Problem

Of cancers affecting both men and women, colorectal cancer (CRC) is the fourth most commonly diagnosed cancer in the USA.1 CRC is the second leading cause of cancer death in the USA.2 Ninety per cent of those diagnosed with CRC are over the age of 50, but in the USA only 62.9% of this population is receiving CRC testing consistent with current guidelines.3 Although the incidence of CRC has decreased from 2003 to 2012, it remains one of the leading causes of cancer-related deaths across the world accounting for 8.5% of cancer deaths.3 4

Medically underserved populations in the USA include people who face geographic, economic, cultural or linguistic barriers to healthcare.5 Within underserved populations, CRC screening rates are suboptimal which likely contribute to high CRC burden among these populations.6 Low socioeconomic status (SES) is a significant barrier to successfully completing CRC screening.7 In the USA, there is not a system of universal healthcare. So, people of low SES, especially undocumented people, may have no access to screening services such as colonoscopy.

The site for this quality improvement (QI) project was an urban Federally Qualified Health Center (FQHC) in the USA. FQHCs are the safety net health centres that serve patients regardless of ability to pay for care. This FQHC provides comprehensive health services including primary care, nurse midwifery, oral health and behavioural health. Primary care staff within the organisation include family physicians, family nurse practitioners and certified nurse midwives. Unlicensed assistive personnel are predominantly medical assistants (MA), a role requiring a vocational training programme of 6–9 months, and care coordinators (CC), a role requiring on-the-job training to assist patients in completing provider-recommended services. In 2015, the FQHC cared for 30 197 adult patients. Of those patients, 92.4% self-identify as racial or ethnic minorities. 94.6% of the FQHC patients are at or below 200% of the federal poverty level. The FQHC’s CRC screening rate among eligible patients is 39.7%. This compares to a US average screening rate of 62.9%.8

The aim of this QI project was to increase the number of orders for CRC screening to eligible patients by using unlicensed assistive personnel and automated telephone outreach calls to offer 100 patients CRC screening during an 8-week period. Forty patients would receive outreach calls from CCs. Forty patients would receive automated telephone call reminders to call a CC to obtain an order for CRC screening. Twenty patients would be offered CRC screening by an MA as part of their scheduled office visits (figure 1).

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Figure 1

Colorectal cancer screening project design and outcomes. CRC, colorectal cancer; PDSA, plan-do-study-act.

Background

Prevention and early detection of CRC is possible by increasing access to and utilisation of screening tests.9 Screening tests for CRC can identify abnormal growths before becoming cancerous, or detect CRC at an early stage prompting further intervention. With successful early detection, the initiation of appropriate interventions and treatments often leads to a cure. Increased use of colonoscopy has led to a large decrease in CRC incidence and its death rate in the past decade.9

While colonoscopy is considered the ‘gold standard’ for CRC screening,9 other screening methodologies are available. The US Preventive Services Task Force provides equal recommendations for faecal immunochemical testing, sigmoidoscopy and colonoscopy.9 So screening test selection should be guided based on patient preference and resources. ‘The best test is the one that gets done,’ embraces the view that screening patients for CRC, regardless of test methodology, is the best strategy for preventing CRC among underserved populations.6

At our agency, current practice for ordering CRC screening is for providers to order testing, typically colonoscopy, at the point of care when an eligible patient is identified in the office. This is an example of opportunistic screening. This approach limits screening only to those who attend healthcare encounters and relies on provider workflow to assure screening is offered. Organised screening, a population health intervention, versus opportunistic screening is more successful at identifying all members of a population who are eligible for screening.10 Effective population health interventions include automated phone calls to recommend screening11 and CC-offered screening.12 When opportunistic screening is used, an effective strategy to increase the impact of this approach is to authorise MAs to order screenings based on a standing order set.13

Measurement

The focus of this project was to improve the process for ordering CRC screening, and we did not address completion rates. We tracked two process measures: number of patients for whom screening was ordered and patient intention to act on the screening order. Our outcome measure of interest was cost to deliver the intervention. Our balancing measures included: intervention acceptability to patients and intervention acceptability to staff.

