Download Slide - Stratis Health

Improving Colon Cancer
Screening Rates
July 31, 2013
Presenters
• Matt Flory
Health Care Partnerships Director
Midwest Division American Cancer Society (ACS)
• Beverly Annis, RN
Community Quality Improvement Consultant
Former member of MNCM’s Measurement and Reporting Committee
• Sue Schneider, HIM
Clinic Coder, Health Information Management Department
Renville County Hospital and Clinics
• Jerri Hiniker, RN, BSN, CPHER
Program Manager
Stratis Health
This webinar is sponsored by:
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Stratis Health
American Cancer Society
Minnesota Community Measurement
Aligning Forces for Quality Improvement
Objectives
• Describe cancer screening measures and
procedures
• Identify tools and resources to help
improve screening rates
• Develop a plan to increase screening rates
in your clinic
SCREENING
MEASURES/TESTS
Why Not Colonoscopy for All?
• Screening rates are disappointingly low
• Patient preference
– Many individuals don’t want an invasive test or a test that
requires a bowel prep
– Some may not have access to the invasive tests due to lack
of coverage or local resources
• Greater patient requirements for successful completion of
tests that detect both polyps and cancers
– Endoscopic and radiologic exams require a bowel prep and
an office or facility visit
• Evidence does not support “best test” or “gold standard”
– Colonoscopy misses 5 – 10% of significant lesions in expert
settings
– Questions about efficacy in proximal colon
– Higher potential for patient injury than other tests
– Test performance is highly operator dependent
Fecal Occult Blood Tests
• Rationale
– Detect blood in the stool
– Cancers tend to bleed
– Large polyps also may bleed
(although less likely to bleed than cancers)
• Two methods:
– Guaiac (gFOBT)
– Immunochemical (FIT)
Guaiac Tests (gFOBT)
• Most common type in U.S
• Best evidence (3 RCTs)
• Need specimens from 3
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bowel movements
Non-specific
Results influenced by foods
and medications
Older forms (Hemoccult II)
have unacceptably low
sensitivity
Better sensitivity with newer
versions (Hemoccult Sensa)
Immunochemical Tests (FIT)
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Specific for human blood and for
lower GI bleeding
Results not influenced by foods or
medications
Some types require only 1 or 2
stool specimens
Higher sensitivity than older forms
of guaiac-based FOBT
Slightly more costly than guaiac
tests
FIT use in the U.S. will likely increase due to recent elimination
of guiaic- based testing by LabCorp and Quest Labs
High Quality Stool Testing
• CRC screening by FOBT should be performed with
high-sensitivity FOBT – either FIT or a highly sensitive
gFOBT (such as Hemoccult SENSA)
– Older, less sensitive guiaic tests (such as Hemoccult II)
should not be used for CRC screening
• Tests should be repeated yearly
• In-house FOBT is essentially worthless as a
screening tool for CRC and should be strongly
discouraged
• All positive screening tests should be evaluated by
colonoscopy
FOBT Quality Issues
• Guidelines recommend that all positive
FOBTs be evaluated with a
colonoscopy. However:
– Follow up of abnormal test (2005)
• Repeat FOBT 29.7%
– Follow up of abnormal test (2010)
• Repeat FOBT 17.8%
Clinician’s Reference
Using the Four Essentials
• Be clear that screening is important, but also
ask/engage your patient in the decision.
• Involve clinic staff to create and implement a
stronger plan using a team approach.
• A simple tracking system will help you follow up
with patients as needed.
• Measure your progress to tell if you are doing as
well as you think. Make adjustments.
Follow a continuous improvement
model
ADJUST
PLAN
STUDY
ACT
Make a Recommendation
Essential #1
Essential #1
Determine the screening
messages you and your
staff will share with patients.
Explore how your practice will
assess a patient’s risk status
and receptivity to screening.
Develop a Screening Policy
Essential #2
Create a standard course of
action for screenings,
document it, and share it.
Essential #2
Compile a list of screening
resources and determine the
screening capacity available in
your community.
Be Persistent with Reminders
Essential #3
Determine how your practice will
notify patient and physician
when screening and follow up is
due.
Essential #3
Ensure that your system tracks
test results and uses reminder
prompts for patients and
providers.
Measure Practice Progress
Essential #4
Discuss how your screening
system is working during regular
staff meetings, and make
adjustments as needed.
Essential #4
Have staff conduct a screening
audit, or contact a local
company that can perform such
a service.
Communication
• How are the members of your team
communicating with each other throughout
your process?
• How are the members of your team
communicating with other healthcare
professionals? (i.e., medical specialists)
• How are your team members
communicating with the patient?
CASE STUDIES/
INTERVENTIONS
Renville County Hospitals
and Clinics
• Located in the city of Olivia, Minnesota, in Renville
County
• Critical Access Hospital with three rural health clinics
in:
– Hector
– Renville
– Olivia
• Providers include:
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5 family practice physicians
3 physician assistants
2 nurse practitioners
multiple consultants in many different specialties
Improve Data Entry
• Ensure that data reflects services rendered
– At check-in ask patient if they have had tests ordered or
completed by other providers
• Capture data in appropriate data location
– Health Maintenance section of EHR = Good
– Free text in progress note = Bad
• Ensure that scanned reports are “filed” or results are
entered in discrete data fields
• Perform data clean-up as appropriate
Improve Data Entry (cont.)
• Consider:
– Is the information available to providers and
staff that will be doing future screening?
– Is the information available within the EHR to
generate reminders?
– Is the information available to report on
overall clinic performance and queries of
patients due for screening?
Integrating Reminders
• Reminders and alerts
– Must be timely
– Examples from within EHR
• Pop-up alert
• Color-coded alert
– Examples generated through EHR reports
• Phone reminders
• Letters
• Emails
Integrating Tracking
• Electronic flow sheets
– Examples: health maintenance, immunization,
chronic disease
• Registries
– Allows a clinic to maintain a list of patients with
a specific condition or finding
Reduce Barriers
• Redesign workflows
– Example: EHR alert prompts staff rooming
patient to offer information sheet on CRC
screening
• Use standing orders when appropriate
– Obtain provider consensus
– Adopt related policies and procedures
Increase Patient Follow-through
• Develop scripted messages for staff
– Link screening to staying healthy for family
• Provide educational materials with
screening information and timeframes
Increase Staff Engagement
• Provide data to care teams on a regular
basis
• Recognize teams with high and
improved performance
• Provide missed opportunity reports
• Hold periodic meetings of staff to
generate ideas for process changes
LESSONS LEARNED
DISCUSSION
GETTING STARTED
Action Plan to help you start
Worksheets for Planning
Tools and Templates
QUESTIONS?
Thank You!
• Matt Flory
[email protected]
• Beverly Annis
[email protected]
• Jerri Hiniker
[email protected]
This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do
not necessarily reflect CMS policy. 10SOW-MN-C9-13-17 073013