WOMEN PRINCIPLE FORUM

AVOID BREAST CANCER  FOR WOMEN


 RESEARCH PROPOSAL FOR PORTES FOUNDATION
This is a study of the application of a clinical registry to colon cancer screening. The intent is to describe the process of registry maintenance and extend our experience with the application of the registry as a tool to promote colon cancer screening.
Colon Cancer Screening
 is a high priority preventive service. According to the Partnership for Prevention, and their systematic analysis of preventive services for the clinical preventable benefit (CPB) and cost effectiveness, colon cancer screening ranks high compared to other preventive services.1 The U.S. Preventive Services Task Forces gave a rating ―A‖ recommendation, strongly recommending men and women aged 50-75 years get screened for colon cancer2. Populations that are screened for colorectal cancer have been shown to have better colon cancer survival, detection of neoplasia at earlier stages, and a higher likelihood of resection.3 reflecting the importance of colon cancer screening, screening completion is a Leading Health Indicator of Healthy People 2020, with a target for colon cancer screening set at 70.5%. According to the National Health Interview Survey (NHIS), CDC-National Center for Health Statistic data 52.1 percent of adults aged 50 to 75 years received a colorectal cancer screening based on the guidelines in 2008.The accompanying health statistics show differences in reported screening rates based upon race/ethnicity, education, and income. The most striking difference is in the screening rate of 60.4% in insured population compared to only 21% in uninsured,4-5 Other reports have also observed that colon cancer screening has not been fully disseminated,6 and with disparities in screening uptake based upon race/ethnicity and insurance status. A disparity in colon cancer screening was noted to have increased over time. In 2005, screening rates for whites was significantly higher than for Asian Americans, Hispanic Americans, and African Americans.7 The disparity in screening contributes to the difference in cancer the rate of incidence and mortality experienced by these vulnerable populations.8 Data from the National Health Interview Study shows an ordering of reported screening; with highest rates among NHWs, intermediate among African-American, and lowest among Hispanics.9
Taken together, this data suggests that a focused effort to enhance screening in the CCHHS, with both predominantly African American and Hispanic populations and with large uninsured and Medicaid populations, can address important disparities in colon cancer screening.
colon cancer screening in U.S. health system is also very important. It is a high priority to reduce the incidence and mortality from colon cancer10-11. It has been shown that interventions like tracking screening-eligible patients, mailing patients a physician letter and brochure before medical visits, health literacy training to help physicians improve their communication with patients, and establishing a ―feedback loop‖ to routinely monitor patient compliance improve colorectal cancer screening rates among patients served by community health centers. 12 In a recent article, different strategies are offered to address challenges and increase rate of colon cancer screening in community health centers, one of which is use of the well-established tool, the clinical registry
A clinical registry
can be an extremely useful tool for taking population-based approaches and supporting clinical quality improvement. They are well-established tools for chronic care management, and for tracking cancer screening and immunizations.14 The Chronic Care Model has been used in multiple settings as a guide to clinical improvement for preventive services and chronic disease care. The Chronic Care Model identifies patient registries as an important clinical information tool. According to the Institute for Healthcare Improvement,
―A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care. The registry is the foundation for successful integration of all the elements of the Chronic Care Model. The entire care team uses the registry to guide the course of treatment, anticipate problems, and track progress.‖ (Institute for Healthcare Improvement, www.ihi.org).
       


           THE PICTURE  SHOW  BREAST  CANCER  FOR  WOMEN







Health Information Technology and Quality Improvement (HRSA) describes registries as a prime tool for care management and for promoting preventive care. The American College of Physician has endorsed the use of registry. Another important organization, the California Health Care Foundation, a leading proponent of the Patient Centered Medical Home, supports this innovative tool and describes the use of registries as an active tool for health system improvement of chronic care and advocates integration of registries into the routine practice of physicians15. In publications describing use of registries, the registry can be used to identify and guide care or special interventions for targeted patients within a practice. They can also be used 3 to audit and feedback performance. The features of an ideal monitoring system for CRC screening and quality is described in terms of data quality, acceptability, compliance, costs and usefulness, in an AHRQ Evidence Report/Technology Assessment.16 to audit and feedback performance. The features of an ideal monitoring system for CRC screening and quality is described in terms of data quality, acceptability, compliance, costs and usefulness, in an AHRQ Evidence Report/Technology Assessment.16
The Colon Cancer Screening Registry in the Cook County Health and Hospitals System was started in 2011. We have an invaluable experience in building and initiating clinical application of the registry. It has proven to be an effective tool in our health system, and one that we continue to strengthen and develop.
