TPMG experience in improving colorectal cancer screening rates Theodore R. Levin, MD Clinical Lead for CRC screening, The Permanente Medical Group, Inc
Kaiser Permanente Northern California Kaiser Permanente Kaiser Foundation Health Plan Kaiser Foundation Hospitals The Permanente Medical Group KP Northern California Region 3.3 million members 29 medical offices 19 hospitals 7,000+ physicians 54,000 employees $16 billion op revenue 34% market share
KPNC CRC performance Gastro, 2011 Nov;141(5):1551-5
CRC Stage at Diagnosis 2000 New Cases 1500 1000 500 SEER summary stage Localized Regional Distant Unknown Total 0 2004 2005 2006 2007 2008 2009 2010 Year
KPNC CRC Incidence Incidence 70 60 50 40 30 20 10 0 2004 2005 2006 2007 2008 2009 2010 Year Males Females Total
Key to Success: Leadership Alignment and Clear Goal Setting: Regional Medical Group Leadership sets screening targets Alignment of Incentives: Performance Based allocation to Med Centers Shape the Path: Regional Quality/Operational Support to Med Centers Find the Bright Spots: Med Centers have operational quality infrastructure responsible for performance on metrics, they are constantly innovating and the regional team tells the story of their success to other sites
CRC Screening in Northern California 1994-2003 2004 CoCaP program FSIG Capacity Built FSIG > FOBT Screening rates followed by survey HEDIS Performance Improvement Opportunity FIT an improvement over Guaiac 05 06 Performance Allocations Facility-based FOBT CRC Screening pilots 07 09 Regionally managed mailed FIT outreach Monitored colonoscopy follow-up
Choosing a Screening Strategy Science Sweet Spot Patient Choice Standard of Care Operations HEDIS Performance
Outreach Using Fecal Immunochemical Testing 2005 assumptions: If you were a KPNC member for 2 years and hadn t been screened, you either: Weren t being seen enough to get a referral Had been offered Flex Sig and refused FIT outreach: Lab Directors requested an automated test Better quality control, minimize repetitive strain Pilot tested in 2006, region-wide in 2007
Overview CRC Screening Program Outreach Inreach Evolution from Basic Infrastructure to Targeted Strategies Leveraging Technology to Optimize Workflows Robust tracking to ensure FIT+ have follow-up colonoscopy
Outreach Details HEDIS Population identified, HEDIS guidelines Aged 51-75 Screening adherence reviewed to identify those due this year: FSig q5 yrs, Col q10 years, FOBT q 1 yr A random sample selected each week >13,000 tests per week Front loaded to complete outreach by September, allow last 4 months for local follow-up. Demographic data uploaded to fulfillment vendor Mailing kits assembled, sent by vendor Test used: Eiken FIT, licensed by Polymedco, machine read. Single sample, cut off of 100 ng Hgb/mL buffer.
2009 CRC Screeing: Outreach Program Basic infrastructure for outreach program FIT Kit Mailed Reminder Postcard 6 weeks after kit
2010 CRC Screening: Outreach Program Improved outreach materials and increased local follow-up PCP Pre-letter Pilot One week prior to kit FIT Kit Mailed Reminder Postcard 6 weeks after kit Regional Program Enhancements Revised outreach letter and multi-language FAQ Revised instructions Pre-letter pilot Local Innovation Robo-call reminders Secure message followup 2 nd kit mailing
2011 CRC Screening: Outreach Program Increased regional initiatives based on previous pilots and local innovation PCP Pre-letter Mailed FIT Kit Mailed Robo-call Reminder Reminder Postcard Secure Msg MA Calls One week prior to kit 3 weeks after kit Regional 6 weeks after kit Local Distribute Kit At Office visit Or Flu Clinic Region-wide 2 nd kit mailing to non-responders
Increase in FIT Outreach Response 80% 60% 50.8% 52.1% 58.3% 60.8% 40% 20% 0% 2008 2009 2010 2011
Increase in Colonoscopy Volume 100,000 80,000 60,000 40,000 20,000 0 2008 2009 2010 2011
Quality Assurance, Reminders and Reporting Crossing the Quality Chasm Report Detailed Medical Center Performance Reports FIT Follow-up reporting: summary and MRN level reports Time to colonoscopy Population Management Tool Preventive Health Prompts PACTS PROMPT Cancer Incidence/Stage Adenoma detection rates at screening colonoscopy (Research)
We still have work to do. Address disparities: Age, race, ethnicity Increase colonoscopy capacity Improve follow-up for positives Research: Optimize FIT: demographics, clinical factors, seasonal variation, number of samples, evaluate role of biomarkers, Reduce variation in colonoscopy quality
Conclusions CRC screening rates can be increased through organized outreach and enhanced opportunistic screening Collaborative Effort: Multiple Stakeholders: local and regional, business/data analytic/operational/clinical Align finances with performance Takeaway for non-kp sites: Leadership engagement and alignment is key Engage every member of your team: receptionists, MAs, nurses and doctors Measure what you do, recognize and reward the incremental success along the way.