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Using survey data to plan a program to increase colorectal cancer
screening the Medicare population
Anna P. Schenck, PhD, MSPHCarrie Klabunde, PhDRenee Taylor, MPH
Nelson Gunter, MD, MPH
American Public Health Association 2002 Meeting
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Collaborators
Carolina Medical ReviewSharon Eubanks, RN
Aunyika Tocharoen, PhD
Nelson Gunter, MD, MPH
Medical Review of NCRenee Taylor, MPH
Louise Henderson, MSPH
Sue Hunter, MPH
Leslie Hill
Lee Hurley
Robin Brown
Anna Schenck, PhDCenters for Medicare &
Medicaid ServicesJim Coan
Catherine Gordon National Cancer InstituteCarrie Klabunde, PhD
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Who we are
Medical Review of North Carolina and Carolina Medical Review (in South Carolina) are Quality Improvement Organizations
Contract with Centers for Medicare & Medicaid Services to assure quality of care for Medicare consumers in each state
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Background Colorectal cancer is the second most deadly
cancer in the US
Early detection and treatment are the best
defenses against colorectal cancer
Use of screening tests is low
Medicare introduced screening benefit in 1998
for enrollees age 50 and older
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Medicare Coverage of Screening Tests
FOBT• yearly
Sigmoidoscopy• every 48 months
Colonoscopy• every 24 months for high risk • every 10 years for average risk (as of 7/1/2001)
Barium Enema• as alternative to sigmoidoscopy or colonoscopy
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Project Overview
Center for Medicare & Medicaid Services awarded 2-year project to NC and SC• calculate national and state screening rates • develop and pilot interventions
NCI interest resulted in collaboration• focus groups• baseline and evaluation telephone survey
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Baseline Survey Design
• each state selected intervention and comparison counties– SC (mixture of rural and urban)– NC (primarily urban)
Methodology• telephone survey conducted before the intervention• age 50 - 80, non-HMO, African American or White• randomly selected Medicare enrollees in NC and
SC intervention and control counties
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What did we want to know? Beliefs, knowledge and attitudes
• risk factors• screening• Medicare coverage
Behaviors• which screening tests are being done• are guidelines being followed
Barriers• why are some not screened
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Response
2004 completed interviews• NC = 1003• SC = 1001
Overall response rate 69%• NC = 67%• SC = 70%
Differential response among subgroups indicated a need for weighted analyses
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Characteristics of Sample Sex
• Male = 43% Race
• White = 77%• African American = 23%
Education• Less than High School = 25%• High School or Equivalent = 36%• Post High School = 32%
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Understanding of Risk of Colorectal Cancer
50
35
19
0
20
40
60
80
100
% r
esp
on
din
g co
rrec
tly
age increases risk equal risk amongsexes
both facts
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Physician Recommendation for Colorectal Cancer Test
57
37 36
74
0
20
40
60
80
100
% w
ith
MD
rec
omm
end
atio
n
FOBT Sigmoidoscopy Colonoscopy Any Test
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Ever Had Any Colorectal Cancer Test
56
37 35
72
0
20
40
60
80
100
% e
ver
had
tes
t
FOBT Sigmoidoscopy Colonoscopy Any Test
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Had Test According to Guidelines
2025
33
55
0
20
40
60
80
100
% w
ith
tes
t in
rec
omm
end
ed i
nte
rval
FOBT Sigmoidoscopy Colonoscopy Any Test
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Potential Barriers to Colorectal Cancer Testing
25 22
52
0
20
40
60
80
100
perc
ent
do not need toworry
do not agreetreatment helps
survival
do not knowMedicare pays
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Use of other preventive services
Women• those who had
mammogram in past year were more likely to have had colorectal cancer test
• those who had pap smear in last 3 years were more likely to have had a colorectal cancer test
Men• those who had PSA
test in last year were more likely to have had a colorectal cancer test
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Reasons for no test
Among those who had not had the test according to guidelines, two reasons most often listed:
• “I didn’t think it was needed” 12% - 18% (depending on test)
• “My doctor didn’t order the test” 77% - 82% (depending on the test)
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Where do Medicare consumers get most useful health information ?
