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					  Together, We Can Do Better:
Improving Cancer Screening Rates

                Robert A. Smith, PhD
               American Cancer Society
                    Atlanta, GA


 Fall Learning Session: Aligning Quality Efforts in Primary Care
                             Settings
   Wilderness Resort - Glacier Canyon Lodge, Wisconsin Dells
                    Tuesday, October 6, 2009
   In the U.S., we promote screening for breast,
cervix, and colorectal cancer in average risk adults.
We advise men to make an informed decision about
             prostate cancer screening
Screening is not a single event, but rather
           a cascade of events
                       The Test
                       • Quality Control
Individual             • Interpretation




                           Results
  Follow-up                  -/+
                         Failures at any step
                         can reduce the
 Repeat screening        benefits of screening
      Trends in Recent* Pap Test Prevalence (%), by Educational
      Attainment and Health Insurance Status, Women 18 and Older,
      US, 1992-2006

                 100
                                                                       All women 18 and older

                  80
                                    Women with no health insurance

                          Women with less than a high school education
Prevalence (%)




                  60



                  40



                  20



                   0
                   1992   1993   1994   1995   1996   1997 1998    1999    2000     2002    2004     2006
                                                         Year

* A Pap test within the past three years. Note: Data from participating states and the District of Columbia
were aggregated to represent the United States. Educational attainment is for women 25 and older.
Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public
Use Data Tape (2000, 2002, 2004, 2006), National Center for Chronic Disease Prevention and Health
Promotion, Center for Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.
    Mammogram Prevalence (%), by Educational Attainment and
    Health Insurance Status, Women 40 and Older, US, 1991-2006
                     70

                                              All women 40 and older
                     60


                     50
    Prevalence (%)




                                                     Women with less than a high school education
                     40


                     30
                                                           Women with no health insurance

                     20


                     10


                      0
                      1991   1992   1993   1994   1995   1996   1997   1998   1999   2000   2002   2004   2006
                                                           Year


*A mammogram within the past year. Note: Data from participating states and the District of Columbia were
aggregated to represent the United States.
Source: Behavior Risk Factor Surveillance System CD-ROM (1984-1995, 1996-1997, 1998, 1999) and Public Use Data
Tape (2000, 2002, 2004, 2006), National Centers for Chronic Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, 1997, 1999, 2000, 2000, 2001, 2003, 2005, 2007.
                  Trends in Recent* Fecal Occult Blood Test Prevalence (%), by
                  Educational Attainment and Health Insurance Status, Adults 50
                  Years and Older, US, 1997-2006


                  30
                                                         1997         1999          2001       2002
                                                         2004         2006
                  25              24
                                       22
                             21
                        20
                  20                        19                  18
 Prevalence (%)




                                                 16    16 16         16
                                                                          14
                  15
                                                                               12              12
                                                                                           9        9   9
                  10                                                                   8                    8

                   5

                   0
                                  Total               Less than a high school          No health insurance
                                                             education


*A fecal occult blood test within the past year. Note: Data from participating states and the District of Columbia were
aggregated to represent the United States.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001,
2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control
and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.
             Trends in Recent* Flexible Sigmoidoscopy or Colonoscopy
             Prevalence (%), by Educational Attainment and Health Insurance
             Status, Adults 50 Years and Older, US, 1997-2006


                      60                     56
                                                          1999      2001     2002      2004      2006
                                        50
                      50         45
                           44 44                                        43
                                                                   41
                                                    37
    Prevalence (% )




                      40                                 36 36

                      30                                                                                 25
                                                                                     22 21 21 22
                      20

                      10

                       0
                                Total             Less than a high school           No health insurance
                                                         education


*A flexible sigmoidoscopy or colonoscopy within the past ten years. Note: Data from participating states and the
District of Columbia were aggregated to represent the United States.
Source: Behavioral Risk Factor Surveillance System CD-ROM (1996-1997, 1999) and Public Use Data Tape (2001,
2002, 2004, 2006), National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control
and Prevention and Prevention, 1999, 2000, 2002, 2003, 2005, 2007.
      Recent* Prostate-Specific Antigen (PSA) Test Prevalence (%),
      by Educational Attainment and Health Insurance Status, Men 50
      Years and Older, US, 2001-2006


