A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention focus group of study practices was conducted. The primary outcome was patients being current with CRC screening recommendations and having received a CRC screening within the past year. A secondary outcome was the presence of a CRC screening recommendation recorded in the medical chart. This research was conducted from February 2008 through January 2009. All materials and procedures were approved by the Penn State Milton S. Hershey Medical Center Institutional Review Board.
We recruited primary care practices (n = 4) in four counties of north-central PA through existing partnerships with ACTION Health Cancer Task Force, a community-based coalition of Northern Appalachia Cancer Network (NACN) and Penn State Ambulatory Care Research Network (PSARN). The NACN is a regional member of the National Cancer Institute (NCI)-funded Appalachia Community Cancer Network, whose goal is to develop, test and disseminate evidence-based interventions that measurably reduce cancer-related health disparities [7
]. PSARN aims to link primary care research with patient care, medical education, and community service in central PA [25
]. Three practices are members of a large multi-practice primary care health network which shares a full electronic medical record (EMR), but are geographically separated, while the fourth practice is affiliated with a major academic health system and uses a paper-based record.
We planned the study using the PRECEDE/PROCEED conceptual model for population health improvement, which guides users through a systematic process to identify factors that influence health and health behaviors [26
]. The development of the study procedures included key informant interviews of medical office assistants, nursing staff, office administrators, and providers to assess current policies for preventive health care and screening practices at each participating practice. In addition to interviews, we conducted an environmental assessment of the practice, including screening tools, medical record flow sheets, computerized databases, patient education handouts, and patient brochures on CRC screening.
The health care providers, physicians and nurse practitioners, at each practice answered a health care provider survey. The survey instrument collected information on screening practices, follow-up and referral procedures, and characteristics of the practice. A lead nurse at each practice distributed the survey after the practice agreed to participate in the study and again after data collection was completed at each site. The health care provider survey sought to provide the research team with important information about the early detection of CRC, including screening recommendation behavior, opinions about screening, and some general questions about the individual medical practice. Once the survey was completed, the answers were transcribed and saved to a database. Unique identifiers for the respondents were established by the lead nurse of the clinic so surveys before and after the intervention could be linked. The list of identifiers was not shared with the research team providing anonymity for respondents.
Upon completion of the pre-intervention practice assessment, each of the four practices received three separate AD visits that reviewed four different learning modules. The intervention was delivered by a physician-led team including, a senior nurse and PhD-level behavioral health specialist who were trained by the lead physician. The academic detailers covered various topics (Table ), reinforced standard medical practice, supplied providers and staff with county-specific cancer incidence and mortality data and ACS educational tools (e.g., wall poster, client reminders, scripts).
Summary of information reviewed during academic detailing sessions
Outcome measures were collected through medical chart abstraction performed prior to the AD intervention and six-months after the intervention. Abstraction was completed by abstractors hired from the participating practices. Abstracted data were entered directly into NCI's BioInformatics Grid®
(caBIG) through Oracle C3D. Developed to support translational and clinical research in oncology, the caBIG is a nationwide computer-based network "grid" of data-sharing tools and medical data intended to improve cancer care [30
]. The abstraction protocol guided the abstractor through each step, including selection of medical records, determination of eligibility, recording screening results, and follow-up care.
Eligibility for medical record abstraction included patients seen in the practice during the previous two months who were aged 50 years or older. Ineligibility was conferred to patients seen for acute reasons, those with symptoms of CRC (e.g., rectal bleeding), and those with a prior diagnosis of CRC. The primary outcome measures were being current with CRC screening recommendation using FOBT, FS, or colonoscopy and having received a CRC screening of FOBT, FS, or colonoscopy during the previous year. We also documented the presence of a recommendation of CRC screening during the previous year as a secondary outcome measure. Information abstracted from the chart included age group in increments of 5 years, family history of CRC, interval since the previous physician visit, and any completed CRC screening tests along with their results. Patient names or other identifiers were not recorded in caBIG.
The prevalence of the outcome measures were calculated by dividing the number of patients who had a CRC screening (or recommendation) by the total number of eligible medical records reviewed. The statistical significance of differences in the estimates of the pre- and post-intervention screening rates were compared using chi square, or Fishers exact tests if the expected cell size was small. We used Wilcoxon tests to examine differences in median time to colonoscopy follow-up.
To assess acceptability and participant experiences in the intervention, a qualitative evaluation with key informant interviews was used to examine intervention processes, including participant perceptions of the program and consistency with programmatic goals. This was accomplished at the completion of chart data collection.
Semi-structured in-depth, face-to-face interviews with physicians, other health care providers and medical office directors were conducted by a trained qualitative researcher who was not a member of the research team, to insure open dialogue with interviewees. The semi-structured interview format sought to elicit specific information about the content and conduct of the intervention, including the acceptability of the intervention to providers and office staff, perceptions of what did and did not work as desired, and ways in which the provision of academic detailing could be improved.
The interview was tape recorded and transcribed. All names and other identifying information were removed from the transcript before the research team was able to review for content analysis.