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Colorectal cancer (CRC) screening has been supported by strong research evidence and recommended in clinical practice guidelines for more than a decade. Yet screening rates in the United States remain low, especially relative to other preventable diseases such as breast and cervical cancer. To understand the reasons, the National Cancer Institute and Agency for Healthcare Research and Quality sponsored a review of CRC screening implementation in primary care and a program of research funded by these organizations. The evidence base for improving CRC screening supports the value of a New Model of Primary Care Delivery: 1. a team approach, in which responsibility for screening tasks is shared among other members of the practice, would help address physicians’ lack of time for preventive care; 2. information systems can identify eligible patients and remind them when screening is due; 3. involving patients in decisions about their own care may enhance screening participation; 4. monitoring practice performance, supported by information systems, can help target patients at increased risk because of family history or social disadvantage; 5. reimbursement for services outside the traditional provider—patient encounter, such as telephone and e-mail contacts, may foster enhanced screening delivery; 6. training opportunities in communication, cultural competence, and use of information technologies would improve provider competence in core elements of screening programs. Improvement in CRC screening rates largely depends on the efforts of primary care practices to implement effective systems and procedures for screening delivery. Active engagement and support of practices are essential for the enormous potential of CRC screening to be realized.
Evidence from clinical studies1 and guidelines from national expert groups2–4 support the use of several modalities to screen average-risk adults aged 50 years and older for colorectal cancer (CRC). The decentralized nature of health care delivery in the United States necessitates that primary care providers play a central role in implementing national guidelines by recommending, performing, and/or referring patients for CRC screening. Yet despite evidence and guidelines, CRC screening rates in the United States are considerably lower than screening rates for other types of cancer (Fig. 1). Although some office-based interventions to increase primary care providers’ use of CRC screening tests have been evaluated and shown to be efficacious,5–11 there is little evidence to suggest that they have been widely adopted into routine practice.12 Further, many primary care providers are already overburdened with the delivery of a broad range of medical care to their patients.13,14
Practice pressures, widespread levels of dissatisfaction, and concern about the future have prompted 2 professional organizations, the Society of General Internal Medicine and the American Academy of Family Physicians, to delineate specific strategies for transforming primary care. These reports15,16 have particular relevance for CRC screening as the disciplines represented—general internal medicine and family medicine—are the most actively engaged in delivering preventive services to adults. The reports show what primary care practice might look like in the near future, and embrace 6 major elements of a new model of practice which, if implemented, would serve as the groundwork for improving the overall quality of primary care in the U.S. At the same time, the elements of this model describe an infrastructure that could facilitate the introduction into routine primary care of evidence-based strategies aimed at improving CRC screening rates.
Recognizing the critical need for more research to improve the uptake and delivery, and evaluate the short-term outcomes of CRC screening in primary care practice, the National Cancer Institute (NCI) and Agency for Healthcare Research and Quality (AHRQ) issued in December 2001 a program announcement (PAR-02-042/PAR 04-036, Colorectal Cancer Screening in Primary Care Practice) under which many innovative studies have been funded (see Appendix A). In April 2005, NCI and AHRQ convened a conference in Rockville, Maryland entitled “Improving Colorectal Cancer Screening Delivery, Utilization, and Outcomes: the State of the Science” that included several of the program’s grantees (see Appendix B for a listing of participants). This meeting provided a forum for describing and discussing innovative approaches to implementing CRC screening in primary care practice, challenges to widespread adoption of CRC screening, progress toward evaluating CRC screening at the population level, and research gaps. In this report, we use the framework of the New Model of Primary Care delivery15,16 to highlight evidence about interventions that could be implemented in primary care settings to increase CRC screening rates, describe current research supported by NCI and AHRQ to improve CRC screening in primary care practice, and note areas where more research is needed.
Through the NCI/AHRQ research program, it is likely that several evidence-based interventions for enhancing CRC screening uptake and delivery in the U.S. will be identified. However, this work—while important and necessary—will ultimately have value only if effective strategies are actually put to use in practice. An assumption of the NCI/AHRQ meeting was that evidence-based CRC screening strategies are more likely to be implemented and sustained when they are applied in the context of general efforts to provide high-quality care. Moreover, almost all of the intervention strategies discussed at the meeting could conceivably support practice improvements for other screening services in addition to CRC. Implementation of the strategies, however, requires a practice’s leadership to be prepared, proactive, and committed to providing high-quality care across the continuum of the practice.17 Many practices may need to make significant changes to their current approaches to care delivery to achieve this.
