Best Practices in Chronic Disease Prevention, Sally

Report
Finding Best Practices in
Chronic Disease Prevention
Sally Honeycutt, MPH, CHES
Evaluation Team Lead
Emory Cancer Prevention & Control
Research Network (CPCRN)
These highlighted evaluation projects are supported by the Emory CPCRN, which is part of the
Prevention Research Centers Program. It is supported by the Centers for Disease Control and Prevention
and the National Cancer Institute (Cooperative agreement # 1U48DP0010909-01-1)
Project Goal
Generate practice-based evidence to
address gaps in the research literature
for cancer prevention and control by
identifying and evaluating promising
cancer prevention programs developed
and conducted by organizations in
southwest Georgia
Project Activities
Environmental Scan
Evaluability Assessment
Evaluations
Dissemination
Environmental Scan
• Community Advisory Board (CAB) recommended
scan & referred programs
• Selection committee
- Emory CPCRN
- CAB
- Southern GA Evaluation Association
• Identified 8 potential programs
- 4 invited to apply
- 2 selected for next stage
Evaluability Assessment (EA)
• Pre-evaluation activity
• Determine whether or not program is ready for
outcome evaluation
• Emory CPCRN EA Objectives
- Describe and assess the program model
- Determine the program’s capacity to produce needed
evaluation data
- Assess stakeholder interest in evaluation & intended use
- Determine feasibility of outcome evaluation
EA Components
Site Visit
Document
Review
Expert Review &
Recommendations
Literature
Review
EA Data Collection & Analysis
• Site visits
– Work with program staff to identify appropriate
participants & format
– Langdale: 8 participants from 4 organizations
– Cancer Coalition: 18 participants from 7
organizations
• Discussions/interviews recorded and transcribed
verbatim
• Used matrix organized by EA questions to abstract
and summarize relevant information
Evaluability Assessment Findings
Descriptive Case Study
The Langdale Company and
TLC Benefits
The Langdale Company
• Started 1894 as a family owned timber
company
• Headquarters: Valdosta, GA
(subsidiaries in rural areas)
• Diversified enterprise, subsidiaries in
forest products, automotive, banking,
hospitality, land development, etc.
• About 800 employees
What is Unique about Langdale?
Health Plan/Health Delivery Approach:
• Not only self-insured, but self-administered
• Necessitates preventive approach to care
• Partner with organizations to provide:
- Comprehensive Medical Management
- Case Management
- Disease Management
- Compliance/Health Advocacy support
Case Study Question & Methods
How does an employer-owned and operated health benefits
plan utilize the Chronic Care Model1 (CCM) to deliver quality
chronic disease care to employees and their dependents?
• Qualitative Data collection
– Individual interviews (n=6)
– Group discussions (n=2)
– Semi-structured interview guide with questions modified from
Assessment of Chronic Illness Care (ACIC)
• Qualitative analysis to identify themes/concepts related to
each CCM element
1 Wagner,
E. H., Austin, B. T., & Von Korff, M. (1996). Organizing care for patients with chronic illness.
[Review]. Milbank Q, 74(4), 511-544.
Preliminary Findings
CCM Element
Degree of Fit with Langdale Approach
Clinical Information
Systems
Fully developed clinical information system for chronic
illness care and care coordination
The Community
Fully developed system of linkages between Langdale’s
employee benefits program and the community
Self-Management
Support
Reasonably good to full support for self-management
care within Langdale’s benefit programs
The Health System
Reasonably good to full support for chronic illness care
throughout the organization
Delivery System
Design
In applicable areas, reasonably good to fully developed
delivery system design around chronic illness care
Decision Support
Less applicable to the employee benefits setting
Implications for Practice
• The CCM (and particular constructs) may help provide a
framework for a worksite or employee benefits program
to organize the delivery of quality chronic disease care.
• Future research should assess more broadly how
worksites and employee benefits can be integrated into
the CCM.
Community Cancer Screening
Program
• Community Cancer Screening Program™
(CCSP) Goal:
To reduce and ultimately eliminate cancer
screening disparities among low-income,
uninsured and under-insured patients of local
community health centers and other primary
care practices
Promoting Colorectal Cancer Screening
• Goal: increase appropriate use of colonoscopy
– 304 colonoscopies in 2010
• Patient Navigation Model
– Establish and maintain clinical systems to identify and enroll
patients into CCSP
– One-on-one education to encourage adherence to referrals
for screening
– Address health care system and patient barriers to screening
CCSP: Evidence-based strategies
The Community Guide to Preventive Services: Intervention
Categories Recommended for Colorectal Cancer Screening2
Intervention Category
Evidence for Method
Provider Assessment & Feedback
Sufficient: FOBT

