9/30/2017 IMPROVING COLORECTAL CANCER SCREENING RATES USING MOTIVATIONAL INTERVIEWING ALICIA R. MALONEY, DNP, APN, ANP-BC

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1 IMPROVING COLORECTAL CANCER SCREENING RATES USING MOTIVATIONAL INTERVIEWING ALICIA R. MALONEY, DNP, APN, ANP-BC OBJECTIVES SCHOLARSHIP DNP SCHOLARLY PROJECT 1

2 PROJECT PURPOSE To implement and evaluate an evidenced based protocol utilizing motivational interviewing (MI) as an intervention to improve colorectal cancer screening rates among a Veteran population. BACKGROUND: COLORECTAL CANCER SCREENING Colorectal cancer (CRC) is the second leading cause of cancer related death in the U.S. All people over age 50 are at varying levels of risk Early diagnosis through screening is associated with survival rates higher than 90% Healthy People 2020 goal C-16: Increase the proportion of adults who receive a colorectal cancer screening based on the most recent guidelines Baseline: 52.1% of adults aged 50 to 75 years received a CRC screening based on the guidelines Target: 70.5% (American Cancer Society, 2011; CDC, 2015; Healthy People, 2015) CLINICAL PROBLEM In 2013, the CDC challenged the Veterans Health Administration (VA) to increase and track CRC testing in hospital & clinic settings The VA responded with setting a national CRC screening benchmark of 82.1% and committed to a regular external review at their 163 medical centers Clinic metrics for CRC screening at Jesse Brown VA (JBVA) 74.8% in % in % in % in 2015 (CDC, 2013; Veterans Health Administration, 2012, 2013, 2014, 2015) 2

3 SCREENING GUIDELINES U.S. Preventive Services Task Force recommends CRC screening for low risk men and women aged using: High-sensitivity fecal occult blood testing (FOBT) annually Sigmoidoscopy every 5 years Colonoscopy every 10 years Several screening tests are readily available but currently underutilized in urban primary care setting Despite strong evidence and access to national guidelines for CRC prevention, participation rates remain low. (CCAC, 2016; CDC, 2013; CDC, 2014; USPSTF, 2014) FECAL OCCULT BLOOD TESTING VS. FECAL IMMUNOCHEMICAL TEST FOBT Sensitivity & Specificity 50% and 98% Uses chemical guaiac to detect blood Requires three samples Dietary and medication changes FIT Sensitivity & Specificity 100% and 99% Uses antibodies to detect blood Requires one stool test No dietary or medication changes (CCAC, 2016) BACKGROUND: MOTIVATIONAL INTERVIEWING (MI) An evidenced-based method of communication to discuss change with clients Client-centered, therapeutic approach aimed to help patients understand and resolve ambivalence surrounding behavior change Traditional models of healthcare rely on patient education and persuasion as ways to elicit healthier behaviors In MI, a partnership is formed; the goal is to lead the patient towards identification of barriers preventing the health change goal The healthcare provider simply facilitates. The patient verbalizes their ideas to evoke change and forms the action plan to proceed when ready (Park et al, 2006; Miller & Rollnick, 2002; Rollnick, Miller, & Butler, 2008) 3

4 MOTIVATIONAL INTERVIEWING: FOUR KEY PROCESSES Therapeutic Engagement Focus on Agenda Evoking Change Making a Plan of Action (Miller & Rollnick, 2013) THE MOTIVATIONAL INTERVIEWING ROADMAP The goal of MI, specific to this Project, was to support participants to think and talk about feelings concerning CRC screening A MI roadmap was adapted, based on Wahab, Menon & Szalacha (2008) for MI telephone intervention Article focuses on design, training and delivery of MI in RCT MI is an interpersonal style; it allows the encounter to be authentic, yet aides in the skill and technique needed to navigate the conversation SAMPLE ADAPTED ROAD MAP Assess motivation, confidence and readiness to get screened What works now? What doesn t? What have you tried before? What makes you concerned? What s most important now? What makes you concerned about colorectal cancer? What makes you think it s a good idea (or not) to change? Why would now be a good time to start/continue your annual screening? Elicit change talk and enhance motivation Tell me more about that This idea further explores the desire, ability and need to change. Looks at what steps have been taken already and plans for future change. Where does all of this leave you now? What next? Where do you stand on this issue, at least for today? How confident are you that you can make this change? When else in your life have you made a change like this? Support commitment and enlist support On a scale of 1-10, where were you before? And now? What will remind you? How can I help? (Wahab et al., 2008) 4

