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Problem: Low screening and referral rates for colorectal cancer at a primary care clinic suggest the need for alternative methods to identify patients and complete the screening process.
Design: A review of >5000 medical charts established baseline screening and referral data. After a 3-month trial of a screening protocol, the research team conducted a follow-up medical chart review to determine referral levels.
Background and setting: The clinic is an 8-physician primary care facility in Southlake, Texas, and is one of 36 clinics affiliated with HealthTexas Provider Network.
Key measures for improvement: The goal was to increase referrals for colorectal cancer to at least 85% among patients aged 50 to 75 years. Strategies for improvement: The entire staff of the primary care clinic and the gastroenterology office became involved in the referral process. The team used simple tools such as chart stickers to draw attention to patients requiring screening, generation of referral forms that were numbered for follow-up and faxed to the gastroenterologists, and patient educational material on colorectal cancer screening. These tools were designed to overcome specific barriers to successful screening that the team had identified.
Effects of change: Referrals for sigmoidoscopy, colonoscopy, and double- contrast barium enema increased from 47% to 86%. Fecal occult blood testing was arranged for additional patients through the primary care office. Revenues related to colonoscopies increased by about 50% for the gastroenterologist group, the hospital, and the pathology group affiliated with Southlake Family Medicine.
Lessons learned: This colorectal cancer screening protocol succeeded in its 3-month trial because it was collaborative, opportunistic, simple, and made good business sense. The protocol is now being implemented at other HealthTexas Provider Network offices.
“Providing the right care at the right time, in the right way, in the right place, in the right amount, at the right price and being able to prove it” is one way to characterize quality. Our chief executive officer, Joel Allison, has encouraged us to think in these terms. Other mentions of quality goals exist throughout the Baylor organization. The mission of Baylor Health Care System refers to “exemplary health care,” and the vision statement declares that Baylor Health Care System will, before the end of this decade, become the most trusted source of comprehensive health services. On September 26, 2000, the board of trustees of Baylor Health Care System resolved “to give patient safety and continuous improvement in the quality of patient care the highest priority.”
To further these goals, a systemwide Best Care Committee has been formed to focus on quality outcomes and continuous improvement. In addition, more than 2 dozen physicians from the Quality Committee of the HealthTexas Provider Network have attended and graduated from the Advanced Training Program in Health Care Delivery Improvement at Intermountain Health Care in Salt Lake City. The course director, Dr. Brent James, describes quality improvement as the “science of process management,” with its purpose being “to close the gap between practice and the best available evidence.” Attendees are taught tools and techniques to rapidly challenge and improve the delivery of health care. Students are required to complete quality improvement projects. They are also encouraged to continue to investigate and attempt to improve the delivery of health care in their field of influence.
The following article is the first such project to be published in the health care research and improvement section of BUMC Proceedings. Instead of using the introduction, methods, results, discussion format, it applies a structure that is more appropriate for quality improvement projects, as proposed by BMJ and Quality and Safety in Health Care (1, 2). Joyce Stroud, DO, a member of the HealthTexas Quality Committee and a graduate of the Intermountain Health Care course, demonstrates how she propelled the Southlake Family Medicine division of HealthTexas to top rankings for screening of colon and rectal cancer.
—F. David Winter, JR., MD
Chairman, Quality Committee HealthTexas Provider Network
1. Smith R. Quality improvement reports: a new kind of article. BMJ 2000;321:1428.
2. Moss F, Thompson R. A new structure for quality improvement reports. Qual Health Care 1999;8:76
Physicians and patients alike are well aware of the importance of regular screening for the early detection of colorectal cancer, which is the second leading cause of cancer-related deaths and is the third most frequently diagnosed cancer among men and women in the USA. Public awareness campaigns to encourage regular screening for colorectal cancer include educational material distributed through physician offices, celebrities undergoing sigmoidoscopy on television, “traveling colon” exhibits, and even satirical syndicated newspaper columns (wherein colonoscopy involves “a large, cruel medical technician named ‘Horst’ and 70,000 feet of chairlift cable”) (1, 2). Despite the widespread recognition of the value of screening and the ominous consequences of ignoring early signs and symptoms, neither physicians nor patients are adequately doing their part to detect this lethal but treatable disease (3–23). During 2001, for example, US health care providers diagnosed 135,000 new cases of colorectal cancer, and 56,700 patients died from colorectal cancer or its complications (24).