Guided by the Chronic Care Model,17 we undertook an improvement process for colon cancer screening for primary care patients at the Cook County Health and Hospitals System (CCHHS), beginning with the General Medicine Clinic at Fantus Health Center in 2011. Our work was developed in a partnership with the Illinois Division of the American Cancer Society and funded with support from the Cancer Society and the Illinois Department of Public Health. The improvement process included adoption of fecal immunochemical testing (FIT) into our clinical practice, development and dissemination of patient education materials, education of doctors and other clinic staff about colon cancer screening with an emphasis on the 2008 update to US Preventive Services Task Force recommendation1



We built the registry with the assistance of Information Technology specialists from the CCHHS Collaborative Research Unit who will participate in this proposal. The registry is web-based, and is able to pull demographic, appointment data, and fecal occult blood tests from the electronic medical record. We populated the registry using volunteer physicians reviewing the electronic medical record notes and data. In our registry, screening-aged patients (age 50-75) are identified and then categorized as follows: Category Description  
Screen Eligible Individuals 50-75 who are appropriate for screening  
Surveillance History of adenomatous polyps or inflammatory bowel disease, high risk of family history; these individuals require regularly scheduled colonoscopy  
Work Up in Progress Individuals having symptom/sign driven colonoscopy evaluation (e.g., bleeding, weight loss, anemia)  
Poor Health Status Interruption of screening due to prognosis of less than 5-7 years  
Indeterminate Missing health records necessary to accurately categorize  
Personal history Previous diagnosis of colon cancer


A clinical registry can be an extremely useful tool for taking population-based approaches and supporting clinical quality improvement. They are well-established tools for chronic care management, and for tracking cancer screening and immunizations.14 The Chronic Care Model has been used in multiple settings as a guide to clinical improvement for preventive services and chronic disease care. The Chronic Care Model identifies patient registries as an important clinical information tool. According to the Institute for Healthcare Improvement,
―A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care. The registry is the foundation for successful integration of all the elements of the Chronic Care Model. The entire care team uses the registry to guide the course of treatment, anticipate problems, and track progress.‖ (Institute for Healthcare Improvement, www.ihi.org).
Health Information Technology and Quality Improvement (HRSA) describes registries as a prime tool for care management and for promoting preventive care. The American College of Physician has endorsed the use of registry. Another important organization, the California Health Care Foundation, a leading proponent of the Patient Centered Medical Home, supports this innovative tool and describes the use of registries as an active tool for health system improvement of chronic care and advocates integration of registries into the routine practice of physicians15. In publications describing use of registries, the registry can be used to identify and guide care or special interventions for targeted patients within a practice. They can also be used
to audit and feedback performance. The features of an ideal monitoring system for CRC screening and quality is described in terms of data quality, acceptability, compliance, costs and usefulness, in an AHRQ Evidence Report/Technology Assessment.16
The Colon Cancer Screening Registry in the Cook County Health and Hospitals System was started in 2011. We have an invaluable experience in building and initiating clinical application of the registry. It has proven to be an effective tool in our health system, and one that we continue to strengthen and develop.
Guided by the Chronic Care Model,17 we undertook an improvement process for colon cancer screening for primary care patients at the Cook County Health and Hospitals System (CCHHS), beginning with the General Medicine Clinic at Fantus Health Center in 2011. Our work was developed in a partnership with the Illinois Division of the American Cancer Society and funded with support from the Cancer Society and the Illinois Department of Public Health. The improvement process included adoption of fecal immunochemical testing (FIT) into our work was developed in a partnership with the Illinois Division of the American Cancer Society and funded with support from the Cancer Society and the Illinois Department of Public Health. The improvement process included adoption of fecal immunochemical testing (FIT) into our clinical practice, development and dissemination of patient education materials, education of doctors and other clinic staff about colon cancer screening with an emphasis on the 2008 update to US Preventive Services Task Force recommendation18.