5 LITERATURE REVIEW Over 200 randomized control trials showing positive effects of MI on many health conditions Brief MI intervention (15-30 minutes) have improved dietary habits, exercise participation, medication adherence Improved health outcomes with MI: blood pressure reduction, BMI and cholesterol levels Studies have shown promise in improving health promotion behaviors, including cancer screening (Hettema, Steele, & Miller, 2005; Lundahl et al., 2013; Miller & Rollnick, 2012; Rubak, Sandbaek, Lauritzen, & Christensen, 2005) LITERATURE GAPS Majority of efforts to increase CRC screening rates used education-based approaches Few studies have focused on the effects of using MI and CRC screening rates More used to explore behaviors surrounding barriers of CRC screening Growing literature of individualized intervention Telephone counseling for disease prevention Patient navigator in attempt to improve screening rates (Ferreira et al., 2005; Green et al., 2013; Jandorf et al., 2005; Menon et al., 2011; Mosen et al., 2010; Rollnick et al., 2008; Wahab et al., 2008) LITERATURE REVIEW Only study to directly correlate a telephone based motivational interview with FOBT return rates Goal: assess efficacy of two separate interventions phone based interventions were designed to increase CRC screening tailored health counseling & motivational interview Both interventions address beliefs such as benefits to screening, self-efficacy and barriers to screening choices Both groups produced small increases in CRC screening Tailored counseling group had 2.2 increased odds of completing the post-intervention CRC screening This study utilizes the roadmap adapted for DNP project (Menon et al., 2011) 5

6 IMPLEMENTATION MI TRAINING University of Colorado Motivational Interviewing for Healthcare Professionals course Kaiser Permanente: proficiency course MI & chronic disease VA smoking cessation clinic Practicum time with Linda Ehrlich-Jones; member of the Motivational Interviewing Network of Trainers (MINT) PRACTICE SITE UIC/VA Institutional Review Board approved project under expedited review; waiver for recruitment and documentation of consent approved Lakeside VA Community-based primary care clinic ~1100 patient visits per month Staffed by 6 physicians, 2 part time NP providers, clinical pharmacist, RN care managers, LPNs Teaching clinic physician residents and nurse practitioner students 6

7 PARTICIPANTS Goal: to gain 50 participants from JBVA Lakeside Primary Care Clinic Scheduled or unscheduled appointments in clinic Inclusion criteria: English-speaking, men or women ages 50-75, enrolled in primary care and in need of annual CRC screening Excluded: known history of CRC or total colectomy Information collected: name, last four of social (EMR look up only), age, ethnicity, date of visit, telephone number and any previous experience with CRC screening All data was de-identified and stored on password protected VA computer USUAL CARE Electronic medical record (EMR) embedded annual clinical reminder system Provider to place electronic lab order for FIT testing Provide FIT packet, including instructions on use and pre-paid return envelope PROTOCOL Patient arrives and checked in at front desk EMR reviewed for eligibility Called to exam room where the purpose of the project was stated If willing to participate, a participant information sheet was provided Provided a FIT kit, verbal instructions and written instructions Paper flyer for provider to order Participant was asked questions about any previous CRC screening experience and/or general knowledge about CRC screening A de-identifying number was assigned and telephone number verified 7

8 PROTOCOL: MI PHASE Two weeks after clinic visit, EMR reviewed to ensure FIT was ordered and assess if FIT returned If order was missing, an available provider was requested to place the order If FIT was returned, participant was not contacted, as CRC screening was complete If FIT was not returned, the participant contacted by phone to begin MI intervention If reachable, MI roadmap guided the call If not reached, a scripted message was left A second phone attempt was made 3-5 days later Final EMR review one month after FIT was received OUTCOMES DEMOGRAPHICS 50 participants between August - December 2016 All participants were male Veterans Majority were African American (72%) Average age of 65 (SD=6) 8

9 RETURN RATES As per project protocol, 14% (N=7) completed/returned before 2 week EMR review For three participants, FIT orders were never placed Two participants contacted explained they had mailed back their FIT These 12 participants were not eligible for the MI intervention Therefore, eligible 38 participants were contacted by telephone EFFECTS OF MI INTERVENTION 34% received MI intervention (N=13/38) Of these participants, 62% (N=8/13) successfully returned their FIT MOTIVATIONAL INTERVIEWING INTERVENTION The time spent on MI call ranged 3-9 minutes in length Mean time 5.6 minutes (SD=2.29) A few insights to share about the intervention: Asking for permission and inquiring about previous knowledge was important first step Exploring ambivalence came as a natural topic of conversation Eliciting change talk: difficulty getting to the point of decreasing resistance talk agreement for participating simply because someone took the time to follow up 9