                        70
                                                                                2001             2002
                             58                                                 2004             2006
                        60        55        54
                                       52
                        50                            46
       Prevalence (%)




                                                            42
                                                                  39   40
                        40
                                                                                       30   28
                        30                                                                              27
                                                                                                 25

                        20

                        10

                         0
                                   Total           Less than a high school          No health insurance
                                                          education



*A prostate-specific antigen (PSA) test within the past year. Note: Data from participating states and the District of
Columbia were aggregated to represent the United States.
Source: Behavioral Risk Factor Surveillance System Public Use Data Tape (2001, 2002, 2004, 2006), National Center
for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2002, 2003, 2005,
2007.
     Breast Cancer Screening Rates,
             BRFSS 2006
               US      40-64 with     40-64     65+
              Adults      health     without
                        insurance     health
                                    insurance
Mammography   61%        63%          35%       65%

Mammography   53%        57%          30%       52%
& CBE
  Adherence Status among women in N.H.
   Mammography Network, 1996-2000
Age                           Screening Interval (%)

                  14 mo.             15-26 mo.     No return
                                                   within 27
                                                   months
40-49                    36                   23        41
50-59                    49                   21        30
60-69                    52                   20        28

Screening 50+ in the past 2 years: BRFSS: 82% /
NHMN: 64%
Source: Carney PA, et al. Cancer 2005;104:8
  Trends in Cancer Screening Rates
• Overall, trends in cancer screening have
  been relatively flat in recent years
• Colorectal cancer screening has been
  increasing, but annual increases are less
  than ideal
• These patterns suggest that under the
  current model of health care delivery,
  increasing screening rates beyond current
  levels is a major challenge
Practical Goals in Cancer Screening

• Increasing rates of regular screening
• Improving the quality of screening
  – Test quality
  – Follow-up
  – Informed and shared decisions
Practical Goals in Cancer Screening

• Increasing rates in unscreened groups
  –   Some ethnic minority groups
  –   Uninsured, and underinsured
  –   Healthy elderly
  –   Adults with low awareness of need
• Identifying individuals at high risk due to
  family history
• Discouraging inappropriate screening
    Example: Colorectal Screening Rates
    are Still Low:
    Reasons….. (according to Patients)

•   Low awareness of CRC as a personal health threat
•   Lack of knowledge of screening benefits
•   Fear, embarrassment, discomfort
•   Time
•   Cost
•   Access
•   “My doctor never talked to me about it!”
•   More structural issues
     • Insufficient referral (not enough information, patient confusion,
       inertia, etc.)
The NCCRT* Developed An Evidence-Based Toolkit and
Guide to Increase Colorectal Cancer Screening Rates




*NCCRT = National Colorectal Cancer Roundtable
Four Essentials for Improved Screening Rates




Your Recommendation
An Office Policy
An Office Reminder
System
An Effective
Communication System
Q: Is a Doctor’s Recommendation Really
   That Useful?




       Yes. Unequivocally!

   A physician’s recommendation is
   the most consistently influential
      factor in cancer screening
   Essential # 1:
   Your Recommendation

The Importance of a Doctor’s Advice

 The important role of the
  physician’s advice in cancer
  screening has been repeatedly
  documented
 The doctor’s advice is usually
  cited as the most important
  reason that an adult has had
  a recent screening test
 The most common reason cited
  for not having had a screening
  test is that the doctor has not
  recommended it.
 Other reasons are “proxies” for
  lack of physician endorsement
Essential # 1:
Your Recommendation

            Evidence from Statewide Surveys
                   on CRC screening
Maryland:
  85% of those who reported a recommendation had
  an endoscopy vs 25% who did not
  (73% ever received recommendation)

Those who were not up-to-date with screening endoscopy when
asked “why”, said:

                         “doctor didn’t order it”
                                     or
                     “doctor didn’t say I needed it”.*



    *23% (most common single reason)
   Essential # 1:
   Your Recommendation


    Goal = Recommendation to each eligible patient
 Requires an opportunistic/global approach*
     • Don’t limit efforts to “check-ups”

 Requires a system that doesn’t depend on the doctor alone
 An opportunistic approach doesn’t justify an in-office FOBT which
  has negative evidence.




