Improve Colorectal Cancer Screening Rates and Save Lives! Wednesday, May 18, 2016

Transcription

1 Improve Colorectal Cancer Screening Rates and Save Lives! Wednesday, May 18, 2016

2 We Want To Hear From You! Type questions into the Questions Pane at any time during this presentation

3 Patient-Centered Primary Care Institute Online Modules Webinars Website Learning Collaboratives Trainings TA Network

4 PCPCH Model of Care Oregon s PCPCH Model is defined by six core attributes, each with specific standards and measures Access to Care Health care team, be there when we need you Accountability Take responsibility for making sure we receive the best possible health care Comprehensive Whole Person Care Provide or help us get the health care, information and services we need Continuity Be our partner over time in caring for us Coordination and Integration Help us navigate the health care system to get the care we need in a safe and timely way Person and Family Centered Care Recognize that we are the most important part of the care team - and that we are ultimately responsible for our overall health and wellness Learn more:

5 Introduce Presenter Patricia Schoonmaker, MPH Health Systems Coordinator Oregon Health Authority Public Health Division Gloria Coronado, PHD Senior Investigator, Endowed Scientist for Health Disparities Kaiser Permanente Center for Health Research

6 Learning Objectives Define national and Oregon context for screening; Know your colon cancer screening options and the research behind them; Recall best practices for developing systems to appropriately tracking screenings; Survey several useful national and local tools to aid improvement efforts.

7 Increasing colorectal cancer screening saves lives!

8 Why a national priority? Colorectal cancer is #2 cause of cancer deaths Individuals with insurance go unscreened Health inequities exist Challenge of the ick factor not an easy sell Action needed to make screening acceptable and accessible Join the call to action: 80% by 2018

9 Oregon legislative support for CRC screening 2005: CRC screening was a required screening for Oregon insurance plans (public and private) 2014: Screening colonoscopy with polyp removal will have no out-of pocket costs (effective on passage) 2015: CRC blood stool test and follow-up colonoscopy, with or without polyp removal, will have no out-of pocket costs (effective )

10 Colorectal cancer in Oregon What the data tell us

11 Population data: two sources BRFSS Behavioral Risk Factor Surveillance System (1997+) Source: Telephone survey of Oregon adults age 18+ Type: Colorectal cancer screening prevalence OSCaR Oregon State Cancer Registry (1996+) Source: Mandated cancer reporting by health providers Type: Incidence, mortality, stage of diagnosis

12 CRC screening in Oregon We ve made great progress: Increased by 50% since 1997 And we can do better: 2 out of 3 Oregonians were screened as recommended

13 CRC screening among ages in the general and Medicaid population 66.0% Recommended Colorectal Screening (%) 49.8% General Medicaid Note: Medicaid population is included in the general population Sources: Generalpopulation (BRFSS 2014) Medicaid Population (Medicaid BRFSS 2014)

14 Screening disparities among Oregon adults age 50 to 75, Met Screening Recommendation (%) 58.8% 60.5% 62.9% 52.9% 55.7% 20.8% All White,NH African Am.,NH Asian/PI,NH Am. Indian,NH Hispanic Unadjusted estimates. Source: Behavioral Risk Factor Surveillance System, Race Oversample ( )

15 Colorectal cancer in Oregon, new CRC cases 862 men (53%) 767 women (47%) Remember prevention! CRC incidence decreases with increased screening! Source: Oregon State Cancer Registry (OSCaR)

16 Colorectal cancer stage at diagnosis, Oregon % of reported cases are diagnosed at late stage Early stage 41.5% Late stage 52.1% Unstaged 6.4% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

17 Colorectal cancer late stage diagnosis by race and ethnicity, ages 50-74, Oregon % 53% 41% 42% 40% Percent of adults(%) White Black Asian/PI AI/AN Hispanic Source: Oregon State Cancer Registry (OSCaR)

18 Saving lives is our goal! 669 deaths due to CRC 2 nd leading cause of cancer deaths Health inequities continue to exist among Oregon s African American, Native American and Hispanic/Latino populations If we reached 80% screening, nearly 3,000 Oregon lives would be saved between !

