cancers.

And there are two types of test; guaiac tests and immunochemical tests. Next slide?

Guaiac tests are by far the most common in the U.S. because they've been around awhile. We have some of the best evidence; at least three randomly-controlled trials. We do need specimens from three different bowel movements for these tests, because they do detect blood but it's any kind of blood so they do sometimes result in false positives. Results can be influenced by foods and medications and some of the older forms just are not as sensitive as some of the newer tests. So one of the things that I really want to encourage people to do is to review which, if you are using stool-based tests or FOBTs, to find out which ones you're using, whether it's an older test like the Hemoccult 2 which has low sensitivity or one of the newer tests like Hemoccult SENSA which is much stronger. Next slide?

The other type of stool tests, the immunochemical tests; are slightly more costly but they specifically test for human blood and for bleeding in the lower-GI area. Results are not influenced by foods or medications, so there is no diet restriction you need to require patients to take, and some types actually require fewer samples, just one or two. So it's higher sensitivity than the old guaiac-based FOBT tests and easier for patients to comply with. Next slide?

So we want to encourage you to consider not only recommending tests or offering the option for a patient to get a colonoscopy or sigmoidoscopy; but to make sure that these stool tests are options. If you are going to use stool tests, we encourage you to make sure you're using a high-sensitivity FOBT like Hemoccult SENSA or a FIT test. The sensitivity is much higher and we're going to talk a little bit about a patient resource to help you refer this. These stool tests do need to be done annually, so it needs to be done more frequently and it does require more follow up to make sure that both the patient actually completes and test and that appropriate follow up is done if something is positive.

And another thing I really want to underscore; there's an older practice of occasionally doing an in-office stool sample as a follow up to a DRU. We really want to discourage that. It's been shown that it's not very effective. Jerri, can you give me the next slide?

So although it's very convenient for a physician to do essentially an in-office smear after doing a digital rectal exam, the sensitivity is much lower; even in the Hemoccult 2 tests; both the sensitivity in terms of detecting lesions or detecting cancer. Next slide?

Quality issues require us to do follow up on FOBTs if they're positive. We don't want the ball to be dropped. So if a patient has a positive FOBT, you want to do follow up and make sure they get recommended for a colonoscopy to see if they really do have a cancer that can be dealt with as quickly as possible. Next slide?

We kind of captured a lot of this information quickly into a simple one-page reference that we do want to make available to everyone on this call after the fact. The first side of one page compiles information about the sensitivity of different tests, including the newer FOBT tests and the FIT tests. The backside again, really summarizes the basic recommendations for what a high-quality stool test program would look like. So we want to encourage you to use high-sensitivity tests, eliminate the use of the older FOBTs which are less sensitive, never use in-office FOBT, and then to make sure that there's a process in place both to repeat the test annually and to follow up on any positive test.

So we think that this resource or this simple fact sheet might help you generate some discussion in your clinic and encourage physicians to get up to date on the most recent tests; but also think about which tests you want to use. Next slide?

So now I've talked a little bit about screening and essentially just kind of made the case that there are multiple tests that work and that providing options is a good one. I want to shift a little bit to what your clinic may do in practice to try to identify potential ways you can improve your screening rates.

What we're going to do consistently is come back to the idea of four essentials or four buckets. But we want to be clear that screening is important when talking to patients, but also engage them into the discussion in the decision. I want to encourage you to involve clinic staff to create and implement the plan in team way so that everyone is sort of built into it. They're not just doing what they're told, but they were part of coming up with the idea. I want to encourage you to make sure you have a simple tracking system in place to help you follow up with patients. And I want you to think about how you're going to measure your progress to tell if you're doing as well as you think, and to make adjustments along the way. Next slide?

We want of course always in these quality-improvement efforts, following a continuous improvement model. So it's not linear. Although we can cross our fingers and hope it's perfect the first time, it's really more of a circle or a cycle. And what's most important is to develop a plan, based on your current approach, but with some opportunities for improvement. What new things might you try?

To act on that plan, we want you to engage the staff in the clinic and make sure everybody knows what their team roles are. But if you don't have a clear measurement in place, it's harder to study results and to really make sure you can make adjustments in your plan to continue to improve. Next slide?

So we pull these things together into four essentials or four elements that really are around making sure that there's a consistent recommendation for screening, that there is a consistent policy in the office so that all the members of the clinical-care team or of the care team have an idea of what their role is and are bought into what they're doing and are able to engage it.