    (Collins, et. al. Ann Int Med 2005)
Essential # 2:
An Office Policy

 An office policy is vital

 Only a systematic
  approach can insure
  that the physician’s
  recommendation is
  delivered to all patients

 An office policy is
  the foundation of a
  systematic approach
Essential # 2:
An Office Policy

An Office Policy states the intent of the practice

 Tangible, maintains consistency,
 Prerequisite for reliable, reproducible practice
   • Algorithms easiest policies to follow
   • Beware: one size does not fit all practices!
   • Beware: one size does not fit all patients!
Essential # 2:
An Office Policy

Factors to Consider in Your Office Policy

1. Individual Risk Level (“risk stratification”)
2. Medical resources (endoscopy available?)
3. Insurance (insured? covered? deductible? copay?)
4. Patient Preference
        Patients do have preferences
        We often neglect to ask about them
        We won’t know unless we ask
Essential # 3:
An Office Reminder System

 Reminder systems are
  “Cues to Action”

 Reminder systems can
  be directed at patients,
  clinicians, or both

 Reminder systems can
  be simple, or complex,
  with the more complex
  systems having the
  greatest benefit
Interventions to Increase Preventive Care

Why are Reminder Systems So Important?

 Opportunistic (i.e., coincidental) preventive care
  is inherently unproductive
   • Encounter based, not population based
   • Situational context of encounter is a limiting factor
   • High potential for omission or error (preoccupation,
     forgetfulness, lack of familiarity with recommendations,
     or non-evidence based policy)
   • Partial adherence is more likely than complete adherence
   • More complex situations (follow-up, greater risk, etc.)
     are less likely to be properly addressed
   Physician Reminders - Evidence



                         Reminder         Level of Screening
  Meta-Analysis
                           Tools            Improvement
35 RCT’s on           Chart prompts,            13.2%
mammogram rates       staff roles, logs

33 RCT’s on increase Chart prompts,              13.1%
in use of preventive alerts, ticklers         (5.8 – 18%)
services
Essential # 3:
An Office Reminder System

   Most Physician Offices Either Have No
    System, or a Simple Paper System

             Physician Reminder Systems


        Paper
       Reminder
         37%


                                             No
                                          Reminder
                                            58%


           Computer
           Reminder
             5%
  Examples of Reminder Systems

           Chart                     Electronic Reminder
           Prompts                     Systems (EMRs)

 Preventive services list in      Computer systems are more
  each chart                        common for scheduling and
                                    billing, less so for EMR’s
 Office staff can pull charts
  before patient visits and        ERS’s are more effective
  identify what services are        than paper based systems,
  needed                            but they are more expensive,
                                    and require a considerable
 Stickers or other “flags”         investment of time and
  can efficiently identify “who     commitment
  needs which services.”
Physician Interventions to Increase CRC
Screening

                        • Physician In Office
                          Network (PRONET)
                        • 10 Group Practices
                        • 599 patients
                        • 2 x 2 factorial randomized
                          clinical trial
                        • Patients randomized to
                          receive tailored or non-
                          tailored message
                        • Practices received
                          enhanced vs. non-
                          enhanced interventions
Physician Interventions to Increase
CRC Screening

 • Non-enhanced
   – PPIP protocol
   – 30 minute education
     session with MDs; 60
     minutes with office
     staff
 • Enhanced
   – Office based
     protocols for referral
   – Track patients
   – Resolve patient
     barriers
   – Follow-up of non-
     adherent patients
 Physician Interventions to Increase
 CRC Screening

• Patients in enhanced office and patient
  management practices had higher rates of
  lower endoscopy after 1 year
  (approximately 54%) than did patients in
  non-enhanced practices (approximately
  40%).