10 VOIC MESSAGE(S) 66% (N=25/38) were unreachable by telephone and left a scripted voic twice Exception: two participants only received one message Phone disconnection Full mailbox After one or two voic messages 40% (N=10/25) returned their FIT DISCUSSION AND FUTURE DIRECTION PARTICIPANT EXPERIENCE WITH CRC SCREENING General questions about participant familiarity/experience level with screening options were addressed during recruitment phase conversation Majority replied they were aware of test(s) availability and verbalized the importance for their health Of total participants: 76% (N=38) had successfully completed a screening test (colonoscopy or FIT/FOBT) 20% (N=10) had a test ordered but never returned/canceled Only 2 participants had never participated in any type of screening 10

11 DISCUSSION MI improved CRC screening rates Feasibility of written protocol versus costly intervention Voice message(s) increased FIT return rate (N=10/25) Automated voice message reminder more feasible/cost appropriate choice for Lakeside clinic The initial recruitment encounter was a missed opportunity SYSTEMS LEVEL ISSUES Lack of FIT orders placed by providers ~15 charts missing FIT orders Despite EMR reminder and paper flyer Inconsistent guidelines interpretation for CRC screening by providers (physician residents) Patient outreach Factors effecting pre-postage mail back process FUTURE DIRECTIONS Expand ordering capability of the RN to place FIT orders Link EMR reminders to real time ordering capabilities Ongoing and continuing education for providers can standardize the way guidelines are followed and managed Recommendation for the VA to share individualized metrics with physician residents to recognize areas for improvement and ultimately increase adherence to screening guidelines 11

12 PUBLICATIONS Pending submission of DNP project to Health Education & Behavior Maloney, A. R., Ehrlich-Jones, L. (2017). Implementing motivational interviewing training: Strengthening the role of the registered nurse. Journal of Nursing Education and Practice, 7(8), doi: /jnep.v7n8p51 QUESTIONS? CONTACT INFORMATION Alicia R. Maloney 12

13 REFERENCES American Cancer Society. (2011). Cancer facts and figures for African Americans Atlanta: American Cancer Society. CDC. (2013). Vital signs: Colorectal cancer tests save lives. Retrieved from CDC. (2015). Colorectal cancer statistics. Retrieved from CCAC. (2016). Screening and diagnostics: A guide to FOBT & immunochemical-based FOBT. Retrieved from Ferreira, M. R., Dolan, N. C., Fitzgibbon, M. L., Davis, T. C., Gorby, N., Ladewski, L.,... Bennett, C. L. (2005). Health care provider-directed intervention to increase colorectal cancer screening among veterans: Results of a randomized controlled trial. Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, 23(7), doi:23/7/1548 [pii] Healthy People (2015). C-16 data details. U.S. Department of Health and Human Services. Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, doi: /annurev.clinpsy Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling, 93(2), doi: /j.pec REFERENCES Menon, U., Belue, R., Wahab, S., Rugen, K., Kinney, A. Y., Maramaldi, P.,... Szalacha, L. A. (2011). A randomized trial comparing the effect of two phone-based interventions on colorectal cancer screening adherence. Annals of Behavioral Medicine : A Publication of the Society of Behavioral Medicine, 42(3), doi: /s z Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press. Mosen, D. M., Feldstein, A. C., Perrin, N., Rosales, A. G., Smith, D. H., Liles, E. G.,... Glasgow, R. E. (2010). Automated telephone calls improved completion of fecal occult blood testing. Medical Care, 48(7), doi: /mlr.0b013e3181dbdce7 Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: Helping patients change behavior. New York, NY: Guilford. Rubak, S., Sandbaek, A., Lauritzen, T., & Christensen, B. (2005). Motivational interviewing: A systematic review and meta-analysis.the British Journal of General Practice: The Journal of the Royal College of General Practitioners, 55(513), U.S. Preventive Services Task Force. (2014). The guide to clinical preventive services. (No ). U.S. Department of Health and Human Services Agency for Healthcare Research and Quality. Veterans Health Administration. ( ). Clinical guidelines prevention index: Fiscal year 2012 exit survey. (VHA External Peer Review Program). JBVAMC: Marilou Mendoza. Wahab, S., Menon, U., & Szalacha, L. (2008). Motivational interviewing and colorectal cancer screening: A peek from the inside out. Patient Education and Counseling, 72(2), doi: /j.pec