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 screening rates.
The System Approach to Tracking and Increasing Screening for Population Health Improvement of Colorectal Cancer (SATIS-PHI/CRC) intervention is a population-based, system-level redesign of the way CRC screening and followup are conducted in a network of primary care practices. It was implemented by the following members of the CNA Health ACTION Partnership (CNA):
- CNA (a nonprofit research and analysis company).
- The Lehigh Valley Health Network and its associated physician-hospital organization (LVPHO).
- Thomas Jefferson University.
The project was part of a task order funded by the Centers for Disease Control and Prevention (CDC) under the Accelerating Change and Transformation in Organizations and Networks (ACTION) program of the Agency for Healthcare Research and Quality (AHRQ).
The purpose of this toolkit is to inform potential new users about the SATIS-PHI/CRC intervention and CNA's experiences implementing it. CNA developed the toolkit consistent with research findings about effective CRC screening programs and techniques. SATIS-PHI/CRC is intended to assist primary care practices to better provide guideline-based preventive health care to their age-appropriate patients, who are at average risk for CRC and who are not up to date in their screening. It assists practices in encouraging, facilitating, and providing screening. It also helps educate both clinicians and patients about CRC screening.
This toolkit is designed to facilitate the spread of the SATIS-PHI/CRC intervention. Therefore, this toolkit includes tools, process guidelines, tips (based on implementation lessons learned), and evidence of the intervention's effectiveness.
What Is SATIS-PHI/CRC?
- Population-based, system-level redesign for conducting CRC screening and followup in primary care practices.
- Assists primary care practices in providing guideline-based CRC screening:
- Providing, facilitating, and encouraging screening.
- Educates both clinicians and patients about CRC screening.
The primary intended users of this toolkit are potential adopters of the intervention. They include integrated delivery systems, independent practice associations or foundations, multisite primary care practice networks, insurers, accountable care organizations (ACOs), regional health information organizations (RHIOs), and State and local public health agencies and related entities.
This toolkit may also be of interest to those who can inform and influence potential new users, or those who may be interested in the intervention and findings for purposes of conducting followup research. These users may also be interested in incorporating intervention elements into other CRC screening efforts or developing next generation versions of the intervention.
Rationale and Supporting Evidence for SATIS-PHI/CRC
SATIS-PHI/CRC is based on the premise that busy primary care practices could benefit from assistance in carrying out population-based screening programs (Zapka, 2008). A central entity provides this assistance by:
- Identifying patients who are eligible for but not up to date in their CRC screening.
- Sending invitations to be screened and screening information and material to those patients.
- Tracking whether patients get screened.
- Sending reminders to those who do not screen and then issuing reminders to the practices to follow up with screened patients.
The major components of SATIS-PHI/CRC are supported by recent literature. CNA incorporated a central entity to identify and communicate with eligible patients. Michael Pignone, M.D., a clinician and researcher with the University of North Carolina, Chapel Hill, medical school observed that most health care systems do "not have the ability to identify and then mass communicate with people who are not up to date with screening. ... more systems need to develop that kind of capability" (quoted in Pinkowish, 2009). CNA's central entity performs these functions for primary care practices. The central entity also conducts academic detailing about CRC screening at participating practices and provides information about CRC and screening to eligible patients of these practices.
Educating both the provider and patient about the importance of CRC screening has been shown to be effective in increasing screening in patients (Levy, 2007; Geller, 2008; Zapka, 2008). Receiving information and recommendations for CRC screening from their health care provider, particularly their primary care provider, has been found to be a predictor of patients getting screened (Carcaise-Edinboro, 2008; Griffith, 2008; Sarfaty, 2007; Zajac, 2010). Therefore, all mailed communications to patients from the central entity are sent on behalf of the providers in each patient's primary care practice (e.g., all letters are signed by all providers in the practice) rather than coming from the central entity itself. Mailed communications have been shown to be effective (Vernon, 1997; Snell & Buck, 1996). In one study comparing mailed reminders to patients and electronic reminders to physicians, the mailed reminders were more effective in increasing population-based screening rates (Sequist, et al., 2009).
Patients have varying preferences for CRC screening modalities (DeBourcy, et al, 2008; Hawley, et al., 2008), and opportunities for screening can be lost if patients are not given a choice of modality, especially when it comes to offering colonoscopy only. Thus, CNA provided patients with a choice between colonoscopy and a less invasive test they could use themselves at home, a stool test kit. The fact that colonoscopies may be a barrier to screening can be seen in a story that appeared in the Wall Street Journal in July 2009 (Mathews). A company that mandated that all employees get certain exams and tests within a year or lose their insurance coverage excluded colonoscopy from the list of requirements because, according to the company's vice president for human resources, colonoscopies were "too intrusive" and mandating them might "create a lot of resistance and resentment."
Finally, since "failures to inform patients or to document informing patients of abnormal outpatient test results are common" (Casalino, et al., 2009), CNA built in a feedback mechanism to remind providers to properly follow up with patients regarding test results. CNA also provided tools to assist practices and clinicians to track and document patient notification and followup.
Overview of Toolkit Contents
The SATIS-PHI/CRC toolkit includes the following:
- A background description of the intervention and requirements for a central entity administering it.
- The intervention steps.
- Tips, based on lessons learned implementing the steps.
- Each step's corresponding tools.
Tables 1 and 2 list the tasks associated with each of the six intervention steps and with the optional assessment step, respectively, along with their corresponding tools. Section 3 of the toolkit provides more information about the steps and copies of each tool.