Individual Health vs. Public Health

• If you’re the 1/1000, it’s a 100% for you

• What absolute level of risk will society/an individual tolerate?

• Population-based approach should account for safety, cost, availability

Medicare 1998 - 2001

Average Risk

• FOBT Annually• Flex Sig q 4 yrs

Screening Colonoscopy q 10 yrs

High Risk

• 1st degree relative w/adenoma or CA• FAP, HNPCC• Personal hx adenoma or CA or IBD

Colonoscopy q 2 yrs

Uncertainty in 50-64 age group

Prevalence of FOBT/Sigmoidoscopy - 1997

AGE 50

FOBT - 1 Year FS/Procto - 5 Years

Total M F Total M F

19.8 18.4 21.0 30.6 35.2 26.8

Behavioral Risk Factor Surveillance System

Ries L, Cancer 2000;88:2398

• Risk Appropriate Screening

• Provider Endorsement/Education

• Public Acceptance

• Cost/Efficiency

• Help Physicians

• Risk Appropriate Screening

• Provider Endorsement/Education

• Public Acceptance

• Cost/Efficiency

• Help Physicians

Sigmoidoscopy Use in 1o Care Physicians in Allegheny County

• Surveyed 400 physicians - 70% response rate• Median age 44; most full time clinicians

Training: 44% rigid; 28% flexible

Proficiency: 32% rigid; 22% flexible

Schoen RE, Weissfeld JL, Kuller LH; Preventive Medicine 1995

49% equipment available

Regularly refers or schedules pts: 34%Of those: 50% 5 pts/month

Sigmoidoscopy Use in 1o Care Physicians in Allegheny County - Attitudes

• 83% sigmoidoscopy impt

• 88% agree with ACS rec’s

Factors that influence decision to recommend:

Cost - 62%

Low prob finding a lesion - 52%

Patient discomfort - 48%

ACES:Physician Knowledge of Reimbursement for Screening FSG (N=95) - 1999

Provider Endorsement

Medical services are not baseball stadiums:

“Build it and they will come” does NOT Apply

Altering Physician Behavior - CRC Screening

• Media Effect

• Liability

Pittsburgh Post-GazetteMay 20, 2000

• Risk Appropriate Screening

• Provider Endorsement/Education

• Public Acceptance

• Cost/Efficiency

• Help Physicians

Satisfaction with Flexible Sigmoidoscopy (N=1221)

General % Strongly Agree

Very Satisfied with care 97.6

Pain/Discomfort (Didn’t) have a lot of pain 96.2 More comfortable than expected 68.5 (Didn’t) cause me great discomfort 78.1

Enthusiasm

Willing to have another 93.1 Sigmoidoscopy will benefit my health 91.1 Strongly recommend to friends 74.9

Schoen. Arch Intl Med 2000;160:1790

• Risk Appropriate Screening

• Provider Endorsement/Education

• Public Acceptance

• Cost/Efficient Delivery

• Help Physicians

NP’s and Sigmoidoscopy

Back to Back FSG, N = 249

PerPolyp

Missed Adenomas

Missed Adenomas 1 cmPer Patient

No polyp FS #1, Polyp FS #2

No adenoma FS #1, Adenoma FS #2

GI

20% (6/30)

2/10

21% (3/14)

0/4.91

NP P

Schoenfeld. Gastro 1999;117:312

12%

3%

6%

2%

.12

.43

10,164

AvailableT3 Visit

1,360

Did not completeT3 FSG

8,804 (86.4%)Completed

T3 FSG

Adherence with T3 Flexible Sigmoidoscopy

688Had T3 Visit

672No T3 Visit

Weissfeld. Cancer 2002 (in press)

Sigmoidoscopy & Mammography

• Need training for proficiency• Need Consistent Experience to Maintain

Proficiency• Need Current Technology• Infection Control• High Through-Put• Standardize Reporting/Terminology• Follow outcome

• Risk Appropriate Screening

• Provider Endorsement/Education

• Public Acceptance

• Cost/Efficiency

• Help Physicians

Systems Approach to Prevention

• GAPS

• Put Prevention Into Practice (AHRQ)

Goal setting regarding preventive careAssessment of existing routinesPlanning to modify existing routinesStarting and maintaining improved preventive care system

Deitrich. Arch Family Med 1994;3:126

• PPP

Goals

• Help physicians assess risk

• Help physicians recommend action

• Create visible, high quality, high volume, efficient delivery

• Affordable

• Accessible