Attach 7 - Revised Training Curriculum

1. Implementation and Evaluation
   of an Intervention to Increase
   Colon Cancer Screening
   in Primary Care Clinics

 

1. The Study

• Funded by the Centers for Disease Control and Prevention (CDC) 

• Evaluated by Battelle, Centers for Public Health Research and Evaluation (CPHRE) 

• Designed by Battelle, Henry Ford, Lovelace, and CDC 

• 2 performance sites: 

• • •Henry Ford Health System 

  • •Lovelace/Albuquerque Health Partners  

• Overall goal is to test ways to increase colon cancer screening among average-risk patients in primary care clinics 

 

1. The Challenge

• There is evidence that when a prompt is available from CarePlus, up to 96% of annual physical exams include a discussion about colon cancer screening 

• But nearly half of patients who received a recommendation for screening have not been screened 6 months after their visit 

• This intervention addresses potential reasons for this discrepancy and provides tools to help close the gap 

   

 

1. Evaluation Study Design

 

1. Evaluation Study Design

 

1. Intervention Components

1. Clinic Component:

• We will give you evidence-based techniques to:  

• • •motivate patients to get screened and  

  • •make conversations about screening more productive 

• We will provide pointers on using the clinic system to increase screening rates 

   

1. Patient Component:

• Patients are sent educational materials about colon cancer screening before scheduled visits so that they come to you informed about their options 

 

1. Clinic Session Overview

• Session 1: 

• • •Module I: Project Background 

  • •Module II: Colon Cancer Screening Statistics and Guidelines 

  • •Module III: Training on Motivational Conversations and Skills Practice to Increase Screening 

• Session 2: 

• • •Module IV: Review and System Tips 

    • –Review of Practiced Motivational Conversations 

    • –Tips on Using Office Systems 

 

1. The Bottom Line

1. We are asking for:

• Your attention and active participation in the CME/CE sessions (today and one more meeting) 

• Completion of one survey 

• Awareness of two patient surveys 

1. We promise to:

• Deliver 2 hours of CME/CE training to you 

• Not interfere with patient flow 

• Provide tools to help you motivate patients to get screened 

• Report evaluation findings to you 

 

1. Module II

1. Colon Cancer:  Screening Guidelines, Efficacy and Screening Statistics

 

1. 
   
   
   
   
   Colorectal Cancer Burden is High

• Third most common cancer diagnosed in the U.S. among both men and women 

• Second leading cause of cancer death 

• Average person dying of CRC loses 13 years of life 

 

1. Adenoma-Carcinoma Sequence

• Over 95% of colon cancer arises in adenomatous polyps  

• By age 50: 

• • • 25% of adults have adenomatous polyps   

  • • 5%  would progress to cancer if left in the colon  

• Transformation from polyps to carcinoma takes 5–15 years 

• Non polypoid (flat or depressed) neoplasms: 

• • •Less common (7-15% of neoplasms) 

  • •But more likely to lead to colon cancer 

 

1. Colon Cancer Detection

• Colon cancer is the most preventable cancer 

• When colon cancer is detected at an early, localized stage: 

• • •5-year survival is 90% 

• 5-year survival drops to: 

• • •67% if detected at regional stage  

  • •10% if detected at distant stage 

• Only 38% of colon cancer is currently discovered at the localized stage 

 

1. Screening Guidelines:
   Average-Risk Patients (age 50-75)

Screening Test	US Preventive Services Task Force	Henry Ford Health System
Colonoscopy	Every 10 years	Every 10 years
3 card FOBT	Annually	Annually
Flexible Sigmoidoscopy	Not recommended alone	Every 5 years
Flex Sig + FOBT	Every 5 years with FOBT every 3 years	Not addressed
Barium Enema	NOT recommended	NOT recommended
CT Colonography	Insufficient evidence	Not addressed
DRE/In office FOBT	NOT recommended	NOT recommended

 

1. CRC Screening Evidence Summary

1. FOBT

• Randomized controlled trials 

• • •Reduces colon cancer incidence by 17-20% 

  • •Reduces colon cancer mortality by 15-33% 

1. Flexible Sigmoidoscopy

• Case-control, retrospective, & prospective studies 

• • •May reduce colon cancer mortality by 59-75% 

1. FS plus FOBT: no studies

 

