Michael A. Preston, Ph.D., M.P.H. University of Arkansas for Medical

Transcription

1 Michael A. Preston, Ph.D., M.P.H. University of Arkansas for Medical Community Health Centers of Arkansas Annual Conference Little Rock, AR 27 September 2018 No Financial Conflicts of Interest to Disclose

2 Colorectal Cancer in the U.S. Second leading cause of cancer-related deaths 135K+ new cases; 50K+ deaths; 1+ million survivors Past 20+ years, death rates have decreased Disparities remain among medically underserved populations Early detection is a major contributor to the overall decline in new cases and deaths Screening allows for detection and removal of precancerous polyps before they progress to cancer (Cancer Facts & Figures 2012) Screening allows for earlier detection when disease is easier to cure Improvement in treatment over the years Healthy People 2020 screening goal 70.5% HOT TOPIC at 2014 NCCRT Annual Meeting: 80% by 2018 Normal Adenoma Carcinoma

3 Colorectal Cancer Screening Rates Colorectal Cancer Screening* (%), in Adults 50 Years and Older, 2014 OR 68 WA 70 MT 63 ND 64 MN ID 62 SD WI WY NV 62 UT CA 71 CO AK AZ 66 NM IA NE KS 66 MO 64 OK 59 AR 62 TX 63 LA 66 IL 62 MS 62 MI OH IN WV 65 VA KY NC TN SC 69 GA 68 FL 69 NH VT 74 ME MA NY RI 76 CT 74 NJ 66 DE 73 MD 72 DC HI 69 *A fecal occult blood test within the past year, or sigmoidoscopy within the past five years or colonoscopy within the past 10 years. Note: The colorectal cancer screening prevalence estimates do not distinguish between examinations for screening and diagnosis. Source: Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, Public use data file. Source: CDC. BRFSS, 2014

4 Problem: Colorectal Cancer 2 nd leading cause of cancer death in AR Lack of access: providers and facilities not equally distributed Lack of coverage: uninsured and underinsured Lack of knowledge: navigating the health care system Low screening rates Medically underserved areas Hotspots (17 counties) Fear, embarrassment, discomfort Time, Cost My doctor never talked to me about it!

5 Physician Visits Patient education, mass mailings and reminders alone do not improve screening rates Increased odds of CRC screening and early-stage diagnosis with routine physician visits (Ferrante JM, et al, 2011) Early detection must be increased to improve survival Five-year survival rate is 90% when CRC is diagnosed at an early stage where cancer is localized and 60% for those with regional disease Five-year survival rate is only 10% when cancer is not diagnosed until it has spread to distant organs of the body (ACS, 2009)

6 Physician s Recommendation: Is It That Useful? Gastroenterology Department

7 Answer YES! Multiple studies have shown that physician s recommendation is the most consistently influential factor in cancer screening.

8 How to Reduce Patient Barriers?

9 Multifaceted Approach SE CRC Consortium Multi-state messaging on screening options Utilization of Toolkits EB Policy Dissemination CRC Provider Education NCCRT 80% by 2018 Annual meeting ACS Toolkit for FQHCs NIH/NCI Priorities CRC Screening Recommendations USPSTF ACG ACS Health People 2020 Patient Protection and Affordable Care Act of 2010 (ACA/OBAMACARE) SEC Coverage of Preventive Health Services Arkansas CRC activities CDC Program The Community Guide Provider assessment/feedback Provider reminders Patient reminders Reduce structural barriers for patients Arkansas Cancer Coalition Arkansas Cancer Plan Arkansas CRC Roundtable % by 2018 Pledge (Governor Asa Hutchinson) BLUE Lights & BLUE Ribbon Arkansas State Legislation ACT 2236 of 2005 ACT 516 of 2017 (59% screening rate) UAMS HIDR CRC Screening & Prevention Program Patient Navigation Community Health Promoters

10 Solution: Colorectal Cancer CRC Demonstration (ACT 2236) Develop CRC Screening Program Statewide Educate providers & patients Reimbursement for screening uninsured & underinsured pts ACT 516 of 2017 Patient Navigation Program Navigates participants EB Policy Dissemination Importance of Health Policy

11 Objectives To reduce the physical and economic burden of CRC by increasing the awareness and participation in CRC screening programs To meet the goal of screening 80% of the target population by 2018

12 Program Facts Collaborate with physicians and gastroenterologists to increase CRC screenings rates and help decrease mortality from CRC Provide funding for screening to at-risk and underserved populations Participants found to have cancer are navigated through the health care system for additional evaluation and treatment

13 CRC Screening Options Fecal Immunochemical Test (Stool Test) Colonoscopy

14 Methods Provide access to CRC screenings statewide Facilitate CRC prevention and control through collaborations: academic health centers, state health departments, health care providers, and lay communities Work with local physicians to provide on-site Fecal Immunochemical Test (FIT) kits Provide support for patients that may have barriers Develop provider and CBO CRC Toolkits

15 CRC Toolkit Provider Community-based

16 i.e., Case Study 51 y/o male presents to PCP for f/u for HTN. During the visit, the PCP recommends CRC screening to the PT and provides the PT a CRC enrollment form. The PCP educates the PT on available test options for Colorectal Cancer Screening and Education Program. PT family history (-) for CRC; No GI symptoms. PT chose FIT screening modality.

17 Principal Findings Since 2016, a total of 5,900+ FIT kits have been distributed to 90+ participating health care providers and CBOs across the state. The estimated rate of return for FIT was 64.0% (n=908/1,420) with 105 positive results which needed further evaluation by colonoscopy. Follow-up care included 61 individuals that were screened by colonoscopy. In addition, program efforts have resulted in the adoption and implementation of CRC screening by FIT as an order/billing item in all primary care clinics at an academic health center. # FIT Referrals FIT Returns FIT Returns **Intervention established as a RTIPs by NCI

18 Conclusion Such programs that take a multifaceted approach are effective mechanisms to remove access barriers for individuals who seek CRC screening Such programs that incorporate PN at both levels are effective mechanisms to remove access barriers for individuals who seek CRC screening Equity of access to CRC screenings among disadvantaged populations may be achieved with the utilization of PN programs

19 Implications for Policy and PH Practice With the introduction of the ACA, such programs are focused on prevention and navigation of patients through the health care system With more Americans gaining access to the health care system, we expect fewer deaths related to CRC PN provides an ideal mechanism for PPH strategies that address CRC health disparities Our program supports stronger health policies for poor resourced communities that are less likely to receive preventive services or have difficulty accessing the health care system New administration roll-back of the ACA, it is important to examine health policies that may be affected beyond 2017

20 HIDR Team Jonathan Laryea, MD Nicole McGehee, BA Karen Crowell, MD M. Nicole Woods, BA Ronda S. Henry-Tillman, MD, FACS HIDR Staff

21 For More Information Supported by the State of Arkansas, NIH NCI #U01 CA114607, NIH NMHHD #R24 MD002805, UAMS WPRCI HIDR Michael A. Preston, Ph.D., Archive: University of Arkansas for Medical Sciences Health Initiatives and Disparities Research Little Rock, AR