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Colorectal Cancer Screening: A Process Guide for Practices

Introduction

Thank you for participating in this intervention. This process guide explains the System Approach to Tracking and Increasing Screening for Population Health Improvement of Colorectal Cancer (SATIS-PHI/CRC) intervention and your practice's role in this intervention. Your effort here will help improve colorectal cancer care within your practice.

SATIS-PHI/CRC is a population-based, system-level redesign of colorectal cancer screening and follow up in primary care practices. SATIS-PHI/CRC is intended to assist primary care practices to better provide guideline-based preventive health care to their age-appropriate patients. It assists practices in encouraging, facilitating, and providing screening. It also helps educate clinicians and patients about colorectal cancer screening.

This effort may be your first time participating in population-based health care. On your behalf, we will contact all the patients in your practice ages 50-79 and of average risk and invite them into an evidence-based screening program. You may receive questions from patients about the process and about colorectal cancer screening. This guide is meant to help clarify the process and answer patient questions. You should also review the 2008 evidence-based guidelines for colorectal cancer screening published by the (1) American Cancer Society, U.S. Multi-Society Task Force on Colorectal Cancer, and American College of Radiology and (2) U.S. Preventive Services Task Force (USPSTF).

In addition to this overview, we have also included copies of the letters that we will send your patients, as well as a Screening Tracking Sheet that can help your practice track patient screening. [ATTACH ALL MATERIALS REFERENCED IN THIS DOCUMENT AND CREATE A CD FOR ELECTRONIC COPIES]

Below is an outline of the information included in this packet:

• Introduction
• Part I: Recommended Screening Guidelines
• Part II: Initial Records Review
• Part III: Baseline Practice Survey (Optional)
• Part IV: Academic Detailing and Optional Baseline Practice Focus Group
• Part V: Patient Screening Eligibility Assessment Mailing (Optional)
• Part VI: Patient Invitation to Screen Mailing
• Part VII: Responding to Patient Screening Requests
• Part VIII: Patient Reminder Mailing(s)
• Part IX: Tracking Patient Screening
• Part X: Post intervention Practice Survey and Focus Group (Optional)
• Part XI: Patient Focus Group (Optional)

Part I: Recommended Screening Guidelines

We are using the March 2008 guidelines from ACS/U.S. Multi-Society Task Force/ACR, which have been widely endorsed and adopted over the past year. A detailed version of the guidelines is at: . 

We are also using the 2008 guidelines from the USPSTF. A brief summary chart is attached. The summary chart is available at: . 

We find that many physicians think colonoscopy is the only successful screening method for colorectal cancer. Some may be unaware that several methods of screening are known to be effective, including stool blood testing. In fact, colorectal cancer screening by stool blood testing remains the only method of screening proven in randomized clinical trials.

In a population effort, it is important to offer effective screening options to all patients. This is why we are providing patients with information about effective screening methods along with an immunochemical stool blood test kit. Patients who receive only a recommendation for colonoscopy often go without screening because of fears about the test; this prevents them from participating in other effective screening measures.

Part II: Initial Records Review

We will review your current electronic databases (claims, billing, and/or electronic medical record) to establish your current documented screening rate. Most of this review will be external to the practice. However, we may ask for clarification from the practice.

Part III: Baseline Practice Survey (Optional)

You may have already completed the preintervention practice survey before receiving this document, or if not, you should complete it prior to the Academic Detailing session. It should be completed by every member of your practice. It will tell us what their current beliefs and processes are about colorectal cancer screening, as well as telling us a little bit about them as members of the medical team.

Part IV: Academic Detailing and Optional Baseline Practice Focus Group

After the survey, but before any patients are contacted, we will come to your office to review the basics of this SATIS-PHI/CRC intervention and of current guidelines (i.e., hold an Academic Detailing session). We may also ask questions to clarify how your practice perceives colorectal cancer screening. Afterward, we will stay to answer questions. We may get back in touch with you later to clarify your information.

Part V: Patient Screening Eligibility Assessment Mailing (Optional)

The daily work of hectic practices, or missing communication from specialists, may have prevented documentation for all patients whose screening is current. In addition, some patients may decline screening. We will send your patients a brief letter asking them to let us know if they are ineligible to be screened but slipped through the documentation process. We will also ask for some brief demographic information. We will collect all of this information. If we discover any patients who are not screened, we will pass their information back to you as they provided it so that you can update their chart.

At this stage, some patients may call you with questions. They may want to verify that this mailing did indeed come from your practice. In this case, we would appreciate your verification of the eligibility assessment's legitimacy.