1. Utilization: CRC Screening Rate HEDIS and Clinic-by-Clinic Comparison (2007)

 

1. Colon Cancer Screening Rate: Clinic-by-Clinic Comparison (2007)

 

1. When Asked, Patients Report
   Screening Preferences

• Past studies have found that patients report screening preferences (Ling et al, 2001; Pignone et al, 1999; Marshall et al, 2007; Schroy et al, 2007) 

• A recent study (Hawley et al, 2008) also found that patient preferences for CRC tests vary: 

• • •37% preferred colonoscopy 

  • •31% preferred FOBT 

  • •15% preferred barium enema 

  • •9% preferred flex sig 

 

1. Colon Cancer Screening Summary

1. 1)   Colon Cancer screening saves lives

   2)   Guideline-recommended screening includes:

• • • –3 card FOBT (guaiac cards) 

    • –Colonoscopy 

    • –Flexible Sigmoidoscopy w/FOBT 

1. 3)   When it comes to Colon Cancer screening, one size does not fit all

 

1. To Learn More

• USPSTF Guidelines (October 2008): 

1.         www.ahrq.gov/clinic/uspstf/uspscolo.htm

• Annals of Internal Medicine - In the Clinic: 

1.         www.annals.org/intheclinic/

• Hawley S et al (2008). Preferences for colorectal cancer screening among racially/ethnically diverse primary care patients. Medical Care; 46(9 Suppl 1), S10-S16. 

 

1. Module III

1. Talking with Patients about Colon Cancer Screening

 

1. 
   
   
   
   
   What helps get your patients screened for colon cancer?

• You (the clinic team) 

1.  

• The patient 

1.  

• The clinic/system, the environment 

 

1. 
   
   
   
   
   What are the common barriers
   to colon cancer screening?

• You (the clinic team) 

1.  

• The patient 

1.  

• The clinic/system, the environment 

 

1. Giving a recommendation is only one piece of the puzzle

• Missed opportunities 

   

• Incomplete conversations 

   

• Lack of follow-up 

   

 

1. Making conversations more effective

• We know a variety of factors affect or motivate prevention behavior (Montaño & Kasprzyk, 2008) 

• Individual-level factors  

• • •Attitudes, norms, self-efficacy, barriers, facilitators 

• System-level factors 

• • •Information, reminders, cues  

• You have conversations with patients 

• They don’t follow through 

• Conversations are not focused on factors that matter 

 

1. Motivational Techniques Work

• Smoking counseling works:  a 10-second conversation by a physician gains us a 4% change in patient behavior 

• A brief 3-5 minute provider assessment of factors affecting patient motivation and addressing them in a conversation works to change patient HIV risk behavior 

• We will teach you to have more effective focused, conversations to increase your patients’ motivations and increase colon cancer screening 

• 4 steps: in about 4 minutes 

 

1. Four Steps; Four Minutes

• <number>

 

1. Review

• Giving a recommendation is not enough – there are a number of factors that affect whether or not your patient is going to get screened for colon cancer 

1.  

• To understand what your patients think about colon cancer screening, you have to ask and listen 

   

 

 

1. Build Motivation

• Ask open-ended questions 

• Elicit self-motivational statements 

• Listen reflectively 

• Affirm the patient 

• Reframe statements 

• Summarize 

• Present personal feedback 

   

 

1. Get a Commitment

• Recognize readiness for change and to take action 

• Communicate free choice 

• Discuss a plan 

• Discuss consequences of action/inaction 

• Give information and advice 

• Deal with resistance 

• Make an action plan 

 

1. Scenario 1

• Mrs. Smith is a 60 year old healthy woman seen in your clinic for a routine physical. 

• • •She has recently had her mammogram, but she twice hasn't returned the stool cards that you sent home with her. 

  • •How would you re-approach colon cancer screening with this patient?    

• <number>

 

1. Scenario 2

• Mr. Jones is a 70 year old man seen in your clinic for a routine physical.   

• • •On his last visit a year ago you recommended that he have screening colonoscopy.  He flatly refused at that time and you didn't pursue the issue further.   

