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NEWS & VIEWS |
They found a significant increase in the number of patients who were up to date with colorectal screening recommendations when physicians participated in an office-based intervention given by ACS staff. The ACS helped fund the research.
"Physician recommendations have been shown to be effective in getting people to go for screening, so that’s why we targeted primary care providers," said lead study author Esther K. Wei, ScD, of Brigham and Women’s Hospital. "The problem is, a lot of physicians have limited time, so having the facilitators go in and help them set up is key."
Primary care clinicians in Massachusetts, New Hampshire, and Connecticut were recruited for the study. Each filled out a questionnaire about how they educated patients about colorectal cancer screening, how they identified patients who needed screening, how they verified and enabled patient compliance with screening, and how they informed patients of colorectal test results.
The ACS facilitators (one per state) met with participating doctors to discuss their responses and make suggestions for improving performance through use of a "tool kit" provided by the researchers. The tool kit included patient education materials (brochures and posters), provider education materials (screening guidelines, recent journal articles, descriptions of the various screening procedures), and compliance materials like screening reminder postcards, flow sheets, and a manual log for tracking fecal occult blood tests (FOBT).
About 6 months later, the facilitators contacted the doctors again to assess their progress. In addition to a follow-up questionnaire, some of the physicians provided medical records of screening-appropriate patients for review. Overall, 127 physicians returned both questionnaires, and 35 provided records for a total of 551 patients.
The researchers noted significant improvements in patient education efforts. At baseline, just 20.5% of physicians displayed posters or brochures about colorectal screening in the waiting or examination rooms. By the end of the intervention, however, 69.3% did. At baseline, only 15% of providers actively distributed educational brochures to patients; at follow up, that number had increased to 43.3%. Nearly all clinicians (96%) said they discussed colorectal screening with patients at baseline; this percentage was essentially unchanged by the intervention. However, the intervention increased the number of staff members who also had this discussion with patients from 20.5% to 36.2%.
The percentage of clinicians who advised asymptomatic patients to use a home FOBT increased from 85% to 89%, and the percentage of those who monitored compliance with FOBT increased from 26.5% to 52%. The authors attribute this latter improvement directly to the intervention, as the ACS facilitators helped offices set up effective manual tracking systems.
"What we found was that a lot of providers, even if they were giving out FOBT cards, were completely unaware of whether people returned them," Wei explained. "You can give them out as much as you want, but if nobody returns them, it’s really not an effective tool."
With the manual tracking system, office staff could log when a patient was given an FOBT card, and then use the list to follow up with patients to make sure the cards were returned for analysis.
The review of medical records showed that more patients were up to date with screening recommendations (the clinician had discussed screening with them) after the intervention: 38.7% versus 56.1%. Likewise, more patients became up to date on screening tests (the patient actually had a test) at follow up compared with baseline: 34.4% versus 43.2%. Together, these changes were highly statistically significant.
"This study reinforces the importance of office systems as a method to increase colorectal cancer screening, and in all likelihood other preventive services as well," said Durado Brooks, MD, MPH, Director of Prostate and Colorectal programs at the ACS. "Primary care physicians have tremendous demands on their time, which can lead to focusing on urgent [care] and illness care while important services like screening fall by the wayside."
Wei said the simple tools used in the intervention were important to its success because they provided doctors an alternative to costly computer tracking systems.
"I think overall providers know and care about colorectal cancer screening, but it’s difficult for them to incorporate these recommendations on a daily basis," she said. "Having low cost tools can really help, and that’s a hopeful message."
Having facilitators also was crucial.
"Tool kits that are just mailed to providers may not get used because providers don’t have time," she explained. "The facilitator helps them set up the system and works with the office staff, showing them how to use the tracking materials, how to customize tools [for their practice]."
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