Base line numbers for the categorization of screening status (June, 2012) showed there were 91% screening eligible, 4% were work up in progress, 1.5% had personal history of colon cancer, 1% had poor health status, and the rest were indeterminate in their screening status. We have used the registry to log the delivery of face-to-face patient education, the screening preferences of our patients who are exposed to our educational program (FIT annually vs. FIT every three years with flexible sigmoidoscopy every five years), and to track patients through their diagnostic evaluation when the screens are abnormal. Only 0.5% of patients refused screening. In our institution screening colonoscopy is not available. Flexible sigmoidoscopy performed by two primary care endoscopists.
Early in the development of the registry, we determined the rate of return of FIT for a sub-sample of patients completing our educational program. We identified predictors of return of FIT, finding that African-American patients had higher odds of not returning FIT after an educational session in a multi-variable model.
We have increased the exposure of our patients to screening. At present, International Medical School graduates are trained to provide education about colon cancer, the screening options, helping patients select a screening modality. We have educated 4794 unique patients since the start of the health education program and the registry. Medical Assistants and Registered Nurses also provide basic education to help the patients to complete FIT tests.
We have seen the number of stool tests increase. In 2011 there was an average of 156 stool tests returned per month (5% FIT), in 2012 there were 200 stool tests returned per month (69% FIT), and through September of 2013 there were 250 stool tests returned per month (95% FIT). The number of flexible sigmoidoscopies has increased as well, from 207 in 2010 to 287 in 2011 and 311 in 2012. Most patients with abnormal screens complete diagnostic work-ups. In 2011, 65% of 48 patients with positive stool tests completed colonoscopy and in 2012 80% of 41 patients with positive stool tests completed colonoscopy. For FS, in 2011 91% of 75 patients with FS requiring colonoscopy completed the colonoscopy. The corresponding rate for 2012 was 78% of 55 patients and in 2013, to date, was 94% of 50 patients. Taken together, during the period of our intensified quality improvement activities and development of the clinical registry we have educated large numbers of patient, transitioned to FIT, increased rates of screening, and have a good track record of completing diagnostic assessments for positive screens.
Recently, a pilot using the registry has been successfully completed. In April 2013, we designed a pilot to use the registry as a tool to initiate re-screening. We linked the registry to the clinical appointment system and identified patients with primary care appointments in April and who were 9 months or more out from their last completed FIT. Linking this list to the EMR demographics, we created mailing labels for each patient and wrote a personalized letter to inform them of it being time to repeat the FIT and that they could return the sample when they came to their April appointment. The letter and FIT kit were mailed approximately two weeks before the appointment. The mailing included a DVD demonstrating how to complete the FIT along with written instructions and a personalized letter from the director of the Colon Cancer Screening Program, informing them that they are due for colon cancer screening. Both the DVD and instructions were in English and Spanish.
There were 182 patients for whom mailing labels were generated for April. A chart review (in September and October) showed that there was one incorrectly recorded medical record number (so outcome could not be assessed), 11 patients did not return to the clinic between April and October, and 10 had a colonoscopy since the FIT of 2011-12 and before or shortly after their April 2013 scheduled appointment. Among the 160 patients who returned to the clinic and did not have an interval colonoscopy, 138 (86%) returned the FIT over the subsequent 6 months.
There were three important lessons from the pilot of mailing repeat FIT timed to appointments:
1. Using the registry to identify and mail FIT was effective. After the April pilot, we have continued to mail FIT kits in June-September. We are finding that the number of kits returned/month has increased between 80-120 (approximately 50%) compared to the same months last year, and has increased by 44 (19% increase) compared to February, March and May of 2013.