  • •Now he is back for an annual check-up.   

  • •Should you bring up colon cancer screening with this patient?   

  • •If so, how? 

• <number>

 

1. Elicit Knowledge, Feelings & Beliefs

• What do your patients know about colon cancer and screening options? 

• • •“Only men get colon cancer – I don’t need to get screened” 

• How do your patients feel about colon cancer screening?  

• • •“I am afraid of a colonoscopy, my friend almost bled to death when they took out a polyp” 

• What are your patients beliefs about colon cancer screening? 

• • •“All that preparation for a colonoscopy is definitely not worth the trouble” 

 

1. Social Support for Colon Cancer Screening

• Physician recommendation has repeatedly been shown to be associated with colon cancer screening use 

• Make it clear that you support colon cancer screening and you want your patient to get screened 

   

   

 

1. Elicit Social Support

• Other people in your patient’s support system can affect how they feel about colon cancer screening 

• Determine your patients motivation to get colon cancer screening by listening to  their responses about who else supports them getting screened 

• • •“My wife keeps bugging me to get the colonoscopy…” 

  • •“My ‘daughter/son/friend’ has been on this for me” 

 

1. Elicit Barriers &Facilitators

• Is your patient hesitant to get screened? Find out why. 

• • •“I just can’t take time off work, and I’m not sure if my insurance covers these tests” 

• What will help your patients to get screened? 

• • •“The stool cards sound like the easiest test – I can make time for that” 

 

1. Elicit Self-Efficacy

• Reinforce your patient’s ability to get screened 

• Help to boost their confidence  

• • •“I know you can get this done. You’ve really stayed on top of your mammograms. What can I do to help?” 

  • •“I know you can get this done and it is important to your family that you take care of yourself” 

 

1. Beliefs and Counter Messages

• “This doesn’t apply to me” 

• • •1 of 17 people are diagnosed with colon cancer 

  • •Colon cancer is the 2nd leading cause of cancer death 

• “Not now” 

• • •The highest rate of diagnoses occurs at age 70, and colon cancer takes 10-15 years to develop. 

  • •The earlier we detect it, the better the survival. 

  • •Treatment procedures are less complicated if detected early.  

  • •There is almost 100% survival when detected early. 

  • •If polyps are detected, they can be removed before they turn cancerous, so we can cure colon cancer. 

• <number>

 

1. Wrap Up

• Questions? 

• Homework: 

• • •Conversations with your patients using the conversation guide tool 

  • •Volunteers to record 2-4 conversations for review in the next session 

• Next session: 

• • •Review of conversation guide practice 

  • •Review of recorded conversations 

  • •Review of office systems, and tips for using CarePlus for encouraging colon cancer screening 

 

1. Module IV

1. Office Processes to Encourage Colon Cancer Screening

 

1. Session Two Aims

1. 1.Review of background and effective conversation techniques that can help increase colon cancer screening rates 

    

2. 2.Address practical issues at your clinic that impact screening 

 

1. Study Design

• CDC-funded randomized controlled trial to increase colon cancer screening among average risk patients in primary care clinics 

 

1. Colon Cancer Screening

• Saves lives 

• Guideline-recommended screening includes: 

• • • –3 card FOBT (annually) 

    • –Colonoscopy (every 10 years) 

    • –Flexible Sigmoidoscopy (every 5 years) w/FOBT (every 3 years) 

• When it comes to screening, one size does not fit all: there is repeated evidence that patient preferences exist 

 

1. The Challenge

• With CarePlus prompt, up to 96% of annual physicals include a colon cancer screening discussion 

• But nearly half of patients who received recommendation have not been screening 6 months after their visit 

• There is room for improvement in screening discussions 

• Recommendations are necessary but not sufficient – what we say matters 

 

1. Screening Rates: Warren Clinic

• <number>

 

1. Module IV Learning Objectives

• Reinforce effective conversation techniques to encourage colon cancer screening 

• Clarify opportunities for screening conversations that occur throughout patient visits 

• Review available reminder tools and prompts 

• Review best practices for endoscopy referrals and FOBT kit distribution 

   

   

   

   

 

1. Motivational Techniques Work

• Smoking counseling works:  a 10-second conversation by a physician gains us a 4% change in patient behavior 

• A brief 3-5 minute provider assessment of factors affecting patient motivation and addressing them in a conversation works to change patient HIV risk behavior 

• Goal: to help you have more effective, focused, conversations to increase patient motivation for and use of colon cancer screening 

• 4 steps: in about 4 minutes 

 

1. 4 Steps, 4 Minutes

• <number>

 

1. Elicit Knowledge, Feelings & Beliefs

• What do your patients know about colon cancer and screening options? 

