The Impact of an Evidence-Based Multi-component Intervention on Colorectal Cancer Screening in Primary Care at a Healthcare System

Abstract

Practice Problem: Colorectal cancer is the second leading cause of cancer death in the United States; many of the deaths are preventable with early detection. Adherence rates for colorectal cancer screening with fecal immunochemical test kits (FIT) was below the national benchmark at this facility. PICOT: The PICOT question that guided this project was: Among veterans 50 – 75 years old requiring average risk colorectal cancer screening (CRCS) seen in primary care at a veterans affairs healthcare system facility (P), how does the use of a multi-component intervention (I), compared to the usual care (C), affect the number of patients completing CRCS (O) over a period of 12 weeks (T)? Evidence: Review of high-quality studies suggested a multi-component approach, including increasing provider awareness and increasing patient education and outreach, as the most effective approach to increase colorectal screening compliance. Intervention: The multi-component intervention included a standardized CRCS nurse navigation process through standard work which included the teach-back method, patient outreach, and provider feedback. Outcome: There were clinically significant improvements in adherence with returned FIT kits, follow up for abnormal FIT kits, and statistically significant improvements with nursing documentation of patient teaching. The number of patients overdue for CRCS decreased. Conclusion: The multi-component CRCS screening intervention demonstrated significant improvements in the intervention clinics which is consistent with the body of evidence. COLORECTAL CANCER SCREENING IN PRIMARY CARE 3 The Impact of an Evidence-Based Multi-component Intervention on Colorectal Cancer Screening in Primary Care at a Healthcare System “Dying from embarrassment” may be more than a saying when it comes to colorectal cancer. Colorectal cancer (CRC) is the second most common cause of cancer deaths in the United States (American Cancer Society [ACS], 2020; Centers for Disease Control and Prevention [CDC], 2020). However, the five-year survival rate can be as high as 90% when CRC is detected in its early stage (Agency for Healthcare Research and Quality [AHRQ], 2018; ACS, 2020; CDC, 2020). A critical component in early detection is colorectal cancer screening (CRCS) for adults between the ages of 50 and 75 (AHRQ, 2018; ACS, 2020; CDC, 2020). Despite improvements in access to CRCS, other barriers, such as lack of education, fear, and embarrassment (Reynolds et al., 2018), still pose obstacles in reaching higher screening rates. These barriers contribute to premature deaths that could have been prevented by a simple CRCS (Adams et al., 2018; Brouwers et al., 2011b, 2011a; Dolan et al., 2004). The National Center for Health Promotion and Disease Prevention provides guidance for a comprehensive CRC prevention and screening program (U.S. Department of Veterans Affairs [USDVA], 2020a). At the project site, a Veterans Affairs (VA) healthcare system, the CRCS rate from a 2020 random audit (75.6%) was below the national benchmark of 80% (National Colorectal Cancer Roundtable [NCCRT], 2021; Office of Disease Prevention and Health Promotion [ODPHP], 2020a; U.S. Department of Veterans Affairs [USDVA], 2020c). Mitigating missed opportunities to prevent avoidable deaths by increasing CRCS aligned with the VA’s high reliability organization (HRO) journey (AHRQ, 2019; Grabowski & Roberts, 1997). Significance of the Practice Problem COLORECTAL CANCER SCREENING IN PRIMARY CARE 4 Estimates of deaths due to CRC are over 50,000 per year in the United States (Siegel et al., 2018, p. 8). Tragically, many of these deaths could have been prevented with early screenings (CDC, 2020; National Committee for Quality Assurance, 2020; Redaelli et al., 2003; Wilkins et al., 2018; Wolf et al., 2018). Because CRC does not produce symptoms until the more advanced stages, screening before symptoms appear is crucial for early detection (Wilkins et al., 2018; Wolf et al., 2018). In addition to the societal impact of morbidity and untimely deaths caused by CRC, CRC s economic burden is significant (Dieguez et al., 2017; Yabroff et al., 2008, 2011). Yabroff et al. (2011) estimated CRC costs $14.1 billion per year in the United States. Due to its relatively long disease course, CRC has one of the highest economic cancer burdens (Yabroff et al., 2008). Costs include frequent surveillance procedures, surgeries, chemotherapy, radiation therapy, and inpatient comfort care (Redaelli et al., 2003). In addition to healthcare costs, CRC causes an economic burden due to lost productivity by the patient (Bradley et al., 2011; Pearce et al., 2016). Bradley et al. (2011) projected that lost productivity caused by CRC would be $4.2 billion in 2020 (p.5). Most CRCs begin as slow-growing, pre-cancerous polyps (Tobi, 1999). The identification and treatment of pre-cancerous polyps while the lesions are in a localized stage significantly increase survival chances (ACS, 2020; Siegel et al., 2018). Two methods for CRC screenings include stool-based tests and visual examination (Levin et al., 2008; Wilkins et al., 2018; Wolf et al., 2018). The colonoscopy is the most common visual examination CRCS procedure (Levin et al., 2008; Wilkins et al., 2018; Wolf et al., 2018). An example of a common stool-based test is the fecal immunochemical test or FIT (Levin et al., 2008; Wilkins et al., 2018; Wolf et al., 2018) . Data from 2018 shows that 25% of U.S. adults did not get screened for CRC (CDC, 2021). COLORECTAL CANCER SCREENING IN PRIMARY CARE 5 Reducing the prevalence, morbidity, and mortality caused by cancer is one of the leading health indicators of Healthy People 2020 and Healthy People 2030 (ODPHP, 2020a, 2020b). The goal of both Healthy People 2020 and 2030 is to improve wellness by prioritizing the prevention of health threats on the U.S. population (ODPHP, 2020a, 2020b). To reduce the health threat of CRC, prevention must address cultural disparities and stigma associated with the disease (Goldman et al., 2009; NCCRT, 2021). Health Literacy and Colorectal Cancer A relationship exists between a low health literacy rate and adherence to CRCS recommendations (Arnold et al., 2012; Dolan et al., 2004). The veteran population at this facility may have a higher percentage of low health literacy levels than the general U.S. adult population (Nouri et al., 2019; Rodríguez et al., 2013). This organization’s primary mission is to honor its customers by providing “exceptional health care that improves their health and well-being” (USDVA, 2019, VHA Mission, para. 6). Therefore, healthcare providers working at the facility had professional and organizational obligations to maximize efforts for improving CRCS rates among veterans.