The third piece is really to be persistent with reminding patients, both when they need to be screened and/or if there is follow up needed on a positive test. And then finally we want to encourage you to measure practice progress, both in terms of rates, but also in terms of process opportunities; just to see how you're doing. Next slide?

So I want to go a little bit deeper into each of these areas. In the make-a-recommendation area, the first thing I want to encourage you to do is to have a conversation with the physicians and the nurses in your office to make sure that the screening message that's delivered to patients is as consistent as possible. So if a patient goes to Dr. A, they get the same recommendation they get from Dr. B. And that's not always clear, even with the best of intentions; it sometimes requires some bases to be touched.

In addition to that, we really want you to think about how your practice might create some questions for the patient so that that recommendation can be tailored. Ask them about their family history. Ask them about their personal medical history; because that can be so much more impactful in really encouraging the individual patient to understand that it's not just that they are of a certain age, but that the recommendation is a personal recommendation, tailored to them specifically.

The evidence accumulated from over two decades shows that this physician recommendation is the number-one factor in a patient's decision to be screened, but that follow-up assessment of the patient's risk status allows you to kind of see how receptive they are to screening. And it creates an opportunity so if they have hesitations or questions, they have patient preferences; you can talk that through with them instead of letting them leave the office with those questions unanswered and those things that might push them away from screening unaddressed.

And again, at a minimum, we'd encourage you to offer them a choice between a colonoscopy and a high-sensitivity stool test; just because if nothing else, it gives them the opportunity to take some agency and avoids the possibility that they won't follow through on a recommendation that was just one choice or one option.

In addition, we'd encourage you to devote particular attention to anybody from a minority group or a low-income group that may just be less comfortable with this; and to really think about if there are some patients you want to particularly try to message this with in the short term. Next slide?

So in addition-- so once you kind of have a clear sense of what the physician recommendation is or what the consistent recommendation is; we encourage you to develop the screening policy by really bringing your care team together and talking through what the current process is, what realities are at your practice, what resources there are in the community. Maybe your patient preferences are a part of it, but also potentially their insurance mix; to really think about what's not just practical from a general perspective, but how does your specific practice look?

As part of a high-quality screening program, we want to make sure that everybody is on board and that discussion, while it takes more time, really might provide some opportunities for improvement.

For patients, the most effective cues to action are those delivered actively through dialog with a health-care provider; initially in person and subsequently through follow up; and really making sure that everyone who speaks to the patient has an opportunity to think about and to maybe offer suggestions, just creates a more comprehensive approach. We want to educate patients and help them take the next necessary steps before and after they leave the office if we want to increase the likelihood that they actually follow through and get screened. And anything you can do to make the individual feel like that recommendation is for them personally, not just for everyone of a certain age, it just reinforces that it's a personal recommendation and something that they should follow through with because it's important to their health. Next slide?

Reminders are important, particularly if you think about-- it's one thing. I've talked to many practices that have a great process in place for making sure that someone gets a letter if they're not up to date. But then if you ask them what they do after that; they'll say- what do you mean? We sent a letter.

So when we talk about persistence with reminders it's not just making sure that people know they need to be screened, but that persistence is follow up. Did somebody who get the letters schedule a test or not, and if not, what are you going to do next? So we want you, in your practice, to talk and think about how they can notify a patient and the physician when screening and/or follow up is due and making sure that it's on both tracks; so that it's a clear cue to a physician that's something that can be important.

And also I think in this persistence; ensuring that your system tracks tests results and uses reminder prompts from both again, both patients and providers. These prompts can be very technical, something in electronic medical record. But we talked to clinics in the past who used things like post-it notes. They go through the file, and my favorite example from mammography is they used-- there's a clinic that used a pink post-it note if they found no evidence that a woman over 40 had had-- was up to date on mammograms, they put a pink post-it on the top of the file at the beginning of the day and then when the physician got the file, they saw that pink post-it and knew they should bring up mammography.

So think about not only cues or prompts you could do with your electronic record, but even just little things like that. And ask yourself what you can do to really make sure the system is as consistent and as built-out as possible. Physician and patient reminders, based on the literature and the anecdotes, really do increase compliance and it really helps achieve higher screening rates. We encourage you to actively monitor whether screening and necessary follow-up tests are completed in a timely manner. And really if you don't have a good plan to begin with or a good evaluation on the back end, it's hard for those reminders to be as consistent and persistent as we would like them to be. Next slide?