Internet1%
Family or friends
5%
Media5%
Health pamphlets or
books17%
Doctor or health
professional72%
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What the survey told us about consumers
Plenty of room for improvement Lack of knowledge about risk factors and
coverage Those who use other preventive services were
more likely to have been tested Written information such as health pamphlets and
booklets may be useful with this population Media are less influential with this population
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What the survey told us about physicians
Patients expect their doctor to order the test
Doctors may need to convince some
patients of the importance of screening
Physician recommendation strong influence
of whether the patient gets a test
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Intervention Implications
Consumer interventions need to address:• belief in importance and efficacy of screening
• lack of knowledge about risk factors and Medicare coverage
• use of other preventive services
Provider interventions needed to address:• physician recommendation
• tools to convince patients
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Consumer Intervention: CDC Screen for Life Mailing
CDC Screen for Life information was sent to beneficiaries selected in two ways:• randomly selected • selected from persons with regular preventive
service use Total of 16,400 packets were mailed
• 3,000 to randomly selected (NC only)• 5,600 to those with regular preventive service use• 7,800 to targeted aged groups (SC only)
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CDC patient fact sheet
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Consumer Intervention: Birthday Card
Beneficiaries in intervention counties who turned 65 were sent this card on their birthday
Total of 3,514 cards were sent NC only
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Birthday card sent to NC
beneficiaries
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Consumer Intervention: NCI Cancer Information Service
Postcards Beneficiaries randomly selected First card did not generate many calls so the
card was redesigned. NC sent 2 versions of a revised card while SC continued to send original cards
Total of 15,300 cards mailed over 6 months period in both NC and SC
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Revised CIS Postcard - Positive
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Physician Interventions
Provider teleconferences• 2 teleconferences
– promotion of the new screening benefit and project– how to increase screening in the office and get paid
for it
Mailing of physician postcards (SC only) Distribution of FOBT kits through
physician offices (SC only) Provider Toolkit
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Screen for Life Toolkit
Promoted through mailings, web-site, regional meetings, fast-fax through NC Medical Society
Ordered via fax-back forms, mail-in forms, web-site
Contained screening guidelines, billing instructions, state testing data and office-based tools
Total of 380 toolkits were distributed• approximately 20% of MDs in target area
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Patient Assessment used as part of a reminder system
Patient Health Maintenance FormAs your health care providers, we would like to review some important parts of your health history. Please answerthe following questions. Only answer the questions in the sections that apply to you. If you have filled out thisform in the past 6 months, you do not need to do so again; you may stop here.
Name _________________________________________ Date_____________ Date of birth _____________
Have you ever had the pneumococcal vaccine (pneumonia shot)? Yes___ No___ Don’t know___Have you had your cholesterol checked in the past 3 years? Yes___ No___ Don’t know___
Have you had the flu shot this year? Yes___ No___ Don’t know___Have you had your stool checked for blood (FOBT) in the past year? Yes___ No___ Don’t know___Have you had a flexible sigmoidoscopy in the past 5 years? Yes___ No___ Don’t know___Have you had a colonoscopy in the past 10 years? Yes___ No___ Don’t know___
Have you had a mammogram in the past year? Yes___ No___ Don’t know___
Have you had a pap smear in the past year? Yes___ No___ Don’t know___Have you had a breast exam by a health professional in the past year? Yes___ No___ Don’t know___
Have you had a rectal/prostate exam in the past year? Yes___ No___ Don’t know___Have you had a blood test for prostate (PSA) checked in the past year? Yes___ No___ Don’t know___
Have you had an eye exam by an eye professional in the past year? Yes___ No___ Don’t know___Have you had your feet examined in the past year? Yes___ No___ Don’t know___Have you had your urine checked in the past year? (microalbumin) Yes___ No___ Don’t know___Have you had your cholesterol and lipids checked in the past year? Yes___ No___ Don’t know___Has your blood been checked for longer term sugar control in the past 6 months (HbA1c)? Yes___ No___ Don’t know___
Do you use tobacco? Yes___ No___Have you seen a dentist in the past year? Yes___ No___Are there other issues you would like to discuss with your provider? Yes___ No___
If so, please list.
Medical Review of North Carolina, Inc., Health Maintenance Tool, 2001. This material was prepared by Medical Review of North Carolina, Inc., under a contract with the Centers forMedicare and Medicaid Services, formerly the Health Care Financing Administration. The contents presented do not necessarily reflect CMS policy. 6SOW-NC-CRC-01-01
Clinician comments:
Patients 65 years and older
Patients 50 years and older
Women 40 years and older
All women
Men 50 years and older
Patients with diabetes
All patients
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Chart Sticker from Physician Tool Kitused as part of a reminder system
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Stage-of-change based patient education brochures (used with video)
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Post Card for Physicians to send to Patients
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For more information, contact:
Anna Schenck
Medical Review of NC5625 Dillard DriveCary, NC 27511
Check out Medicare Statistics on our website: www.mrnc.org/ncmed
or www.mrnc.org/crcreport