The Southlake Family Medicine (SFM) clinic is an 8-physician primary care facility located in Southlake, Texas, and is part of the HealthTexas Provider Network (HTPN), a wholly owned subsidiary of Baylor Health Care System. During fiscal year 2001, 47% of SFM patients received colorectal cancer screening, a figure somewhat higher than the HTPN average of 42% but significantly below the clinic's screening rates of 80% for cervical cancer, 70% for breast cancer, and 84% for cholesterol.
SFM patients and physicians indicated that they did not pursue screening for a variety of reasons. Physicians often forgot to discuss colorectal cancer with at-risk patients, did not have time or opportunity to recommend screening while attending the presenting problem (e.g., arthritis), or simply mentioned the need for screening but did not impress upon the patient the value and risks associated with compliance or lack thereof. Moreover, the screening process placed excessive responsibility on the patient to follow up with screening even if it was recommended. Patients did not complete the necessary steps in making and keeping appointments for screening procedures because they feared the pain, had too much to remember, experienced delays related to insurance approval or payment, did not understand the importance of the test, were misinformed, or were embarrassed. Further, the gastroenterologists and laboratories were not involved in the referral process.
The team sought to identify methods to increase to at least 85% the number of patients aged 50 to 75 years scheduled for screening (8, 25, 26). Although the US Preventive Services Task Force unequivocally recommends colorectal cancer screening, it does not recommend a preferred method (27). Consequently, the SFM team focused on all currently available screening methods such as fecal occult blood testing (FOBT), sigmoidoscopy, colon-oscopy, and double-contrast barium enema (DCBE) but did not suggest newer screening technologies such as computed tomographic colonography.
The team used the “plan, do, check, act” total quality management approach to organize their efforts, with an emphasis on rapid-cycle improvement. To determine baseline screening rates, they conducted a medical chart audit utilizing a population of patients aged 50 to 75 years seen between July 2000 and July 2001 by 172 HTPN physicians in 36 practices, including SFM. Nurse abstractors examined approximately 30 records per physician, resulting in 5017 total records reviewed. The auditors looked for the frequency with which physicians recommended colorectal cancer screening. The data were subdivided to create baseline data for SMF and for HPTN. Chart audits continued quarterly. The final audit covered the 3-month period beginning in May 2002, when the protocol was implemented, so that the team could review the results of the intervention.
The intervention involved the full range of clinic and referral staff—primary care physicians and nurses, front-desk personnel, schedulers, gastroenterologists, gastrointestinal laboratories, and insurance companies—to meet referral goals. Clinic personnel applied the intervention strategy to each patient in the target population.
During check in, front-desk staff prominently marked the patient's HTPN billing slip, known as a superbill, with a large red “C.” This reminded the physician and nurses to discuss colorectal cancer screening with the patient. Prior to the patient's examination by the physician, nurses reviewed the patient's chart for previous colorectal referrals or screening within proper time limits. If the patient did not comply with prior referrals, the nurse discussed this with the patient to determine why. The nurse also provided new educational material (28) to all patients who either had no prior recommendation for screening or who had failed to complete suggested screening, creating an opportunity for the patient to raise questions or concerns about colorectal cancer or the screening process.
