Increasing Colorectal Cancer Screening in a Safety-net Health System with a Focus on the Uninsured: Benefits and Costs

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1 Increasing Colorectal Cancer Screening in a Safety-net Health System with a Focus on the Uninsured: Benefits and Costs Samir Gupta, MD Assistant Professor Department of Internal Medicine Division of Digestive and Liver Diseases Harold C. Simmons Cancer Center UT Southwestern Medical Center

2 Colorectal Cancer is a Public Health Problem Colorectal Cancer (CRC) is the 2 nd leading cause of cancer death in the U.S. and Texas 5% lifetime risk Affects men and women National Cancer Institute: Cancer Statistics

3 Screening for CRC Prevents Death 3 tests recommended by US Preventive Services Task Force Stool blood test Sigmoidoscopy Colonoscopy Whitlock et al. Ann Intern Med Nov 4;149(9): Zauber et al. Ann Intern Med Nov 4;149(9): Edwards et al. Cancer Feb 1;116(3):

4 Process Goal Stool Blood Test (Fecal Occult Blood Test) Sample stool at home Return kit Check for hidden blood from cancer & polyps Colonoscopy Strong laxative Relaxing medicine Flexible tube through rectum Check for cancer & polyps Remove polyps + Easy Cheap Very Sensitive potential to prevent cancer Reduces Death Stool Less sensitive Yes Invasive Strong laxative Expensive Complications Yes

5 High Rates of Screening Will Have a Major Impact on Reducing Death Whitlock et al. Ann Intern Med Nov 4;149(9): Zauber et al. Ann Intern Med Nov 4;149(9): Edwards et al. Cancer Feb 1;116(3):

6 Major Obstacle Screening participation, especially for the uninsured

7 Participation Rate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Behavioral Risk Factor Surveillance Survey Trends in Colorectal Cancer Screening Year Insured

8 Participation Rate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Source: Behavioral Risk Factor Surveillance Survey Trends in Colorectal Cancer Screening 63% 37% Year 26% Uninsured Insured

9 Safety-Net Health Systems: Opportunity Uninsured, vulnerable populations John Peter Smith Health System (JPS) 66% Uninsured 29% African American, 23% Hispanic Identify unscreened, uninsured Infrastructure to deliver screening Primary care and subspecialty infrastructure Gupta et al. Cancer Epidemiol Biomarkers Prev Sep;18(9):

10 Key Challenge: Screening Approach Standard: Visit-based Physician invites, patient accepts Suboptimal Alternative: Organizational/Systems-based Mail out program with reminders /systematic follow up Safety-net setting? Costs? Myers et al. Cancer Nov 1;110(9): Church et al. J Natl Cancer Inst May 19;96(10): Myers et al. Med Care Oct;29(10): Breslow et al. Am J Prev Med Jul;35(1 Suppl):S14-20.

11 Key Challenge: Test Type Test type dictates infrastructure required Stool Blood Test (Fecal Occult Blood Test) Colonoscopy Benefit 5-10% need colonoscopy One and Done for 70% Challenge Annual test Careful follow up 100% need colonoscopy Choice best made based on Participation rates Best test is the one that gets done. Costs relative to benefits Gupta S. Ann Intern Med Mar 3;150(5):359. Zauber et al. Ann Intern Med Nov 4;149(9): Winawer S. Ann Intern Med Dec 16;139(12): Winawer S. J Clin Oncol Sep 15;19(18 Suppl):6S-12S.

12 Summary CRC is a major public health problem Screening saves lives Screening rates for the uninsured are low Safety-net health systems can intervene Key Challenges Screening approach Test type Cost implications

13 Project Goals Goal 1: Deliver evidence-based screening services to uninsured, unscreened patients served by JPS Patients will be invited by mail, with systematic follow up, to either: a) Stool blood test, with a kit included in the mailing b) Colonoscopy Goal 2: Rigorously evaluate project outcomes Screening rates Cancers detected Costs

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19 Save Lives Increased screening Significance Local Decision Making Invest in mail-out program Invest in stool blood test or colonoscopy Statewide Impact Replication Policy

20 Project Team & Key Supporters Team Member Role Affiliation Elizabeth Carter, MD Physician Champion John Peter Smith Health System Mark Koch, MD Physician Champion John Peter Smith Health System Chul Ahn, PhD Biostatistician UT Southwestern Michael Kashner, PhD, JD Cost Evaluation UT Southwestern Celette Sugg Skinner, PhD Health Communications UT Southwestern Ethan Halm, MD Program Evaluation UT Southwestern Don Rockey, MD Screening Expert UT Southwestern Key Supporters Moncrief Cancer Resources Harold C. Simmons Cancer Center, UT Southwestern John Peter Smith Health System Keith Argenbright, MD James Willson, MD Gwen Griffith, RN Paula Anderson, RN Melanie Senter, RN Bonnie Rose, RN Robert Early Jay Haynes, MD

21 Thank You