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How to Increase Preventive
Screening Rates in Practice:
An Action Plan for Implementing
a Primary Care Clinician’s* Evidence-Based
Toolbox and Guide
*Including Family Physicians, General Internists, Obstetrician-Gynecologists,
Nurse Practitioners, Physician Assistants, and Their Office Managers
This publication was produced by the National Colorectal Cancer Roundtable (NCCRT), which is co-funded by the American Cancer Society and the Centers for Disease Control and Prevention. The information in this new condensed guide is intended to provide clinicians practical, action-oriented assistance that can be used in the office to improve
colorectal cancer screening rates. It is based on an earlier publication:
“How to Increase Colorectal Cancer Screening Rates in Practice:
A Primary Care Clinician’s Evidenced-Based Toolbox and Guide”1 http://www5.cancer.org/aspx/pcmanual/default.aspx.
We gratefully acknowledge the contributions of the following individuals Dr. Terri Ades, DNP, FNP-BC, AOCN Durado Brooks, MD, MPH Edwin Diaz Mary Doroshenk, MA Ted Gansler, MD Cynthia Gelb Carmen Guerra, MD Djenaba Joseph, MD, MPH Debbie Kirkland Dorothy Lane, MD, MPH Barbara Cebuhar Mona Sarfaty, MD, MPH Robert Smith, PhD Michelle Tropper, MPH Gregory Walker, MBA Richard Wender, MD Claire Weschler, MSEd Disclaimer This guide was supported by CDC Cooperative Agreement Number U50/DP001863. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.
Sarfaty, Mona. How to Increase Colorectal Cancer Screening Rates in Practice: A Primary Care Clinician's Evidence-Based Toolbox and Guide 2008. Eds. Karen Peterson and Richard Wender. Atlanta: The American Cancer Society, the National Colorectal Cancer Roundtable, and Thomas Jefferson University 2006, Revised 2008.
Saving Lives through Preventive Cancer Screenings Implement practice changes to achieve the Four Essentials, and increase cancer screening rates. Increasing screening saves lives. A plan for your practice that is evidence-based and tools-specific to colorectal cancer is included on the pages that follow.
Take steps to identify and screen every age-appropriate patient.
Start with patients who are easiest to reach, and incrementally incorporate less
Patients who appear for regular check-ups;
Patients who receive regular care for chronic conditions;
Patients who come in only when they have a problem;
Patients who are part of your practice, but almost never come in.
Involve your staff, and put office systems in place. Given the many demands on your time, getting a recommendation to every appropriate patient will occur only when the screening process happens systematically.
Your Recommendation: Evidence accumulated over two decades shows that a recommendation from a doctor is the most powerful single factor in a patient’s decision to be screened for cancer. Assess the patient’s risk status, discuss their needs, and offer several test options to increase the likelihood that a patient will get screened. At a minimum, offer a choice between a high-sensitivity, multiple sample stool blood test (FOBT or FIT), and a colonoscopy.
Tools for Your Practice: Screening Options and Patient Readiness Understand CRC screening options: Common Sense Cancer Screening, CRC Screening Guideline Tables, and High Quality Stool Blood Tests Assess a patient’s risk: CRC Risk Based on Family History Assess a patient’s readiness: Decision Stage Questionnaire, Decision Stage Flow Chart Addressing Disparities: Members of minority or low-income groups, individuals with less formal education, and older adults are less likely to be given a screening recommendation.
Devote particular attention to screening these groups. Recommendations that are sensitive to specific health belief systems and practices, to linguistic needs, and to economic circumstances can improve receptiveness to screening.
Tools for Your Practice: Outreach to Underserved Populations Use appropriate brochures, pamphlets, and posters geared toward your individual patients: Asian language, Spanish, other
Your Course of Action: Consider the following when developing your screening policy: 1) national screening guidelines; 2) realities of your practice; 3) patient history and risk level; 4) patient preferences and insurance coverage; and 5) local medical resources. As part of a high-quality screening program for your practice, develop a policy for an annual stool blood test (FOBT/FIT). Remember that a single sample stool blood test completed in the office is not a sound procedure.
Tools for Your Practice: Screening Policy and Office Visits
Use these sample CRC screening policies as a starting point: Sample CRC Screening Algorithm 1, Sample CRC Screening Algorithm 2, and Sample FOBT Flow Chart Enhance a standard office visit: Office Policy Worksheet View how one office tracked available resources for individuals in need:
Tiered Covered Services for Eligible Adults Develop a quality colonoscopy referral system: Developing a Quality Screening Colonoscopy Referral System in Primary Care Practice Communication: For patients, the most effective cues to action are those delivered actively through dialogue with a health care provider, initially in person, and subsequently through follow up by telephone. Educate patients, and help them take necessary next steps before and after they leave your office to increase the likelihood that they will obtain screening.
Tools for Your Practice: Patient Education Materials Use these brochures, sample letters, pamphlets, and videos for patients:
View the EDUCATE YOUR PATIENTS section of www.cancer.org/colonmd.
Reminders: Chart prompts, ticklers and logs, and electronic medical records can all provide cues for physicians and their teams to take action. Postcards, letters, prescriptions, in-person conversations, and phone calls can encourage patients to follow through with screening.
Physician and patient reminders contribute to increased screening rates. To achieve high screening rates with take-home stool blood tests, a reminder and tracking systems are essential.
Tools for Your Practice: Reminder Systems Information about Electronic Health Records: ACP Center for Practice Improvement and Innovation, AAFP Center for Health IT, Purchasing an EHR System View sample chart prompt: Sample Chart Prompts Test Results: Record when a recommendation was given, the type of test recommended, and the test results. If additional follow up was needed, track and record whether a referral was made and what follow-up tests were performed. Actively monitor whether screening and all necessary follow-up tests are completed in a timely manner. In the case of a positive stool blood test, do not repeat the test, and always refer a patient for colonoscopy.
Tools for Your Practice: Tracking Information View the Sample Reminders for Your Practice section of cancer.org/colonmd.
View a sample CRC tracking log: CRC Tracking Template
Feedback: During staff meetings, allow time for your team to report what is working well, what can be done differently, whether documentation procedures need improvement, and if there are additional ways to support members of the team. Elicit feedback from your team and your patients to learn valuable information about opportunities to improve your system.
Tools for Your Practice: Staff Feedback ReturnPg6
Monitor Progress: It is essential to complete one review that will serve as a baseline of comparison for all future audits. An initial audit can be completed simultaneously with the baseline review. Audits are not complicated, and the simplest audit involves reviewing a specified number of patient records and documenting key elements.
Tools for Your Practice: Practice Performance