2. There was some egress from the clinic with 6% of patients not returning to the clinic in the interval since April.
3. There were some inaccuracies in the registry, with 6% having received or on-schedule for a colonoscopy since their last appointment.
We have learned from our experience there are several complexities of a screening registry for colon cancer. Though the population is defined by being 50 to75 years old, there may be different factors that lead to a change in their categorization status. This is unlike other chronic disease registries, in which the patient’s status as having the disease generally remains fixed (for example, people with diabetes or COPD rarely are re-categorized as not having diabetes or COPD). But for colon cancer screening persons in the age range for screening may move into or out of the screen eligible category. For example, a person who is screen eligible may develop a symptom (e.g. rectal bleeding) that leads to a diagnostic evaluation. The diagnostic evaluation may yield benign findings, in which case patients cycle back into the screen eligible group or pathological findings that change their categorization (into surveillance or a personal history of colon cancer). There may be other changes in health status that colon cancer screening might be deferred or even stopped in cases where life expectancy has changed. An additional challenge is that some of the data to guide screening categorization is text (colonoscopy and/or pathology reports) as opposed to FIT test lab results that can be read as data. The providers may also have special knowledge of patients regarding completion of tests outside our health system (patients may have care at more than one institution, with colonoscopy or other screening completed), or based upon a clinician assessment (that an individual’s health status no longer warrants screening).
If there is an annual ―screening status change‖ event rate as low as 2-5%, over the course of ten years, the registry would be degraded as a tool; 20-50% of patients might be improperly categorized for some or all of the ten year time frame. With time, an unmaintained registry will lose precision as a tool to guide screening.
Our pilot activity with the registry altered the process of care; it was patient directed. The registry could also be a tool for communication with our provider group, but we have yet to use it in this way, and did not routine enter the physician fields. A recent Evidence Report/ Technology Assessment for AHRQ, Enhancing the Use and Quality of Colorectal Cancer Screening indicates that audit and feedback to providers as a tool to improve screening has not been described or studied.16 We believe that thoughtful reports about system and individual performance can play an educational role, encourage physician endorsement of screening with their patients, and improve the quality of interactions between the Screening Program and the provider group.
We are unaware of any descriptions in the medical literature of how the screening status of a population changes over time. Understanding changes of screening status and predictors of change in status will help health systems anticipate and plan for the infrastructure necessary to develop and maintain an effective colon cancer screening registry. We also intend to extend the application of registry to a defined patient group and as a basis for communication and feedback to practice physicians. Together, these efforts will advance the experience and knowledge of the maintenance and utility of a registry for colon cancer screening. The aims of the study are:
1. To describe the basic epidemiology of change in colon cancer screening status for a public hospital primary care population over time for the period from 2011 through 2013.
2. To extend the function of the registry to persons with a flexible sigmoidoscopy completed prior to the establishment of the registry by (a) establishing their choice to continue screening with FIT alone or FIT + flexible sigmoidoscopy (FIT + FS), (b) assist them to complete FIT using mail-outs timed to their clinic visits, and (c) invite those due flexible sigmoidoscopy (5 years or more since a sigmoidoscopy and wanting FIT + FS) to schedule and complete the test.
3. To assess physician attitudes toward a personalized feedback report on colon cancer screening generated by the registry. For Aim #1, we will describe the overall changes in the clinic population (ingress of new patients, egress of patients from the practice), changes in screening status based upon intervening colonoscopies in our health system or clinician input, and associations of change in screening status based upon age, gender, race/ethnicity, or insurance status.
For Aim #2, we have identified approximately 1000 GMC patients who had a flexible sigmoidoscopy during or before 2011 listed in the registry. This would be the pool of patients from where we would pull a pilot test population to target this planned effort to organize their screening by using the registry.
For Aim #3, we will ask physicians to complete a brief survey on whether the feedback report influenced their knowledge about colon cancer screening, their attitudes toward colon cancer screening, their satisfaction with the overall program, and their communication with patients.
