The effects of teamwork and system support on colorectal cancer screening in primary care practices

Abstract

Background: While cancer screening is generally increasing in the U.S., colorectal cancer (CRC) screening remains low. Most CRC screening interventions focus either on patients or individual clinicians without examining the office context in which CRC screening is implemented. This study examines whether primary care practices that involve staff in general forms of health education have higher CRC screening rates than practices that do not. Methods: Cross-sectional data from 22 New Jersey and Pennsylvania family medicine practices were analyzed. Data include chart audits for 795 men and women eligible for CRC screening (age 50–70) and practice information surveys for each practice. Generalized estimating equations were used to determine CRC screening correlates. Results: Overall, 31.3% (n = 249) of patients received CRC screening. Practices that reported using nursing or health educator staff to provide behavioral counseling to patients on topics such as diet, exercise or tobacco use were significantly more likely to also have higher CRC screening rates (z = 7.30, p < 0.0001). Their patients had 2.96 times increased odds of CRC screening than those in other practices (95% C.I., 2.21–3.96). Reminder system use was also associated with higher CRC screening (z = 4.96, p < 0.0001). In practices that used reminder systems, patients had 2.57 times increased odds of CRC screening than others (95% C.I., 1.77–3.74). Conclusions: These findings suggest that interventions to achieve better CRC screening rates do not need to focus solely on CRC. Higher CRC rates may be achieved by capitalizing on the enhancing contributions of non-physician practice members providing more general health behavior change patient education.

Introduction

Colorectal cancer (CRC) is the third leading cause of new cancer cases and cancer death for men and women in the United States [1]. In 2006, there were an estimated 148,610 new cases and 55,170 deaths from colorectal cancer [1]. Providing evidence based preventive screening for colon cancer has been identified as a priority area for national action by the Institute of Medicine (IOM) [2]. Preventive screening for CRC in the forms of colonoscopy, sigmoidoscopy and fecal occult blood testing (FOBT) have been shown to reduce mortality in randomized control trials and case controlled studies [3], [4]. Appropriate testing could have saved more than half of the 55,170 people expected to die in 2006 from CRC [1].

A number of recent studies [5], [6], [7] aimed at improving CRC screening in primary care practices directly target physicians for CRC clinical interventions examining their attitudes [6], [7] and whether physicians discuss CRC screening with their patients [5]. Although, primary care physician counseling of patients has been positively associated with CRC screening [6], [8], this approach is inadequate due to multiple competing demands and priorities [9], [10], [11]. Increasingly traditional models of primary care practice are being criticized as too physician centric and resulting in care that is mostly reactive and often fragmented [12]. Several reports including the IOM's Crossing the Quality Chasm [13] and the Future of Family Medicine [12] describe optimum health care settings as being “responsive and prospective” practices that include a teamwork approach where multidisciplinary teams and not individual clinicians are the sources of care. Nevertheless, few studies examine the impact of involving other health care team members on CRC screening [14].

There is a growing literature that suggests that office characteristics such as office practice structure [15], [16] and competing demands [17] are associated with cancer screening [15], [16], and several new models of primary care advocate the use of teams in the delivery of health care [12], [13]. The purpose of this paper is to determine if the inclusion of office staff in general behavioral counseling activities has the added benefit of enhancing rates of colorectal cancer screening.