19 Colorectal cancer mortality by county ( ) Clatsop Hood River Multnomah Umatilla Tillamook Morrow North Central Yamhill Clackamas (Wasco-Sherman-Gilliam Counties) Polk Marion Lincoln Wheeler Jefferson Linn Grant Benton Union Baker Wallowa Colorectal cancer mortality per 100,000 Lane Deschutes Crook Suppressed/small numbers Coos Douglas Harney Malheur Lake Josephine Curry Jackson Klamath Data source: Oregon Cancer Registry 2013 PUBLIC HEALTH DIVISION Health Promotion & Chronic Disease Prevention

20 Why focus on safety net clinics Colon cancer is a leading cause of cancer death; Nearly 1/3 of age-eligible adults in the US are not up-to-date, many are in community clinics; Colon cancer can be prevented; survival is 93% for Stage 1 8% for Stage IV; *Centers for Disease Conrol. MMWR Morb Mortal Wkly Rep, 2013 National program grantee data Health Center Data Website. Accessed March 21, 2016.

21 Medicaid expansion led to more adult enrollees Washington increase 625,847 (21% adults) Oregon increase 429,651 (29% adults) Before Medicaid Expansion Dec 2013 After Medicaid Expansion June 2014 % change N N % All ages 659, , % < , , % ,996 41, % , , % , , % , , % ,625 38, % Oregon Health Authority 2014

22 CRC treatment costs increase with increasing diagnosis stage $90,000 $80,000 $70,000 $60,000 $50,000 $40,000 $30,000 $20,000 $10,000 $0 1-year Total Costs of Medical Care for Colorectal Cancer, by Stage at Diagnosis Stage I Stage II Stage III Stage IV Age <65 Age 65+ Banegas 2016 (unpublished)

23 There are multiple recommended screening options

24 CRC screening saves lives Screening test Mortality reduction* Colonoscopy every 10 years 65% FIT every year 64% Flex sigmoidoscopy every 5 years 59% Flex sigmoidoscopy every 5 years plus FIT every 3 years 66% *Microsimulation Screening Analysis; Ann Intern Med 2008;149:

25 Options include Average-risk individuals aged 50-75*: High-sensitivity fecal occult blood test (FOBT), including fecal immunochemical tests (FIT) annually plus colonoscopy for abnormal test results; Colonoscopy every 10 years; Sigmoidoscopy every 5 years plus interval FOBT/FIT. The Affordable Care Act (ACA) mandates that screening tests recommended by the USPSTF be covered with no out-of-pocket costs. *based on US Preventive Services Task Force Recommendations

26 2015 USPSTF draft recommended changes Colonoscopy and fecal testing recommendations were unchanged Sigmoidoscopy recommendation modified: Old recommendation: Sigmoidoscopy every 5 years plus interval FOBT/FIT; New recommendation: Sigmoidoscopy every 10 years plus annual FOBT/FIT. Does not include CT colonography and multitargeted stool DNA USPSFT says these may be useful in select clinical circumstance States that evidence for the tests is less mature (concerns with incidental extracolonic findings and radiation exposure associated with CT colonography)

27 Colorectal cancer screening by test among Oregonians ages in 2014 All Screenings 66.0 Colonoscopy 60.5 Blood stool test 10.9 Sigmoidoscopy 1.8 Sigmoidoscopy and FOBT 0.8 Source: Behavioral Risk Factor Surveillance System, (2014)

28 FIT as a viable option I will not get a colonoscopy unless I believe something is wrong Patients prefer fecal testing over colonoscopy, in studies using data from a given year; Some geographic regions have limited colonoscopy capacity, fecal testing allows for risk stratification ; Fecal testing can motivate patients to get colonoscopy Rates of first-line colonoscopy screening: ~ 40% (without reminders) Rates of follow-up diagnostic colonoscopy: 60-90%

29 Free FIT vs. Free colonoscopy program Study included uninsured patients aged at the John Peter Smith Health Network, a safety net health system. Randomized patients into 3 groups: Free FIT (n = 1593) Free colonoscopy (n = 479) Usual care (n = 3898) All groups Whites Blacks Hispanics Usual Care Free Colonoscopy Free FIT Gupta et al. JAMAIM 2013

30 Fecal testing leads to fewer Colonoscopy every 10 years colonoscopies* 580 fewer colonoscopies 50% adherence 80% adherence 100% adherence N Colonoscopy N lifeyears gained 1094 fewer colonoscopies N Colonoscopy N lifeyears gained 1187 fewer colonoscopies N Colonoscopy N lifeyears gained Sensa every year FIT every year Comparable life-years gained for all strategies Colonoscopy has risks. Risk of serious complications is 5/1000** *Zauber et al. 2009; prepared for the US Preventive Services Task Force **TR Levin 2006; retrospective cohort study conducted at KP Northern California

31 Benefit of FIT-based program Outcome Colonoscopy program Annual FIT program Relative difference Individuals screened 2,747 21, Colonoscopies 2,747 1, performed CRC cases prevented CRC deaths prevented Life-years gained *Assumes fixed state funding of $1 million over 2 years for uninsured, low income population aged Source: van der Steen A et al. Optimal Colorectal Cancer Screening in States Low-Income, Uninsured Populations The Case of South Carolina. Health Services Research, June 2015.