Description of the population: The site of this project is the General Medicine Clinic (GMC) of the Fantus Health Center. GMC is a primary care internal medicine clinic. In 2012, 24,300 unique patients visited the clinic. Overall, GMC serves approximately 21% of the 84,000 empaneled patients in the 14 adult primary care sites of the Ambulatory and Community Health Network of CCHHS. Based upon billing codes, GMC has high rates of chronic conditions, including 81% with hypertension, 46% with diabetes, 21% with coronary artery disease, 13% with congestive heart failure, and 13% with asthma. We estimate that two-thirds of the GMC patients fall within the screening age of 50 to 75 years (11,500). At present there are over 11,000 patients entered into the GMC registry. In 2012, when there were 7525 patients in our registry, 49% were African American, 17% Latino and 12% Caucasian, 10% Asian among the screening eligible population. In the screening eligible category there were 70% were between the age 50 to 64 years, and 58 % females.
The provider group for GMC includes faculty physicians and trainees in the Stroger Hospital Internal Medicine Residency. There are 32 faculty physicians who have continuity clinics in GMC and 127 internal medicine residents who have once a weekly session in GMC. The faculty physicians provide the core group for the primary care preceptors of the trainees. Research Design and Methodology:
We will complete the following steps organized according to the specific aim that they address. The procedures for Aim #1 will be completed first. The procedures for Aim #2 and Aim #3 will be completed in parallel.
Aim #1: Epidemiology of change in colon cancer screening status 9


Create a comprehensive list of active GMC patients. This will be any patient with two visits in 2013 or three visits in the period of 2012-2013. The list will include
Research Design and Methodology:
We will complete the following steps organized according to the specific aim that they address. The procedures for Aim #1 will be completed first. The procedures for Aim #2 and Aim #3 will be completed in parallel.
Aim #1: Epidemiology of change in colon cancer screening status
physician. The source of data is the EMR registrations.
Cross-match the registry with the list of active GMC patients age 49-75 and populate the registry with the name of the assigned physicians. We will report the number of patients currently on the registry who are excluded (not active clinic patients and not of age for screening).
For any active GMC patients not currently on the registry, we will determine the screening classification by chart review. We will report the screening classification for these individuals.
We will download a report of those patients who had a colonoscopy since the registry was developed (2011) and cross-match it with the updated registry. We will report the demographics (age 50-64, 65+), gender, race/ethnicity, insurance status, and screening classification for these patients. We will review all colonoscopy reports (and any associated pathology reports) for the active patient population for the period of time since the registry was developed. We will count the number and rate of changes in the screening status for this review. We will determine the number and rate of patients
who were inappropriately screened with stool tests and/or flexible sigmoidoscopy after their colonoscopy.
We will review and update all patients whose initial screening status was work up in progress or indeterminate. We will count the number and rate of changes in the screening status for this review.
Aim #2: Re-screening of patients who had flexible sigmoidoscopy prior to the development of the registry
We will use the registry to assess the screening status of active patients having a flexible sigmoidscopy (FS) prior to development of the registry. We will categorize as ―Up to Date with FIT + FS‖, ―Up to Date with FIT‖ (no with FS), ―Up to Date with FS‖ (not FIT), or ―Not Up to Date‖. We will report these rates.
We will select a pilot population of 250 active patients who are not up to date and with scheduled appointments within three months of the start of the pilot.
We will outreach by mail the active patients not up to date to inform them that it is time to get screened and to invite them to establish their screening preference. We will report the screening preferences.
For those patients not up to date with FIT, we will mail FIT kits with instructions and a letter reminding them that they are due for screening and inviting them to return the test at their next appointment. We will report the completion rate of FIT at the index visit and over six months.
For those patients not up to date with FS, we will invite them to reschedule a flexible sigmoidoscopy. We will report the completion rate of F.
Aim #3: Assessment of physician attitudes on feedback reports
Develop a template for a feedback report. It will include, information about colon cancer screening, improvement activities to enhance screening, clinic performance metrics (screening rates, diagnostic work-up rate for abnormal screens), personalized screening rate, a list of patients and their categorization of their patients (screen eligible, surveillance, etc.). The report will invite physicians to provide the program with updated information on their patients (for example, date and results
of colonoscopy from other institutions).
