A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population

Abstract

IntroductionColorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50–75. Single-component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi-modal approaches may be more effective.MethodsWe designed, implemented, and evaluated the impact of a multi-modal intervention on CRC screening uptake among unscreened patients in a large managed care population. Patient-level components included a mailed letter with education about screening options and pre-colonoscopy telephone counseling. For providers, we facilitated communication of screening test results and work-flow for abnormal results. System-level modifications included establishment of a patient navigator, expedited work-up for abnormal results, and stream-lined colonoscopy scheduling. We measured the rate of screening uptake overall, screening uptake by modality, change in the proportion of the population screened, and positive fecal immunochemical test (FIT) follow-up rates in the 1-year study period.ResultsThere were 5093 patients in the intervention cohort. Of these, 33.2% participated in FIT or colonoscopy screening within 1 year of the mailing. A total of 1078 (21.2%) participants completed a FIT and 611 (12.0%) completed a screening colonoscopy. The screening rate in the managed care population increased from 65.1 to 76.6%. Fifty-nine patients (5.5%) had a positive FIT, of which 30 (50.8%) completed a diagnostic colonoscopy.ConclusionMulti-modal interventions can result in substantial improvement in CRC screening uptake in large and diverse managed care populations.Translational ImpactHealth systems should shift their focus from single-level to multi-level interventions when addressing barriers to CRC screening.

Development of a Multivariable Prediction Model to Identify Patients Unlikely to Complete a Colonoscopy Following an Abnormal FIT Test in Community Clinics

“…Provider and system-level barriers may include limited colonoscopy capacity, failure to refer the patient to the specialist or schedule the procedure, failure to communicate expectations about the procedure or preparation for the procedure, and lack of adequate workflows to complete the referral (6)(7)(8). Interventions like patient navigation, where a navigator helps address these barriers to screening, can close the gaps and improve follow-up rates (14,15).…”

Undertaking General Practice Quality Improvement to Improve Cancer Screening - A Thematic Analysis of Provider Experiences

“…Health promotional resources were also provided for patients as well as Health Pathways (online clinical guidelines and referral information) for general practitioners (Table 1). Strategies that enhance data entry and extraction, and use of this data in PDSA cycles, increase cancer screening activity (13) and, when combined with incentives in a multimodal approach, have shown greater improvements in screening than singular approaches (14). (15).…”

Development of a multivariable prediction model to identify patients unlikely to complete a colonoscopy following an abnormal FIT test in community clinics

“…Provider and system-level barriers may include limited colonoscopy capacity, failure to refer the patient to the specialist or schedule the procedure, failure to communicate expectations about the procedure or preparation for the procedure, and lack of adequate workflows to complete the referral [ 6 – 8 ]. Interventions like patient navigation, where a navigator helps address these barriers to screening, can close the gaps and improve follow-up rates [ 15 , 16 ].…”