Assuring that such change occurs may be challenging. More than a decade of research has documented the difficulties physicians encounter in trying to alter established routines of care.18–20 The knowledge, attitudes, or beliefs of the individual physician were initially thought to be barriers to change, and several studies of methods to improve care delivery have targeted these characteristics. Interventions that focus on the individual physician, however, have shown limited effectiveness in improving outcomes.21,22 More recent research has cast doubt on the consistency and strength of a relationship between physicians’ attitudes and preventive care delivery. It has been shown, for example, that, whereas most primary care physicians rate the delivery of preventive services as important or very important, in actuality, visit- and practice-specific factors largely determine whether these services are provided.23 Thus, the proposed strategies for improving CRC screening discussed at the NCI/AHRQ meeting primarily target systems of care rather than clinicians’ knowledge or attitudes alone.
Clinicians may be more receptive today to changing the way they practice than at any time in the recent past. Numerous observers have concluded that the pressures and frustrations characterizing today’s health care environment are providing an impetus for innovation, especially among primary care providers.24 As corporate interests and a business ethic have come to dominate U.S. health care, most primary care providers are struggling with increasing administrative burdens, lower reimbursement, and demands for brief visits.25,26 Their willingness to adopt new systems and approaches for improving care delivery may be reinforced by new requirements for measuring and reporting performance and quality. For example, CRC screening has recently been incorporated into several measure sets, including the Health Plan Employer Data Information Set (HEDIS) sponsored by the National Committee for Quality Assurance (http://www.ncqa.org/Programs/HEDIS/index.htm), and the National Quality Forum’s recommended “starter set” of clinical performance measures for ambulatory practices (http://www.qualityforum.org/txAmbCare-Summary-SC-TAP.pdf). Such measure sets may be a strong motivator for primary care practices to improve their CRC screening rates.
The studies funded by NCI and AHRQ address many of the elements of the New Model of Primary Care (Appendix A). A particularly unique and promising feature of this research portfolio is that most of the studies are being undertaken in community-based practices, several within primary care practice-based research networks (http://www.ahrq.gov/research/pbrnfact.htm), and nearly all in multiple clinic or office settings. This portfolio, however, represents a subset of published and in-progress research on CRC screening in primary care. Below, we broaden our consideration of innovative strategies for improving CRC screening in primary care practice by describing the elements of the New Model of Primary Care, highlighting for each the evidence base and research gaps related to CRC screening.
CRC screening is a particularly challenging preventive service to implement in primary care practice. Unlike most other preventive services, there are multiple test options, requiring patients and providers to discuss and select the approach that is most appropriate for, and acceptable to, the patient. There also are procedural complexities. CRC screening is perhaps unique among preventive services in the level of effort required of patients to successfully complete screening. For example, fecal occult blood testing may require dietary restrictions and multiple stool samples, whereas sigmoidoscopy and colonoscopy entail rigorous cleansing of the colon. The use of intravenous sedation during colonoscopy also requires patients to identify someone who can accompany them home post-procedure. These factors combined with unique features of the patient, provider, practice setting, and external environment may explain in part why CRC screening continues to be underutilized.
By increasing CRC screening rates in the United States, substantial reductions in CRC mortality would be realized.66 Improvement in CRC screening rates is achievable largely through the efforts of primary care practices to implement effective systems and procedures for screening delivery. Within the framework of a New Model of Primary Care, we described evidence-based strategies for provision of CRC screening by primary care practices, and an active, innovative research portfolio that NCI and AHRQ have developed to identify effective new strategies. In particular, studies funded under the NCI/AHRQ initiative will contribute new knowledge about 4 elements of the New Model: team approach to care delivery, advanced information systems, patient-centered care, and improved efficiency and quality of services.
Although progress is evident, much remains to be done, as the challenges of providing services in the context of primary care are very real. As Frame has noted, “an ounce of prevention is a ton of work” (P. Frame, personal communication, June 29, 2006). Clinicians who desire more information about practice redesign and the New Model can go to a Web site developed by the American Academy of Family Physicians: http://www.transformed.com. Whereas this paper has focused on the primary care practice setting, numerous factors at other levels impact the processes of care delivered in individual practices.17 For example, public policy at the national and state levels can have powerful influence on whether and to what extent certain procedures and services are reimbursed. Both public policy and standards developed by professional organizations can enable or inhibit the provision of services by various provider types or teams. All sectors at many levels, including federal and state policy makers, professional organizations, and local communities, must recognize their roles and responsibilities in fostering and supporting the efforts of primary care providers to deliver responsive and viable preventive services. Only through the active engagement and support of primary care practices will the enormous potential of CRC screening be realized.
Financial Support and Disclosure Funding support for this review was provided by the National Cancer Institute and the Agency for Healthcare Research and Quality.
Potential Financial Conflicts of Interest None disclosed.