• The tailored letter was associated with a
  small, non-significant increase in lower
  endoscopy in the non-enhanced
  management setting (43.6%vs 37.9%).
Patient and Physician Reminders to Promote
CRC Screening

                      • Randomized Trial
                      • 11 ambulatory health care
                        centers
                      • 21,860 patients (50-80)
                        overdue for CRC screening
                      • 110 primary care physicians
                      • Patients randomized to
                        receive mailings
                      • Physicians randomized to
                        receive electronic reminders
                        during patient encounters
Patient and Physician Reminders to
Promote CRC Screening

• Patient mailings significantly increased
  screening rates (44% vs. 38%)
• Electronic reminders to physicians was
  only marginally influential (41.9% vs.
  40.2%)
• The influence of electronic reminders
  increased with increasing (3+) primary
  care visits (59.5% vs. 52.7%)
 Patient and Physician Reminders to
 Promote CRC Screening

• Why weren’t electronic reminders more
  effective???
  – One-third of patients did not visit their primary
    care physician during the intervention
    period….
  – Half of colonoscopies ordered were not
    completed….
  – Competing demands during brief office
    encounters…..
Have we hit the wall with our current
methods to increase cancer screening?
Cancer Screening & the Periodic
   Preventive Health Exam
              • Retrospective cohort study
              • 64,288 adults ages 52-78 in
                a managed care plan
              • Outcomes focused on
                completion of:
                 – CRC screening
                 – Breast cancer screening
                 – Prostate cancer screening
 Adjusted Incidence of 3 Cancer
Screening Tests by Receipt of PHE




CRC Screening   Mammography   PSA Testing
The Periodic Preventive Health
      Exam…Revisited
It is accepted as common knowledge that the
    annual checkup has questionable value
     The Fall of the Preventive Health
           Examination (PHE)
• Canadian Task Force (1979)
   – Criticized the PHE on the basis that it did not reflect
     the needs of different age groups
   – Questioned the evidence and efficacy of many of the
     tests and procedures used in routine exams
   – The CTF also endorsed an age/gender selective
     approach

• U.S. Preventive Services Task Force (1989)
• American College of Physicians (1991)
• U.S. Public Health Service
   – Each noted a lack of scientific evidence to support
     PHE, and recommended instead the integration of
     prevention into routine clinical care.
Opportunistic vs. Organized Preventive
                Health
• Regular Checkups have been replaced by
  “Prioritization of Preventive Services” during
  incidental encounters with healthcare professionals

• Under the new model, most preventive care in the
  U.S. is opportunistic

• Opportunistic care depends on a coincidence of
  encounters, circumstances, and interests between
  patient and provider
Priorities Among Recommended Clinical
            Preventive Services

                    • U.S. did not attain all Healthy
                      People 2000 objectives
                    • Cancer screening rates were
                      not optimal
                    • 35% of smokers received no
                      advice to quite smoking
                    • 41% of adolescents had not
                      received recommended
                      vaccinations by age 13
                    • Etc…..
      Ranking of Prevention Priorities (2006)
Rankings are based on the magnitude of the total Clinically Preventive
Burden (CPB), which is a measure of the total quality adjusted life years
gained (QALYs) if the service was delivered according to USPSTF guidelines
From Most Important to Least Important
  •    Aspirin Chemoprophylaxis            •   Vision Screening—Children
  •    Childhood Immunization Series       •   Folic Acid Chemoprophylaxis
  •    Tobacco Cessation Counseling        •   Obesity Screening
  •    Colorectal Cancer Screening         •   Depression Screening
  •    Hypertension Screening              •   Diet Counseling
  •    Influenza Vaccine—Adults            •   Hearing Screening—Adults
  •    Pneumococcal Vaccine—Adults         •   Injury Prevention Counseling
  •    Problem Drinking Screening-Adults   •   Cholesterol Screening—High Risk
  •    Vision screening—Adults             •   Diabetes Screening
  •    Cervical Cancer Screening           •   Osteoporosis Screening
  •    Cholesterol Screening               •   Tetanus-diphtheria Booster
  •    Breast Cancer Screening
  •    Chlamydia Screening
  •    Calcium Chemoprophylaxis
Ranking Preventive Health Services
• Five of the highest ranking services are being
  utilized by less than half of the people who need
  them.
   – 1. discussing daily aspirin use with at-risk adults;
   – 2. screening adults age 50+ for colorectal cancer;
   – 3. intervening with smokers to help them quit;
   – 4. vaccinating older adults against bacterial pneumonia;
     and
   – 5. screening young, sexually active women for
     Chlamydia.
How well is this working?
EQUITY: THE RIGHT CARE


