Increasing colorectal cancer testing: translating physician interventions into population-based practice

BACKGROUND

Medicare provides coverage for CRC screening for average risk enrollee age 50 or above through four options: a yearly fecal unknown blood test (FOBT), a flexible sigmoidoscopy or barium enema one time every 4 years, or a colonoscopy each 10 years. The Medicare benefit allows CRC testing within the intervals praiseed by the U.S. Preventive Services Task Force (USPSTF) guidelines (Pignone et al., 2002) However, despite insurance coverage, CRC screening of Medicare enrollee falls below approveed guidelines (Pham et al., 2005)

In 2000 CM capitaled Quality Improvement Organizations (QIOs) in sum of two units States (North and South Carolina) to unravel pilot-test, and evaluate interventions to increase Medicare CRC ordeal use rates. Through an interagency agreement with CM NCI participated with the QIOs in evaluating the CRC interventions. A multilevel approach was designed targeting the pair Medicare consumers and their physicians. This article describes and evaluates the impact of the physician-level intervention upon the utilization of CRC screening experiments for Medicare enrollees.

The importance of physician recommendation for CRC screening is well documented (Brawarsky, rivulets and Mucci, 2003, Rawl et al., 2000; Lewis and Asch, 1999; Mandelson et al., 2000; Stockwell et al., 2003; Taylor et al., 2003; Vernon, 1997) however a number of factors constrain physicians' ability to provide CRC testing to their eligible patients including: lack of awareness or understanding of CRC screening guidelines (Klabunde et al., 2003; Sharma et al., 2000; Cabana, et al., 1999); inadequate reimbursement (Lewis and Asch, 1999); lack of a combination of parts to form a whole to identify those who ne testing; lack of patient knowledge; and too little time during the office visit (Jaen, Stange, and Nutting, 1994; Yarnall et al., 2003)

Office-based interventions to increase physician use of CRC proofs generally target one or more of these constraints and, for the greatest in quantity part, have shown strong evidence of effectiveness (Snell and male 1996; Balas et al., 2000; Shea, DuMouchel, and Bahamonde, 1996; Peterson and Vernon, 2000; Vernon, 1997; Pignone, Harris, and Kinsinger, 2000) wherefore then, if interventions to increase physician CRC testing have been make knowned and shown to work, has CRC trial use remained low? The reason for the gap may be that greatest in quantity of the evidence for efficacy of interventions to advance CRC screening comes from academic or managed care settings, or physician practices where higher authority or equal pressure can be leveraged to encourage physician participation. Proving that interventions are efficacious in similar settings does not guarantee they will be effective in population-based settings (Glasgow, Lichtenstein, and Marcus, 2003) Our investigation examines the outcome of translating clinically proven techniques into low-cost interventions and delivering those interventions to physicians upon a population basis.

METHODS

inquiry Design

A quasi-experimental design was used with intervention and comparison counties designated in each State and measurement of CRC proof use before and after the intervention (Cook and Campbell, 1979) Contiguous counties were pitch uponed for each study group to minimize the likelihood of contamination to be paid to practices with multiple sites being assigned to opposite close attention groups. In North Carolina, the selection proces involved identifying the urban counties and surrounding counties bordering them and selecting single of the areas, which consisted of 12 counties, to receive the intervention. The remaining identified areas, containing 36 counties, subserve as the comparison group. In southern Carolina, 17 contiguous counties were included in the intervention cluster and 17 similar counties were in the comparison collection Intervention efforts targeted internal medicine, family practice, general practice, and gastroentrology physicians in the intervention counties.

The intervention activities occurr above the span of 1 year. For this evaluation, July 2001-June 2002 is treated as the intervention period. In an effort to minimize the potential issue of seasonal variations in CRC testing, the same calendar quarters, single year apart, was selected for measuring the results of the intervention. The baseline period was designated as April 1 2001--June 30 2001; the evaluation period was April 1 2002--June 30 2002 While the evaluation period actually includes the last part of the intervention window, the majority of the interventions had already been delivered by dint of that time so we felt it likely that any impact of the intervention would be detectable in the evaluation period.

Description of the Interventions

sum of two units interventions were offered to physicians in one as well as the other States: telephone-based continuing medical education and office-based tool kits. In southern Carolina, two additional interventions were piloted with small collections of physicians: personalized letters sent through the physician to patients encouraging CRC testing, and distribution of unrestrained FOBT kits in physician offices. A brief description of each intervention is provided. (1)