March is colorectal cancer (CRC) awareness month, so it’s an appropriate time to reflect on how to increase the number of people who get screened for this cancer that’s largely preventable through screening. Between 2005 and 2012, Kaiser Permanente, Northern California, doubled the percentage of our eligible patients who were screened for CRC.
So how did we do it?
We employ a combined screening model with fecal immunochemical test (FIT) outreach and colonoscopy available by primary care physician referral. Our successful systematic approach involves four components.
1. Measuring performance. We do a systematic review of our electronic medical records to track our CRC screening rates, but rates can also be measured through telephone or mailed survey of patients, or a review of a sample paper charts. However it is done, measurement is essential for evaluating the impact of any screening interventions. It allows identification of which patients are up to date with CRC screening, who is coming due and who is overdue for screening. Documentation of screening requires the recording of screening done in the practice, but also screening performed by outside providers.
2. Outreach. Outreach refers to contacting a patient outside of a regular office visit. We used a combination of mailed test kits, followed by phone and secure electronic message reminders. This allows the screening message to be delivered to patients who do not come into the office often enough to be invited to screen. Fecal immunochemical test (FIT) outreach allows the test kit to be mailed to a patient’s home, and saves them from having to travel to the office to pick up the test or to miss any time from work to complete their screening.
3. Leverage support staff. We use our office support staff to remind patients about the need for CRC screening. Support staff can give FIT kits to overdue patients and document outside screening if it has occurred. This allows the primary care physician to spend time with the patient discussing the patient’s concerns, and not having to redirect the conversation to the need for CRC screening. It also helps ensure that the screening invitation is made.
4. Systematic reminders. We use our electronic records to provide real-time systematic reminders to physicians and staff when patients come in for CRC screening. Systematic reminding can also be done with stickers placed on paper charts or prompts in electronic medical records. This helps ensure that everyone caring for the patient at the time of a visit can reinforce the messages delivered by mailed outreach. Some patients will respond to mailed outreach alone, but many reluctant patients need to hear about the importance of CRC screening to their individual health from a physician they trust or from the office staff of that physician.
The Kaiser Permanente, Northern California Experience
A key to our success was organizational and leadership alignment around the goal of improving our CRC screening rates. This signaled to all members of our organization that CRC screening is a priority, and all departments in our multispecialty medical group are pursuing the goal of getting our members screened for CRC.
The American Gastroenterological Association offers CRC guidelines for physicians and information for patients.
Theodore R. Levin is a gastroenterologist and can be reached on Twitter @tr_levin.