              Receipt of Recommended Preventive Care for Older Adults,
             by Race/Ethnicity, Family Income, and Insurance Status, 2002
Percent of older adults who received all recommended screening and
preventive care within a specific time frame given their age and sex*
                                        Adults ages 50–64                                                                                Adults ages 65+
60


                  43                                       45                            43                                                                                45
         40                                                                                                                     40
                                                                     36                            37               38                                                                38
                             34
                                                                               32                                                                                                               31
                                        27                                                                                                28
30                                                                                                                                                               25
                                                  21                                                                                                    22
                                                                                                            18




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* Recommended care includes seven key screening and preventive services: blood pressure,
cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.
Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006                                                                                                                 46
Opportunistic vs. Organized Preventive
                Health
• The “Prioritization of Preventive Services”
  continues the “itemization” of preventive care

• This means some adults get some preventive
  care on some occasions and at some interval

• Few adults receive the full package, or even the
  majority of recommended preventive services
     Preventive Health Exams in the U.S.
                                      • Retrospective analysis of
                                        8413 adult ambulatory visits
                                        from 2002 -2004, for PHEs
                                        and PGEs
                                      •   National Ambulatory
                                          Medical Care Survey and
                                          National Hospital
                                          Ambulatory Medical Care
                                          Survey.
                                      • Population estimates were
                                        obtained from the Current
                                        Population Survey


Source: Mehrotra A, et al. Arch Intern Med. 2007;167(17):1876-1883
   Preventive Health Exams in the U.S.

• 20.9% of adults received a PHE in past year
• 17.7% of adult women received a PGE in the past
  year
• PHEs & PGEs represent 8% of all ambulatory
  visits
• Average duration of PHE = 23.1 minutes vs. 18.5
  minutes for visits for other reasons (+4.6 minutes)
• 19.9% of 8 preventive services occurred at PHEs
  & PGE’s
Source: Mehrotra A, et al. Arch Intern Med. 2007;167(17):1876-1883
   Figure 2. Proportions of preventive care services ordered or
delivered at preventive health examinations (PHEs) and preventive
 gynecological examinations (PGEs). The vertical lines represent
      95% confidence intervals around percentage estimates.




Source: Mehrotra A, et al. Arch Intern Med. 2007;167(17):1876-1883
Source: Mehrotra A, et al. Arch Intern Med. 2007;167(17):1876-1883
What conclusions can we draw from
 the data we’ve presented today?
• Challenging the value of annual checkup was an important
  step in evidence-based medicine

• Evidence reviews were too doctrinaire, relied too heavily
  on RCTs, and threw the baby out with the bath

• Today, both PHEs and OPC fail to deliver the majority of
  recommended preventive services
   – Even with existing knowledge, we do a poor job of intervening and
     arresting risk of chronic disease
   – The consequences are high rates of morbidity, premature mortality,
     and high health care costs
       The Current Challenge
• Determine if there is a cost-effective model
  for an age/gender periodic health
  examination.
• Acknowledge the limits of the current
  model (which is commonly unstructured
  and also opportunistic)
• Address professional issues
• Address issues of cost-effectiveness
• Address issues of access
         The Current Challenge
• There are a number of effective interventions to
  increase cancer screening, but their individual
  impact is modest
• Multi-modal interventions hold the greatest
  promise
• The current system does not support the most
  effective interventions
   – A health care professional engaged with your care
   – Supportive reminder and tracking systems
         The Current Challenge
• Health care reform, and in particular, the
  Medical Home, offer great potential to
  increase rates of regular screening through:
  –   Personalized preventive health plans
  –   Time for prevention
  –   Access
  –   Systems
Thank you

				
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