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Colon Cancer Prevention: A System Approach to Improving Care

Humphrey LL, Shannon J, Douglas D, Genovese BJ, Helfand M. Colon Cancer Prevention: A System Approach to Improving Care. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.


Objectives: Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States. Results from randomized clinical trials of fecal occult blood test (FOBT) screening have shown that FOBT based CRC screening programs among adults over age 50 reduce CRC mortality significantly. While efforts have been made to improve CRC screening rates, data indicate that outside of the research setting, less than half of patients with positive FOBT screening results receive appropriate follow-up. The primary objective of our study is to improve the timeliness and follow-up for patients with positive FOBT tests. Methods: Methods: This is a cluster randomized controlled trial involving 8 VA sites matched by the number of colonoscopies done per year and randomized within the cluster. The intervention involves an electronic templated consult that imports relevant clinical information within CPRS and automatically directs a positive FOBT to the gastroenterology service for review. The matching control sites continued with "usual care". Focus groups were conducted with each intervention site to evaluate the impact of the intervention on clinical care and physician work load and satisfaction. Analysis: Analyses will compare pre- to post-intervention change in rates and timeliness of follow-up within an institution and between intervention and control sites. Further, we will conduct qualitative analysis of focus group data to identify institutional and service level acceptance of the intervention and perceived primary care and gastroenterology provider satisfaction. Results: Pilot data from the Portland VA have shown improvements in the follow-up of positive FOBT tests from baseline of 56% to over 95%. Information from focus groups at the intervention sites has suggested significant improvement in the timeliness of follow-up and high primary care provider satisfaction with the process. We will be analyzing follow-up data from each of the sites over the next 3 months. Implications: Pilot data indicate that implementation of an automated consult process significantly improves the frequency and timeliness of follow-up of positive FOBT colon cancer screening tests. Impacts: We have identified a system process utilizing the electronic record that, on preliminary review, significantly improves the follow-up of one type of cancer screening test. Given the time constraints on providers, as well as the enormous amount of patient related information sent to providers, this system change has the potential to improve follow-up and clinical outcomes and may be generalizable to other screening procedures and processes.

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