The effects of teamwork and system support on colorectal cancer screening in primary care practices☆
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.
Section snippets
Methods
We used cross-sectional data collected at baseline, from April 2003 through December 2004, from a quality improvement intervention study, Using Learning Teams for Reflective Adaptation (ULTRA). The ULTRA study used a multi-method assessment process [18] to inform a facilitated team-building intervention [19] aimed at improving guideline adherence for multiple chronic diseases among 60 practices in New Jersey and Pennsylvania. For this analysis, 22 suburban practices were selected that had
Results
In the 22 practices charts were audited for 795 patients eligible for CRC screening. Over half (55%) were men. The average patient age was 59.30 (S.D. = 5.84). Of the patients eligible for screening, 249 (31.3%) had received appropriate screening, with practice screening rates ranging from 10.3% to 64.9% (median of 31.9%). Twenty out of 22 practices were group practices (91%) with a heavy Caucasian patient panel (average 86%). Most practices reported the majority of their patients had commercial
Discussion
Reports such as IOM's Crossing the Quality Chasm [13] and the Future of Family Medicine [12] identify team approaches and more functional offices as important variables for improving outcomes in the primary care setting. In this study, we examined three generic organizational features to determine if they would also translate into higher rates for a non-targeted recommendation, that of CRC screening. Two of these features; the use of nurse or health educator for health behavior counseling and
Conflict of interest
None declared.
Acknowledgements
This research was supported through grants from the National Heart, Blood and Lung Institute (R01 HL70800) and the New Jersey Commission on Cancer Research (03-40-CCR-S0). It was conducted in conjunction with the New Jersey Family Medicine Research Network (NJFMRN), the Eastern Pennsylvania Inquiry Collaborative Network (EPICnet) and the Cancer Institute of New Jersey's Informatics and Primary Care Research Network Shared Resources. We thank the reviewers for their advice and thought provoking
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Support: This research was supported through grants from the National Heart, Blood and Lung Institute (R01 HL70800), the New Jersey Commission on Cancer Research (03-40-CCR-S0), and the National Cancer Institute (R01 CA112387).