• • •“Only men get colon cancer – I don’t need to get screened” 

• How do your patients feel about colon cancer screening?  

• • •“I am afraid to get a colonoscopy” 

• What are your patients beliefs about colon cancer screening? 

• • •“All that preparation for a colonoscopy is definitely not worth the trouble” 

 

1. Elicit Social Support

• Other people in your patient’s support system can affect how they feel about colon cancer screening 

• Determine your patients motivation to get colon cancer screening by listening to  their responses about who else supports them getting screened 

• • •“My wife keeps bugging me to get the colonoscopy…” 

  • •“My ‘daughter/son/friend’ has been on this for me” 

 

1. Elicit Barriers &Facilitators

• Is your patient hesitant to get screened? Find out why. 

• • •“I just can’t take time off work, and I’m not sure if my insurance covers these tests” 

• What will help your patients to get screened? 

• • •“The stool cards sound like the easiest test – I can make time for that” 

 

1. Elicit Self-Efficacy

• Reinforce your patient’s ability to get screened 

• Help to boost their confidence  

• • •“I know you can get this done. You’ve really stayed on top of your mammograms. What can I do to help?” 

  • •“I know you can get this done and it is important to your family that you take care of yourself” 

 

1. Missed Opportunities

• MD:        Alright.  You, I see that colonoscopy you didn’t want it the last time? 

• PT:        No! 

• MD:        Still not? 

• PT:        No. 

• MD:        No? 

• PT:        No. 

• MD:        Okay.   

• PT:        You know how I feel about that.  I don’t like it.  I don’t the idea, but I know what they do, but I don’t like it. 

• MD:        (I know.)  Okay, but it’s, it’s a prevention.  If you get it and - 

• PT:        Oh, I, yeah I know it’s a prevention.  Yes, I know it’s a prevention but I don’t like it.  It scares me.  I don’t want to have it done. 

• MD:        Okay.   

• PT:        Just put unruly patient down. 

• MD:        No, [laughs] it’s your choice.  Okay.  

 

1. Effective Conversations

• MD:        Alright.  Is there any particular fear you have about the colonoscopy that you don’t want to have it done? 

• PT:        [laughs] Drinking that stuff. 

• MD:        Okay.  What else are you worried about? 

• PT:        Well, having it done. 

• MD:        Okay.  (Now there’s) =  

• PT:        I mean, my husband’s had like, four of them.   

• MD:        Has he had any problem?   

• PT:        No.  (Used to be) my husband. 

• MD:        Okay, okay.  Alright, because I just want to tell you from personal experience.  I’ve been through four of them myself also.  I’m still here. 

• PT:        Well, I know. 

• MD:        No, but what I’m saying is a lot of people worry about that because they’re worried about, you know, just putting this thing up my butt.  Second thing is drinking all that stuff that makes you go and go and go and go and get a little irritated in the anal area.  So, I understand those things because I’ve been through that, but the benefit for you is going to be to find polyps that may turn into cancers early.  And you’re not going to feel any symptoms. 

• PT:        Right. 

• MD:        By the time you start feeling any symptoms, it’s probably pretty advanced, so what you want is to go in there, get those polyps out, see what kind they are, and if they’re anything you have to worry about, they’ll do it again in three to five years.  If it’s completely negative, ten years.  Get that off your (head). 

• PT:        Yeah.   

• MD:        Because this is a life saver.  Colonoscopy is a life saver.  It’s a real important test to do.   

• PT:        Yeah, I will do it. 

• MD:        Okay. 

• PT:        I’ve done good this month.   

• MD:        Alright. 

• PT:        I had my pap, I made my appointment for my mammogram =  

• MD:        Good.  Good, good, good. 

