View source for Improving colorectal cancer screening in primary care practice: innovative strategies and future directions

Article: Klabunde CN, Lanier D, Breslau ES, Zapka JG, Fletcher RH, Ransohoff DF, Winawer SJ. Improving colorectal cancer screening in primary care practice: innovative strategies and future directions. J Gen Intern Med. 2007 Aug;22(8):1195-205. Epub 2007 May 30.

== Introduction ==

Colorectal cancer (CRC) screening rates remain low in the United States despite strong evidence supporting its use. Although many studies have shown that office-based interventions can improve CRC screening, most providers are overwhelmed by the delivery of other medical care to their patients. A New Model of Primary Care Delivery has been proposed that would help improve overall quality of primary care delivery in the US.  This New Model of Primary Care encompasses 6 elements including: 1) a team approach to care delivery, 2) advanced information systems, 3) patient centered care, 4) monitoring practice performance/ efficiency, 5) enhanced practice finances, and 6) training opportunities. Such a model may facilitate the introduction of evidence-based strategies for improving CRC screening rates.

== Methods ==

Experts in the field of CRC screening reviewed the literature on CRC screening in primary care, including new research and information from the conference on “Improving Colorectal Cancer Screening Delivery, Utilization, and Outcomes: the State of the Science” convened by the National Cancer Institute (NCI) and the Agency for Healthcare Quality and Research (AHQR) in April 2005. Using the New Model of Primary Care delivery as a framework, the authors describe current knowledge regarding CRC screening, active research, and areas where more research is required.

== Results ==

The following was highlighted in the New Model. (1) Team approach: Increasing use of a team approach may improve CRC screening by shifting this responsibility to other members of the healthcare team such as nurses, physician assistants, etc. However, more data regarding this approach and provider attitudes regarding a team approach are needed. (2) Advanced information systems: EHR’s are considered essential to identify, track, and inform patients about preventive services. However, it is noted that information technology adoption in primary care is low. (3) Patient centered care: Information technology is improving patient decision making regarding healthcare and CRC screening in particular. By allowing informed patient preferences, CRC screening rates are increased.

However, some evidence regarding informed decision making is inconclusive and more research is needed in this area. (4) Improved efficiency: Organizational systems and practice level interventions targeting providers and patients has worked to improve screening, but more research is needed in efforts to “bundle” preventive services. (5) Enhanced finance practices: Incentives for improved preventive care are needed, since low reimbursement rates have negatively impacted screening rates. More research is needed to determine how payment system redesign will affect preventive services delivery. (6) Training Opportunities: Under the New Model, training will need to include communication skills, information technology, working in teams, and behavior change counseling in order to effectively deliver preventive care services.

== Conclusions ==

CRC screening is a challenging service to implement in primary care. However, improvement can be achieved by implementing effective systems and procedures that enhance screening delivery. The New Model of Primary Care delivery may provide a strategy to this end.

== Commentary ==

Unlike other cancer screening programs, CRC screening seems to be particularly hard to implement. Rather than clinician knowledge or attitudes, studies have shown that visit and practice-specific factors mostly determine if preventive services are provided to patients. It therefore makes more sense to improve the actual systems of care in order to increase CRC screening rates. The New Model of Primary Care Delivery seems to be a good infrastructure on which to build a strategy to improve CRC screening in the context of a general effort at improving quality.

Interestingly, many of the elements of the New Model encompass information technology. Most importantly, EHR’s will provide the ability to identify, and track those needing screening, especially when combined with clinical decision support. In addition, the team approach and patient centered care involve improved communication between providers, patients and outside sources of knowledge. These are all elements that technology can help provide and enhance. Improved efficiency can also be accomplished in part with the use of technology that includes knowledge based systems that can stratify patients for care or tailor patient interventions. Training in technology is also considered one of the keys to this New Model of Primary Care Delivery. Thus, advanced information systems will likely play a big role in improving primary care practice and cancer screening in the future as these models start to be adopted.

== References ==

# http://www.ncbi.nlm.nih.gov/pubmed/17534688

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