Provider Reminder & Recall Systems
Strong: FOBT
Sufficient: Sigmoidoscopy

Client Reminders
Strong: FOBT

Small Media
Strong: FOBT

One-on-One Education
Sufficient: FOBT

Reducing Structural Barriers
Strong: FOBT

2 www.thecommunityguide.org/cancer/
Used by CCSP
Outcome Evaluation of the CCSP
Evaluation Goals
• To explore differences in CRC screening rates
at 4 intervention clinics as compared to 9
comparison clinics
• To explore the degree of patient navigator
effectiveness towards improving colonoscopy
screening rates
Research Design
• Quasi-experimental design
– 2 conditions
– No randomization to condition
• 18-month study period
Eligible
Population
Non-Randomized
Assignment
– Nov. 1, 2009-Apr. 30, 2011
CCSP
4 clinics
Colonoscopy
No
Colonoscopy
No CCSP
9 clinics
Colonoscopy
No
Colonoscopy
Eligibility Criteria
• Seen by a clinic primary health care provider
at least once during the 18-month study
period
• Age 50-64
• Sliding fee scale eligible
Setting: All 13 FQHCs in region
Blue stars = CCSP Intervention Clinics
Green stars = Comparison Clinics
FQHC: Federally Qualified Health Center
Southwest GA Federally Qualified
Health Centers
# Patients
seen (2010)
# Clinics
< 1,000
1
1,001 – 2,000
5
• % Uninsured Patients
2,001 – 3,000
2
– 0-25%: 6 clinics
– 25-50%: 7 clinics
3,001 – 4,000
4
> 4,000
1
• Four FQHC Systems
– 13 total clinics
• Provider/Patient Ratio
– Mean: 0.0039
– Range: 0.0015-0.0087
Sample Size
• Intervention
–
–
–
–
–
• Comparison
4 clinics
Serve 3,009 patients
1,267 eligible patients
Take 25%
350 charts to review
–
–
–
–
–
975 patients
9 clinics
Serve 11,001 patients
2,506 eligible patients
Take 25%
625 charts to review
Data Collection Methods
• Data source: Patient medical charts (EMR & paper)
• Time period: Aug. 2011 – Mar. 2012
• Randomly select charts from list of eligible patients
provided by clinic
• Trained abstractors collect data in clinics
• Rigorous quality control methods
– 10% of records double-abstracted
– 100% double-abstraction for primary outcomes (Colonoscopy
referral & exam)
Data Abstraction Form
• Used to abstract data
from patient charts
• Provides a standard way
to collect data
• Captures
– Demographics
– CRC history
– CRC screening
• Colonoscopy
• Sigmoidoscopy
• Blood Stool Test
Data Analysis
• Analysis to date
– Descriptive statistics
– Identify potential confounders
– Preliminary assessment of differences between
intervention and comparison clinics
• Pending analysis
– Controlling for clustering within clinics
– Screening rates by clinic
– Relationship between navigator contacts and colonoscopy
Preliminary Findings
Evaluation Goal: To determine whether the colorectal cancer
screening component of the Coalition’s CCSP is associated with
increased rates of colonoscopy screening.
• n=809 patients at normal colorectal cancer (CRC) risk
• Patient Demographics
– 66% female
– Mean age 56 years (range 50-64)
– 61% Black; 36% White
Preliminary Findings
Are rates of colonoscopy screening among uninsured/
underinsured patients age 50-64 at the four intervention clinics
significantly higher than at the nine comparison clinics?
Outcome
Had colonoscopy
referral during study
Had a colonoscopy
exam during study
Compliant on any test
No
Yes
No
Yes
Total ˄
No
Yes
Total†
Intervention
108 (42.0%)
149 (58.0%)
167 (65.0%)
90 (35.0%)
257
166 (57.4%)
123 (42.6%)
289
Note. Statistics not yet adjusted for clustering within clinics
˄ Among patients due for colonoscopy during study
† Among all eligible patient
* p < .0001
Comparison
388 (76.1%)
122 (23.9%)
477 (93.5%)
33 (6.5%)
510
464 (89.2%)
56 (10.8%)
520
Total
496 (64.7%)
271 (35.3%)
644 (84.0%)
123 (16.0%)
767
630 (77.9%)
179 (22.1%)
809
c2
86.738*
103.439*
108.962*
Preliminary Findings
What is the degree of CCSP effectiveness towards
improving colonoscopy screening behavior?
Outcome
Wald (c2)
Had colonoscopy referral during study (among due)
Had colonoscopy exam during study (among due)
Compliant on any test
75.447*
79.669*
89.448*
Note. Statistics not yet adjusted for clustering within clinics
˄ Controlling for Race (Black)
† Controlling for Race (Black) and Age (50-59 and 60-64)
* p < .0001
Odds
Ratio
4.260˄
7.708†
6.013†
Limitations
• Non-random assignment
– Possibility program implemented in higher capacity clinics
• Variable quality of chart data
– Intervention clinics: all EMRs
– Comparison clinics: mix of paper and EMR
– CCSP designed to improve quality of medical info in charts
• Contamination
– Patients from comparison clinics referred to intervention
clinics for colonoscopy
Acknowledgments
Emory University CPCRN
Kimberly Jacob Arriola, PhD, MPH*†
Lucja Bundy, MEd, MA
Michelle Carvalho, MPH
Cam Escoffery, PhD, MPH†
April Hermstad, MPH
Sally Honeycutt, MPH
Michelle Kegler, DrPH, MPH†
Joseph Lipscomb, PhD†
Natasha Ludwig-Barron, MPH
Gillian Schauer, MPH*
Iris Smith, PhD, MPH†
Deanne Swan, PhD*†
Amanda Wyatt, MPH
Vera (Jingqi) Yang, MPH
* Evaluability assessment or evaluation project leader
† Expert Review Committee Member
CCSP Staff, Stakeholders & Local Team
Cancer Coalition of South GA: Denise Ballard, MEd
Diane Fletcher, RN
Rhonda Green
James Hotz, MD
Medical College of GA: Alex Brueder
Shavonda Thomas
Jennifer Yam
SW GA Family Medical Residency: Teri Stapleton, MD
TSTC Health IT program: Aisha Viquez
Langdale Staff, Stakeholders & Local Team
The Langdale Company: Barbara Barrett
Mark Wilson
Lowndes County Partnership for Health: Alan Powell
John Sparks
TLC Benefits Solutions, Inc.: Kate Waagner
Doctor’s Direct Health Care: Tina Wise, RN
Questions?
• Ask now, or…
• Look for our posters at
the National Cancer
Conference in August!

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