According to the Centers for Disease Control and Prevention
(CDC) and United States Cancer Statistics (USCS) data, colorectal cancer (CRC)
is the “second leading cancer killer” in the United States among cancers
affecting both men and women. It is also one of the most commonly diagnosed
cancers. In 2006, 139,127 people (70,270 men and 68,857 women) were diagnosed
with CRC, and 53,196 people (26,801 men and 26,395 women) died from it (USCS,
2010). According to CDC, when CRC is found and treated early, survival is high
(90 percent). However, many colorectal cancers are not found early due to low
This report summarizes the experience of the CNA Health
ACTION (Accelerating Change and Transformation in Organizations and Networks)
Partnership in implementing and assessing a health care intervention to
increase CRC screening and followup. The System Approach to Tracking and
Increasing Screening for Public Health Improvement of Colorectal Cancer
(SATIS-PHI/CRC) was a demonstration project conducted in primary care practices
in the Lehigh Valley of Pennsylvania. The practices were affiliated with the
Lehigh Valley Physician-Hospital Organization (LVPHO) and the Eastern
Pennsylvania Inquiry Collaborative Network (EPICNet). This report also contains
a description of our dissemination plans and efforts to date to spread the
uptake of this intervention to other health care settings.
The project was funded by the Centers for Disease Control
and Prevention (CDC). It was carried out as a task order (Contract No.
HHSA290200600014, Task Order No. 290-06-0014-1) under the ACTION program of the
Agency for Healthcare Research and Quality (AHRQ) between October 2007 and July
2010. We implemented the intervention in early 2009, and it ran through February
SATIS-PHI/CRC is a population-based system-redesign
intervention designed to improve CRC screening rates and rates of diagnostic followup
for positive screens. We based the major components of SATIS-PHI/CRC on prior
studies developed in other settings. We used a case study approach, informed by
the PRISM (Practical, Robust Implementation and Sustainability Model)
framework, to determine whether we could:
Implement SATIS-PHI/CRC in the Lehigh Valley setting.
Increase screening and followup rates.
Achieve rate improvements similar to those previously reported.
SATIS-PHI/CRC is a six-step intervention that assists
primary care practices in providing population-based CRC screening. Screening
follows recommendations and guidelines jointly issued in 2008 by the American
Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the
American College of Radiology and by the U.S. Preventive Services Task Force. This
intervention seeks to influence the behavior of primary care providers and
their patients regarding CRC screening and followup through targeted
communications. It also is designed to facilitate the screening and followup
process through improved eligibility identification and screening tracking
The intervention is intended to be conducted by a central
entity, such as a health care delivery system, accountable care organization,
or insurer, affiliated with a network of primary care practices on behalf of
and in conjunction with those practices. Intervention steps include:
Recruiting primary care practices to participate.
Conducting academic detailing to inform and influence the behavior of
practice clinicians and other staff.
Identifying patients of participating practices who are guideline eligible
for, but not up to date in, CRC screening.
Mailing information and reminders to patients regarding CRC screening
and material facilitating screening.
Tracking patient screening and followup of positive screens.
Providing feedback to practices regarding patients who were screened and
recommended for followup.
LVPHO, in conjunction with EPICNet, served as the central
entity for our implementation study. We recruited 26 EPICNet practices to
participate in the study: 20 practices to receive the intervention, 5 to act as
controls not receiving the intervention, and 1 to be the site of a pilot of the
intervention. We used purposive assignment to allocate practices to the
intervention or control group to ensure a satisfactory mix of practice
attributes in each group. We reviewed available electronic records (claims,
billing, and electronic medical records) to identify eligible patients. We
supplemented this record review with eligibility information provided by
patients responding to a screening eligibility assessment (SEA) brief survey
form that we mailed to them.
We identified 7,965 patients from intervention practices and
2,662 patients from control practices who met criteria for inclusion in our
study. We further randomly assigned the 2,347 patients of two intervention
practices to receive alternate versions of mailed screening materials (470
received a stool test kit and 1,877 received a mail-back card for requesting a
kit) to estimate the effect of receiving a kit versus a card on screening
rates. We reviewed electronic records and reports from a clinical laboratory that
processed stool test kits, supplemented by audits of a sample of patients, to
track screening and followup. We also conducted a short survey of participating
practices, focus groups, and key informant interviews with each practice, as
well as focus groups with a sample of patients of intervention practices to
inform our assessment of our implementation effort and its outcome.
Overall, we were able to successfully implement the
SATIS-PHI/CRC intervention in the LVPHO/EPICNet setting and generally achieve an
effect on improving CRC screening rates that was comparable to previous
intervention studies. However, we identified a number of factors that hindered
implementation and that were a likely cause of lower than expected screening
rates. The LVPHO/EPICNet central entity lacked some elements of the ideal
implementation infrastructure. In particular, the central entity did not have electronic
records systems set up for public health population-based patient outreach
programs or experience implementing a program of this size based at the central
entity rather than the practices.