32 FIT test performance Many FIT tests available, they vary by: performance, cost, n samples collected, how processed; Some FIT tests have little evidence to support their use!

33 FIT performance review FIT test % positive a Sensitivity b Evaluated in large numbers OC-Micro % 88.0% OC-Light % 88 96% Insure % 87.5% Hemoccult ICT % 82 98% Hemosure Not available Not available Consult Not available Not available Diagnostics QuickVue Not available Not available One-Step + Not available Not available Additional document on OHA website contains detailed information about FITs a Positivity rate is the proportion of test that have a positive result. b Sensitivity is the proportion of actual positives correctly identified (e.g. % of patients with colorectal cancer who are correctly identified as having the condition).

34 High variation in FIT positivity rates* % positive FIT results 22.6% 25.8% 17.9% 6.0% 11.8% 8.2% 9.8% 6.3% FIT A FIT B FIT C FIT C FIT C FIT D FIT D FIT D *data from STOP CRC 2016 (unpublished)

35 FIT samples can be improperly collected Improperly collected FIT tests: Plan-Do-Study-Act Cycle N collection date missing N improperly collected - other Plan-Do-Study-Act Cycle Data source: Multnomah County Health Department

36 Action Taken: Highlighted Instruction on Letter

37 Action taken: Added Reminder with Instruction 37

38 Colonoscopy Advantages Can remove polyps and prevent colorectal cancer Infrequent exam, if results are negative Disadvantages Requires bowel prep, sedation Costs are high Logistically difficult Requires that patients take time off work Have a friend drive them home Risk of perforation and bleeding Risk of serious complications is 5/1000* *TR Levin 2006; retrospective cohort study conducted at KP Northern California

39 US Follow-up Colonoscopy Adherence Studies Setting N studies N abnormal FITS F/U Colonoscopy adherence Veterans , % Administration 1 Integrated care , % settings 2 Safety net clinic % National studies / , % programs 4* 1 Carlson et al. 2011; van Kleek et al. 2010; Partin et al. 2014; Kistler et al Green et al. 2014; Miglioretti et al Barker et al 2014; Levy et al Laiyemo et al. 2010; Miglioretti et al. 2008; Nadel et al * 97% was achieved in the Nebraska National CDC program (77 participants)

40 Health disparities persist in f/u colonoscopy receipt Colonoscopy receipt w/i 18 mo. (n = 32; 57%) Colonoscopy receipt w/i 60 days (n = 14; 25%) Non-Hispanic Hispanic Non-Hispanic Hispanic 0 0 Based on 56 patients with positive FIT test results (27 non- Hispanic and 29 Hispanic) who received care at Virginia Garcia

41 What are the best practices? Evidence-based interventions to improve colon cancer screening

42 Community Guide Recommendations Intervention Client reminders Client incentives Small media Mass media Group education One-on-one education Reducing structural barriers Reducing client out-of-pocket costs Recommended by Community Guide Insufficient evidence Insufficient evidence Insufficient evidence Insufficient evidence Source: Guide to Community Preventive Services. Cancer prevention and control: client-oriented interventions to increase breast, cervical, and colorectal cancer screening.

43 Strength of evidence for mailed FIT Intervention Classification N studies Improves FOBT/FIT Screening? Strength of evidence Direct Mail 9 Yes High Flu-FOBT/FIT 2 Yes High Clinic processes 2 Mixed Moderate Patient Navigator 2 Yes (overall screening) Moderate Mixed (FOBT only) Education at clinic visit 5 Mixed Low Education with lay health advisors Education with media (community) Education with media (clinic + community) 4 Unclear Low 1 Unclear Insufficient 2 Mixed Low Davis et al systematic review (unpublished)

44 Best practices Invest in readiness Clinician engagement Select a high quality FIT test Update health records with historical colonoscopy Promote 2-step screening process: high quality fecal testing plus colonoscopy follow-up; Plan multiple strategies: In-clinic distribution: trained care teams Mail-out programs Update CRC screening information in your health record; Track and monitor your program s success; Make improvements using Plan-Do-Study-Act cycles.

45 There are helpful tools!

46 The Cancer You Can Prevent campaign Using small media to support patient reminders to: Engage local spokespersons Engage payers, providers and community Share personal stories Encourage others to be screened

47 What Oregonians told us My doctor didn t tell me (to get screened). It costs too much. There s no cancer in my family. I don t have symptoms.