Patients may also want to update you on their screening status or they may express a desire not to be screened. In this case, please encourage them to respond to the Screening Eligibility Assessment as instructed. We will provide you with the necessary information about patients who have been screened.

The Screening Eligibility Assessment is attached.

Part VI: Patient Invitation to Screen Mailing

At this point, we will send all patients who remain eligible to be screened an invitation to participate in screening. This mailing will contain (1) an invitation, (2) information on colorectal cancer screening and methods from the Centers for Disease Control and Prevention, (3) a request slip for an immunochemical stool test kit with instructions [REVISE THIS STATEMENT IF YOU ARE SENDING PATIENTS A STOOL TEST KIT DIRECTLY (VERSION 1), RATHER THAN A STOOL REQUEST CARD (VERSION 2)] and (4) a list of colonoscopy providers whom you recommend.

The invitation endorses multiple methods of effective screening. This includes the stool test kit as well as colonoscopy. Some patients will call and ask for help scheduling a colonoscopy. Some will return the stool test kit to your office. Rarely, someone may ask about a less common method of screening.

If a patient calls for your advice and you prefer to recommend a specific test, please feel free to do so. However, it is important to understand that patients may prefer to choose the effective means of screening that works best for them.

The Invitation to Screen is attached.

Part VII: Responding to Patient Screening Requests

If a patient requests a colonoscopy, please refer the patient using your current process.

If a patient returns a stool test kit, it is to be processed through [INSERT HERE: NAME OF YOUR NETWORK'S LABORATORY SERVICE]. It is important to use [INSERT HERE: YOUR LAB'S NAME] for these kits, as they will help us track results and ensure the safety of your patients. [INSERT HERE: YOUR LAB'S NAME] has provided a short form to return kits to the lab for processing. Please feel free to use it. You can also call the lab for specimen pickup at [INSERT HERE: LAB CONTACT PHONE NUMBER].

Patient safety and the appropriate followup of patients 'screening results are our top priority. Any positive stool test requires a followup colonoscopy, and we want to ensure that all patients who have a positive test return to your practice for that care. [INSERT HERE: YOUR LAB'S NAME] will provide us with the results of each patient's stool blood test so that we can follow up with you.

Although the immunochemical stool test kit is easier to use than the old guaiac kits, some may be unsuitable for developing. In this case, we will remind you of the affected patients so that you can inform them and provide an additional kit if the patient wants to repeat the test. If you need a new kit, please call [INSERT HERE: CONTACT PHONE NUMBER]. Please identify the name of the practice and the name of the patient, including Social Security Number.

The stool test kit will identify the patient by a unique number (the number below the lab return address). We will give you the number with the decoded names in a spreadsheet. By matching this number to the patient on the spreadsheet, you can identify any stool test kit.

SAMPLE STOOL TEST KIT LABEL

SATIS-PHI/CRC
[INSERT PRACTICE NAME]
[INSERT PRACTICE ADDRESS]
ABC00001

In this example, the patient's unique ID is ABC00001. Matching the number to the name shows that Patient ID ABC00001 is Jane Doe.

If a stool test kit is returned and cannot be properly developed, please contact us with the patient's name and patient ID number. We will send the patient a replacement kit. We would like you to contact your patient by phone to let the patient know the test needs to be repeated and that a new kit is on the way.

The contents of the Invitation to Screen mailing are attached, including more information on the immunochemical stool blood test kit.

Part VIII: Patient Reminder Mailing

We will send a simple reminder letter to all patients who do not respond to the initial mailing. If necessary, we may send a second reminder mailing to patients.

A copy of the reminder letter is attached.

Part IX: Tracking Patient Screening

At this point, we will track the results of all patients who are screened. We will specifically followup track all positive results to the point of colonoscopy and subsequent treatment if necessary.

A document called the Screening Tracking Sheet is attached and included on your CD. This document can serve as a simple registry if you want to track your patient results. Personnel from the central entity can show you how to use this tool. It is for your use if you choose. You may already have another method of tracking results you are comfortable with, which makes the Screening Tracking Sheet unnecessary.

Patients who screen positive will require your support and encouragement as their primary care provider to ensure that they receive appropriate care. We will ask you about each positive result to see that the patient has benefited from followup.

Part X: Post intervention Practice Survey and Focus Group (Optional)

We may ask you to repeat the initial survey to assess what may be different about your practice after the intervention. We may also conduct a final focus group to clarify and reflect on your experience.

Part XI: Patient Focus Group (Optional)

We may contact some of your patients to ask them to share their experience of colorectal cancer screening. This task will occur late in the intervention, so we will let you know when patients are being contacted. Some patients may call you to verify the legitimacy of our contact.

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