The physician then discussed the need for colorectal cancer screening with the patient as part of the physical exam. If the physician determined that colonoscopy was appropriate, the primary care clinic staff gave the patient a preparatory checklist and faxed a notification to the gastrointestinal clinic alerting it to the prescribed exam. The primary care clinic staff numbered each faxed notification to facilitate tracking and follow-up. For sigmoidoscopy or DCBE, the primary care clinic staff sent the recommendation to the referral department. For FOBT tests, the clinic staff ensured that the patient received the kit before leaving the office.
Office staff at the gastrointestinal clinic received the referral notification from the primary care clinic and precertified the patient with the insurance provider. The staff then called the patient to schedule the appointment. Once the exam was completed, the gastrointestinal clinic staff notified the primary care clinic by fax that the patient underwent the exam. The results of the exam, if completed, were sent by mail. The primary care clinic staff entered the results into the patient's chart. If the patient failed to show up for the exam, the primary care clinic nurses discussed this with the patient during the subsequent visit to the primary care facility. As an additional check, the primary care clinic staff checked with the gastrointestinal clinic staff weekly to ensure that all numbered referral facsimiles were accounted for and to confirm that the patients had indeed scheduled or undergone the procedure.
Colorectal cancer referral rates for SFM increased from the baseline of 47% in fiscal year 2001 to 86% for the period of May through July 2002 (Figure). This referral rate does not include all cases of screening, since many patients were screened with the FOBT in the primary care office and did not need an out-side referral unless the test's findings required it. Without the intervention, HTPN referral rates increased from the baseline of 42% to nearly 68%. In slightly more than 40% of screened patients, screening results led to further treatment or follow-up. Nearly half of these high-risk patients would have been missed without the proposed intervention. Colonoscopies increased by nearly 120 to a total of 223 during the 3-month trial period.
Aside from the obvious added value to patient care and quality of life due to early detection and treatment of colorectal cancer, the results of this study suggest that this protocol is cost-effective and generates significant financial incentives to encourage increased screening and early detection. For example, the average net income to the gastroenterologist for a colon-oscopy is $430. This translates to $95,890 in revenue for the 3- month study, an estimated increase of $51,600. The hospital receives a reimbursement of $463.66 for a colonoscopy. Over the 3-month trial study, this produced $97,368 in revenue, an estimated increase of $55,639. Pathology revenues (assuming the lowest reimbursement rate from Medicare of $98) during the trial period totaled $22,148, a commensurate increase of $11,760.
Baylor Health Care System is committed to continuous improvement in the quality of health care delivered to its patients. This colorectal screening and referral protocol is one example of Baylor's dedication to finding patient-friendly and cost-efficient ways to enhance health care in North Texas (29).
The screening protocol succeeded in its 3-month trial because it was collaborative, opportunistic, simple, and made good business sense. Rather than rely upon just one person in the chain to initiate colorectal cancer screening, the new procedure involves everyone in the process. Such a team effort minimizes errors of omission and provides continuous reminders, support, and encouragement for the patient to undergo the screening and to follow up with the results. This protocol is not dependent upon a scheduled annual physical or a visit related to preventive services. Instead, it takes advantage of any patient visit to recommend colorectal cancer screening if appropriate. As patients make fewer trips to the doctor for routine checkups, opportunistic preventive procedures may be the wave of the future. This protocol is easy to assess and easy to implement. It involves simple administrative tools that connect the many different steps in the referral and screening process and can be applied without expensive equipment, time-consuming training, and labor-intensive execution. Finally, it is cost-effective, using low-cost tools to generate additional revenues through increased screening procedures. The protocol is now being implemented in other parts of HTPN.
We would like to acknowledge our teammates in implementing the strategy: Lannie Hughes, MD, gastroenterologist and HTPN medical director; James Weber, MD, gastroenterologist with Texas Digestive Disease Consultants; Dorothy Newton, office manager at SFM; Shannon Harkins, MA, medical assistant; and Amy Hardison, office manager at Texas Digestive Disease Consultants. Further, we thank Linda M. Gerbig, RN, MSPH, and Robert S. Hopkins III, PhD, for editorial assistance.