48 What you can say Let s talk about it. Colorectal cancer can be prevented and found early, when it s easier to treat. There are tests proven to save lives. The best test is the one that gets done.

49 Faces and voices of Oregon

50 2015 priority: Latino materials

51 Example: Regional collaboration

52 Regional brochure inside pages

53 How you can use these materials Brochure and poster templates are available to: Print existing materials Add your local spokesperson and logo and print Support education and screening activities: Payer or clinic patient reminder systems Employee wellness programs Community-based education

54 National Colorectal Cancer Roundtable

55 Source: An Action Plan for Implementing a Primary Care Clinicians Evidence-based Toolbox and Guide (8 pages), American Cancer Society

56 Conclusion 1. National and state data show CRC screening rates are low and marked by health disparity; 2. FIT testing and colonoscopy are similarly effective at reducing CRC mortality; 3. FIT is an important component of a CRC screening program; 4. High quality FIT program: 1. Choose high quality test 2. Monitor positivity rate and patient completion 5. Direct-mail FIT programs have strongest evidence; 6. Many resources available.

57 What Questions Do You Have? Type questions into the Questions Pane at any time during this presentation

58 Funding source: NIH Common Fund [UH2AT and 4UH3CA ], Centers for Disease Control [U48 DP , Baldwin, Coronado, Green] and Kaiser Permanente Community Benefit Fund. Dr. Coronado receives support from a technical assistance contract from the Oregon Health Authority. Funding source: The Centers for Disease Control and Prevent Cooperative Agreement #NU58DP with the Oregon Health Authority Public Health Division supports The Cancer You Can Prevent health communication initiative. Acknowledgments

59 Thank You! Please complete post-webinar survey Next Primary Care and Public Health Series Webinar: Chlamydia Screening & Treatment July 20, 2016

60 Resources Increasing quality colorectal cancer screening: an action guide for working with health systems American Cancer Society s Flu/FIT Program: A proven approach to increase colorectal cancer screening. icansinformationsource/flufobtprogram/index

61 Other screening technologies CT Colonography (virtual colonoscopy) Uses low-dose radiation CT scanning to create a 3-D image of the colon (less invasive) Detects polyps >6mm and cancer, recommended every 5 years Included in ACS guidelines Not currently covered for screening by Medicare Not recommended for patients with active Crohn s disease, ulcerative colitis, inflammatory bowel disease or diverticulitis Cologuard Stool Test Combination of a stool DNA test and a FIT 2014 Study indicates higher cancer and polyp detection than FIT alone (Multitarget Stool DNA Testing for Colorectal-Cancer Screening) Kit is completed at home and sample is sent to lab Approved by FDA, covered by Medicare every 3 years

62 References American Cancer Society. (2008). An Action Plan for Implementing a Primary Care Clinicians Evidence-based Toolbox and Guide. Retrieved from the American Cancer Society website at: Centers for Disease Control and Prevention (CDC). (2015). Behavioral Risk Factor Surveillance System (BRFSS). Retrieved from CDC website at: Gupta, S.; Halm, E.A.; Rockey, D.C.; Hammons, M.; Kock, M.; Carter, E.; Valdez, L.; Tong, L.; Ahn, C.; Kashner, M.; Argenbright, K.; Tiro, J.; Geng, Z.; Pruitt, S.; and Sugg Skinner, C. (2013). Comparative effectiveness of Fecal Immunochemical Test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: A randomized clinical trial. JAMA Intern Med 173(18); Oregon Health Authority (OHA). (n.d.). Oregon State Cancer Registry (OSCaR). Retrieved from Oregon.gov website at: US Department of Health and Human Services: HRSA. (2014). Health Center Program Grantee Data. Retrieved from Health Center Data Website. Accessed March 21, US Preventive Services Task Force. (2013). Cancer Prevention and Control: Client-oriented interventions to increase breast, cervical, and colorectal cancer screening. Retrieved from The Community Guide website at: van der Steen, A.; Knudsen, A.B.; van Hees, F.; Walter, G.P.; Berger, F.G.; Daguise, V.G.; Kuntz, K.M.: Zauber, A.G.; van Ballegooijen, M.; and Landsdorp-Vogelaar, I. (2014). Optimal colorectal cancer screening in states low-income, uninsured populations The case of South Carolina. Health Services Research 50(3): Zauber, A.G.; Lansdorp-Vogelaar, I.; Knudsen, A.B.; Wilschut, J.; van Ballegooijen, M.; Kuntz, K.M. (2008). Evaluation test strategies for colorectal cancer screening: A decision analysis for the U.S. Preventive Services Task Force. Ann Intern Med149(9):