• PT:        = I’m, I’m here. 

• MD:        Yes, you are and I’m glad you’re here.  

 

1. Everyone Has a Role

• Focus on opportunistic screening 

• • •Colon cancer screening talk can happen at any visit, not just annual physicals 

• Everyone can be involved 

• • •Checking CarePlus 

  • •Rooming the patient 

  • •In the exam room 

  • •Patient discharge 

  • •Other opportunities? 

 

1. Preventive Services Report

• • •Red = due now or past due 

  • •Yellow = due in 6 months or less 

  • •Green = due in over 6 months 

 

1. Other Tools: CarePlus

• Customizing lab results to include FOBT 

   

   

   

   

   

   

1.  

 

1. Endoscopy Referral Process

1. Gastroenterology consult - all sites

• • •Refer patient to call center at 248-661-6465 

1. Lakeside

• • •Direct PCP referral: fax to 586-247-2697 

  • •Have patient call nurse consult line - 586-247-2985 

  • •Note: Do not give patients prep packet – will be mailed to them 

1. Taylor

• • •Direct PCP referral: fax to 313-375-2165 

  • •Patient can call 313-275-3000 

1. Pierson

• • •No longer an endoscopy site as of 12/31/08 

1. West Bloomfield, Fairlane, Main Campus

• • •Open Access 

 

1. Open Access Colonoscopy:
   WB, Main, Fairlane

1. 1. Two referral methods:

• • •Fax referral form to GI scheduling 

  • •Submit electronic request using CarePlus 

    • • • •Allows for better tracking/accountability 

1. 2. Give prep packet to patient (including prescription for GoLytely)

   3. The patient chart needs:

• • • –Up-to-date clinic note (last 6 months) to serve as an H&P 

    • –Up-to-date medication list 

1. 4. The GI nurse will review the case

• • •If approved, they call the patient to schedule 

  • •If denied, they send the provider an FYI AND send a letter to the patient asking them to follow up with you 

  • •Either way – they put a note in the patient’s chart 

 

1. Open Access Colonoscopy

1. Please do not schedule:

• • •Patients awaiting cardiac testing 

  • •Patients referred prior to recommended intervals 

  • •Patients with shortened life expectancy 

• Make sure that patients can tolerate bowel prep and the procedure 

• ASA and NSAIDS do not need to be stopped 

 

1. Electronic Colonoscopy Referrals

 

1. Endoscopy Referral Tips from GI

• Some patients don’t understand why they are being referred for a colonoscopy 

• Patients are affected by what they hear in primary care clinics about screening 

• Patients often express fears about colonoscopy to nurse schedulers 

• If patients express concerns about colonoscopy that aren’t resolved, they may be less likely to follow through 

• Patients want to have realistic information about how long it will take to be called back 

 

1. FOBT Instructions: The Basics

• Avoid red or rare meat 3 days before and during the test 

• Collect stool samples from 3 bowel movements in a row 

• There are several ways to collect the samples: 

• • •Use the tissues in the kit 

  • •Use plastic wrap over the toilet bowl 

  • •Use a paper cup or plate 

• Use the wooden stick provided to put a small smear of the sample onto the cards 

• Label the cards with name, address, & the date 

• Send the completed cards to the lab using the pre-addressed envelope provided 

   

• <number>

 

1. Fecal Occult Blood Test (FOBT)

• User-friendly instructions can be printed out from Krames online 

 

1. Closing the Loop

• Are there other barriers to screening in your clinic that we haven’t addressed? 

• • •Are FOBT cards returned? 

  • •Are appointments made? 

  • •Are colonoscopies or sigmoidoscopies done? 

• Are there other improvements that can be made? 

• <number>

 

1. Summary

• Using time with patients effectively can help improve colon cancer screening rates 

• Capitalize on opportunities to talk with patients about colon cancer screening 

• Take advantage of the Preventive Services Report and electronic colonoscopy referrals 

• Provide FOBT instructions using Krames online 

• Questions? 

 

File Type	application/vnd.ms-powerpoint
File Title	Evaluation Study Design and Plan
Author	Danke Kasprzyk
Last Modified By	Judith Lee Smith
File Modified	2009-03-24
File Created	2003-02-28

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