Design

The FQHC was not meeting CRC screening goals for its patients and the system for offering CRC screening relied entirely on patient attendance and provider workflow. Through this project, the QI team sought to improve the process for ordering CRC screening. The team consisted of clinical providers (nurse practitioner and physician), administrators, Doctor of Nursing Practice (DNP) students and DNP faculty from an academic partner. This project implemented evidence-based interventions through a series of small tests of change, including: (1) CC phone call outreach in both English and Spanish; (2) automated CRC screening reminder phone call outreach in both English and Spanish; and (3) MAs offering CRC screening during scheduled visits to eligible patients.

The QI team led an education session for the CCs covering CRC, screening methodologies and screening guidelines. The team then generated a report from the clinic’s electronic health record of patients due for CRC screening. Using a structured phone call script, CCs phoned patients and offered CRC screening, entering orders as appropriate using a standing order set. Concurrent to the CC outreach calls, a separate group of patients received automated phone calls reminding them that they are due for screening and requesting the patient to call a CC to arrange a CRC screening order. The MA-offered intervention made CRC screening orders a part of intake into the exam room. While preparing patients for providers, MAs would review patients’ charts to determine if they were due for CRC screening and enter this order prior to the provider seeing the patient.

Strategy

QI project aims should be specific, measurable, achievable, realistic and timely (SMART).14 Our SMART aim was to increase by 5 the number of orders for CRC screening in a population of approximately 100 eligible, unscreened patients over an 8-week period. We used a rapid-cycle quality improvement approach that included two plan-do-study-act (PDSA) cycles over 8 weeks.15 This project was reviewed by our institution’s Office for the Protection of Research Subjects and was determined to be a QI activity, therefore not subject to Institutional Review Board oversight.

Lessons and Limitations

We sought to improve the CRC screening ordering process to assure that more patients who are eligible for screening receive orders. Our approach blended both population health strategies with opportunistic screening strategies. It is clear from our QI project that some patients are responsive to screening offers from unlicensed assistive personnel. However, the costs to get screening orders to the people who need them may be prohibitive. The population health strategy that potentially had the lowest cost (automated phone calls) was the least acceptable to patients and generated no responses. The population health approach that was most acceptable to patients (CC outreach calls) was relatively costly. Potentially, if the CCs became more confident in their knowledge and ability to provide this service, more patients would accept the offer as opposed to seeking a provider visit to discuss screening. This would make the cost per accepted offer lower. That QI team members (RNs who were DNP students) who made follow-up calls to patients in the CC group were able to conclude the call having provided the patient with a screening referral suggests the possibility that patients may prefer to receive screening recommendations from licensed providers. Alternatively, this may simply be that the QI team had sufficient content knowledge to address patient questions more effectively.

While the MA-offered screenings generated the highest number of accepted screenings at the lowest cost per screening, this approach is limited in two significant ways. This approach only reaches patients who are engaged enough in care to attend office visits and it comes at the expense of creating job dissatisfaction for the MA team members. The approach is helpful in that it enables the care team to share the responsibility of assuring that patients receive appropriate screenings.

A key lesson learnt in the MA implementation was that the MAs did not feel a part of the planning process for this QI project. If this approach is used elsewhere, it would be essential to include MA staff members in the original project design. Additionally, the QI team made a false assumption that MAs had knowledge about CRC and screening approaches so did not provide sufficient training prior to implementation.

Several limitations may be considered when interpreting our outcomes. An important limitation of this QI project is that we did not track completed screenings. Patients who accepted screening offers universally communicated an intent to act on the screening. But, the project was not designed to track completion. Another limitation of this study was the small sample size, which affects its generalisability. Lastly, our project was limited to two PDSA cycles. Further cycles would help to refine and improve intervention effectiveness and efficiency over time.

There were two unforeseen challenges in this project. Though authorised to order screenings by a standing order, the CCs did not have permissions configured to enter these orders in the electronic health record at the start of the project. We addressed this and enabled this functionality in the second PDSA cycle. A second challenge had to do with the processing of faecal immunochemical tests. Though the laboratory vendor permitted patients to mail in these testing cards, staff in the clinic instructed patients to return the cards to the clinic in person. This was based on staff members’ experiences with cards being lost in the mail as well specimens rejected by the lab due to incomplete paperwork submitted. This may have been a barrier to patients accepting testing offers when they learnt that they would need to return to the clinic to drop off the specimen.

Our reports of patients who were not current on screening inadvertently included patients who had been screened elsewhere. Reaching out to these patients used resources (CC and MA time). However, an unforeseen benefit is by contacting these patients, we were able to add these results to the patients’ health records.