We implemented the intervention during a period of economic
uncertainty and limitations, resulting in fewer staff available for
implementation at both the central entity and the practices. We also had to
change the intervention protocol to accommodate the decision of the stool test
kit supplier to restrict the number of kits it would make available free of
charge. We thus could only send the kit directly to a small subsample of
patients; the large majority of patients had to request a kit from us by
mailing back a request card. The implementation timeframe was also a period of
change and transformation among primary care practices in the Lehigh Valley that
affected both their electronic medical record (EMR) systems and their ability
to focus on the SATIS-PHI/CRC intervention.
These factors affected our ability to fully eliminate
ineligible patients from our rate denominators and to fully identify completed
screenings (especially colonoscopies) for our rate numerators, leading to low
observed screening rates. Implementation delays shortened the period available
for observing screening and followup. Shortages of colonoscopy providers in the
Lehigh Valley to accommodate an increase in demand for screening likely
depressed observed screening as well as followup rates during the shortened
Despite these implementation shortcomings, we found that the
odds of being screened during the observation period were significantly greater
among patients of intervention practices than control practices. This finding
persisted even after controlling for age, gender, and various practice
attributes, including the completeness of the tracking data available. Factors
increasing the odds of being screened included receiving the stool test kit
directly rather than having to request it and having commercial insurance.
We also found that our observed screening rate was
substantially lower than that achieved by the previous study on which we
modeled the patient outreach elements of SATIS-PHI/CRC. But when we more
closely approximated the research conditions of that earlier study, our rate
more closely approximated that study's rate. In particular, when we sent stool
test kits directly to patients rather than request cards and included only patients
responding to the baseline SEA survey in our analysis, we observed more
We found evidence of 786 patients being screened: 682 (8.6
percent) from intervention practices and 104 (3.9 percent or 4.7 percent with
an adjusted denominator needed for comparison purposes) from control practices.
Of those 786 screens, 363 were by stool test (almost all of the others were by
colonoscopy), of which only 8 were positive (abnormal); we could not ascertain
the results of an additional 18. We tracked the followup experience of these 26
patients for evidence of complete diagnostic examinations; however, their small
number precluded any meaningful assessment of the intervention's effectiveness
in improving followup rates. A comparison of the pre- and postintervention
survey of intervention practices suggests that the academic detailing element
of SATIS-PHI/CRC was somewhat effective in educating providers about current
CRC screening guidelines.
Overall, our assessment of our implementation of the SATIS-PHI/CRC
intervention in the LVPHO/EPICNet setting demonstrates that we were able to:
Successfully implement the SATIS-PHI/CRC intervention in a setting that
differed from those that prevailed in studies on which we based our development
Achieve comparable effectiveness in improving the odds of becoming
screened among guideline-eligible patients not up to date in their screening.
Further, we were able to extract a set of “lessons learned”
from our implementation experience that could help others to successfully
implement SATIS-PHI/CRC in their settings and to achieve comparable
effectiveness outcomes. We describe these lessons learned in this report and
introduce the implementation toolkit we developed to assist those who want to
implement the intervention. This toolkit contains descriptions of how to
implement each of SATIS-PHI/CRC's steps. It also has implementation tips based
on our lessons learned and tools for each step (e.g., forms, materials to mail
to patients, patient eligibility criteria, and practice recruitment and
academic detailing material). We then describe our current efforts to
disseminate the intervention through presentations at professional meetings,
publication of papers, and involvement with health care delivery systems and
with clinical and policy working groups.
Based on our assessment findings and our lessons learned, we
believe that the SATIS-PHI/CRC can be a transferable intervention that can
improve CRC screening and followup. It is most transferable to health care
system settings with a central entity that:
motivated to take the lead in organizing and implementing the effort.
- Has easy
access to up-to-date and reasonably complete electronic records.
and accepts the time and resource commitment needed to undertake the
experience with large, targeted, population-based mailings to patients (either
by conducting such mailings themselves or outsourcing them to reliable
- Has strong
relationships with its affiliated primary care practices.
For successful implementation, it is important to have a
sufficient number of willing colonoscopy providers serving the medical service
areas participating in the intervention to accommodate any increased demand for
colonoscopies resulting from the intervention. In addition, it is best not to have
other competing population-based initiatives in the service area or at the
participating practices that could detract from the support and attention
needed to implement SATIS-PHI/CRC.
Our experience with SATIS-PHI/CRC also demonstrates that
this intervention can be successfully implemented in a wide range of practices.
These include those that are more closely and less closely affiliated with the
central entity and those that have and do not have fully functional EMR
systems. However, the central entity would need access to sufficient other
electronic records (in particular, claims or other evidence of medical services
provided to patents) for practices without fully functional EMR systems. Successful
implementation would also be enhanced if participating practices are dedicated
to population-based preventive health in general and have strong leadership
supportive of the SATIS-PHI/CRC intervention effort. In addition, it helps to
have a clinical champion for the intervention.
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