A Quality Improvement Initiative to Increase Colorectal Cancer (CRC) Screening: Collaboration between a Primary Care Clinic and Research Team

Research Article

J Fam Med. 2017; 4(3): 1115.

# A Quality Improvement Initiative to Increase Colorectal Cancer (CRC) Screening: Collaboration between a Primary Care Clinic and Research Team

Green BB1,2*, Fuller S¹, Anderson ML¹, Mahoney C¹, Mendy P² and Powell SL²

¹Kaiser Permanente Washington Health Research Institute, USA

²Kaiser Permanente Washington, USA

*Corresponding author: Beverly B. Green, Kaiser Permanente Washington Health Research Institute and Kaiser Permanente Washington, 1730 Minor Avenue, Seattle, WA 98101, USA

Received: March 07, 2017; Accepted: March 30, 2017; Published: April 05, 2017

## Abstract

Background: Multiple randomized controlled trials have demonstrated that mailed fecal testing programs are effective in increasing colorectal cancer screening participation. However, few healthcare organization in the US have Implemented such programs.

Methods: Stakeholders from one clinic in an integrated healthcare system in Washington State initiated collaboration with researchers with expertise in CRC screening, aiming to increase screening rates at their clinic. Age-eligible individuals who were overdue for CRC screening and had previously completed a fecal test were randomized to receive mailed fecal immunochemical test kits (FIT) at the start of the project (Early) or 6 months later (Late). Outcomes included comparing FIT completion at 6 months by randomization group, and overall CRC screening rates at 12 months. We also assessed implementation facilitators and challenges.

## Patients

EHR and administrative data were used to identify eligible patients among all enrollees at the Olympia Medical clinic on September 30, 2015. A total of 5,520 patients were identified who were age-eligible (age 51-75) for CRC screening, had no HEDIS criteria exclusions (enrolled in the prior calendar year, no CRC, no total colectomy), and were due for screening (or would be due for screening by December 31, 2016). Of these, 3412 (61.8%) had completed a fecal test in the past (any time since health plan enrollment), and were eligible for the quality improvement initiative intervention.

## Intervention

The mailed intervention was adapted from the SOS study which includes up to 3 mailings. In the SOS study the first mailing includes a pamphlet on CRC screening choices based on US Preventive Services Task Force and Group Health guidelines that states that they are due for CRC screening and will soon receive a FIT kit unless they request one of the other recommended tests (colonoscopy or flexible sigmoidoscopy). The second mailing includes the FIT kit, pictographic instructions and a letter emphasizing the importance of completing screening. If the FIT kit is not received and processed by the lab within 3 weeks, a reminder letter is mailed. The intervention mailing materials are available at the National Cancer Institute Research-Tested Intervention Programs (RTIPs) web site [12].

For the quality improvement initiative, the clinic generally followed the SOS model, but decided not to send the introduction letter because of limited resources. The letter sent with the kit was signed by the medical director of the clinic.

## Randomization

The clinic wanted all eligible patients to receive the intervention, since the overall goal of the project was to improve clinic-wide CRC screening rates. To evaluate the success of the program, the researchers proposed that eligible patients be randomized to either Early or Late intervention groups, stratified by the numbers of fecal tests they had done prior (1 versus >1). Patients in the Early group received intervention mailings within the first few weeks after randomization (mailings were completed between Oct 23 and Nov 20, 2015), and patients in the Late group, who were still overdue for screening, received the intervention 6 months later (mailings May 2-6, 2016). The effect of the mailed kit intervention was based on screening outcomes between randomization and 6months (before the Late group received the intervention). This also provided the clinic with an opportunity to stop the program if the expected increase in FIT uptake in the Early group did not occur.

## Evaluation

The collaboration between the clinic and researchers provided an opportunity to explore key implementation and outcome factors, which the researchers used key domains from the Consolidated Framework for Implementation Research (CFIR) and the Institute for Healthcare Improvement (IHI) “Triple Aims” to describe (Table 1) [13,14]. CFIR was developed by the Veterans Affairs Quality Enhancement Research Initiative as a framework for constructs that are associated with effective implementation of interventions or programs and takes into account contextual factors including the external environment (e.g. policies, incentives), internal setting (e.g. organization culture, priorities), individuals (e.g. champions, expertise), intervention characteristics (e.g. relative advantage, adaptability), and the process of change. The CFIR framework does not include outcomes, such as population reach, effectiveness, and costs, for which we used the IHI’s Triple Aims, improving healthcare (excellent quality and service), health (improving patients’ health outcomes and quality of life), and efficiency of care (providing efficient care and affordability).