We will distribute an email survey 6-weeks after disseminating the report with questions regarding whether the feedback report influenced their knowledge about colon cancer screening, their attitudes toward colon cancer screening being effective, their satisfaction with the overall program and their receipt of personalized feedback, and their assessment of whether the feedback influenced how they communicated with patients about screening for colon cancer or how our health system supports screening for colon cancer.
Analysis: Our analysis plan for each aim is to report:
For Aim #1
A description of the overall patient population, including the basic demographics i.e. age 50-64 years, 65-75 years, gender, race/ethnicity and insurance status. 2. Key screening variables for the patient population, including the categorization (screen eligible, for surveillance, or with a history of colon cancer). For screen eligible patients, we will report if they have an educational session logged and if they are up to date.
Univariate demographic predictors of completing education and status as being up to date (chi-squared test).
The number of colonoscopy for age range of 50 to75 years, the reported indication (screening, surveillance and diagnostic work up), and univariate demographic predictors of having an interval colonoscopy.
The number of registrants who have a change in status based upon their colonoscopy. We will also report how the screening status changes as a result of the colonoscopy result reviews.
The outcomes of the reviews of all patients whose initial status was Work Up In Progress and Indeterminate.
The number and category of updates from physicians (data from other health providers, changes in screening categorization based upon health status For Aim
A description of patient population who had a FS prior to development of the registry (2011 or earlier). We will describe the population demographically, the rate of exposure to our patient education program, and their screening status.
A description of the pilot sample of 250 patients whose screening is not up to date; including demographics, rate of exposure to the patient education program, and details of their screening status.
The proportions of patients selecting on-going screening with FIT alone vs. FIT + FS.
The outcomes of screening outreach, including the number (rate) who returned the mailed FIT kits, the number (rate) accepting and completing a repeat FS.
Calculate univariate demographic predictors of completing screening.
For Aim #3 12

We will report the frequency of question response assessing knowledge about colon cancer screening, their attitudes toward colon cancer screening being effective, their satisfaction with the overall program and their receipt of personalized feedback, and their assessment of whether the feedback influenced how they communicated with patients about screening for colon cancer or how our health system supports screening for colon cancer Timeline:
Month 1 to Month 4 (Aim #1):
Initial hiring and training of Research Assistant.
Collaborative Research Unit IT specialists will work on the registry to cross-match the registry with the list of active GMC patients, add physician fields, and produce a list of patients to be entered into the registry. The Collaborative Research Unit IT specialists will provide a list of GMC patients with colonoscopy since 2011 from an EMR query.
The Research Assistants will add GMC patients to the registry. They will review colonoscopy and pathology reports and record changes to the registry classification. They will review all cases of Work Up In Progress and Indeterminate Screening Status. They will record changes to the registry classification from this review.
Month 5 to Month 8 (Aim #2 and #3):
Use the registry to identify GMC patients who had a flexible sigmoidoscopy during or before 2011 and assess their screening status as up to date or not. A list of these patients due screening
will be generated (target population for the pilot test).
Select a group of patients due screening, with near-term appoints, and outreach them and out-reach them to assess screening status and complete screening (Aim #2).
We will develop reports to individual providers with the categorization about their screening eligible population and the rate of screening rate. We will complete a focus group of faculty and resident physicians regarding the content and presentation of the reports.
We will finalize the report and distribute them. Six weeks after the report distribution, we will ask physicians to complete a brief web-based survey about the report (Aim #3). Month 9 to Month 12:
Completion of data collection and analyses, as described above, and to include:
The overall description of the patient population, including basic demographics i.e. age (50-64 years, 65-75 years), gender, race/ethnicity, insurance status, screening categorization, and screening status.
The changes of the categorization of patients as screen eligible, for surveillance, or with a history of colon cancer based upon the data source (colonoscopy, previous categorization as Work Up In Progress or Screening Indeterminate, feedback from physicians)
The description of the sub-sample of patients with previous FS and the outcomes of the screening outreach efforts with respect to screening preference and completion
The survey results of physicians after receipt of a personalized screening report from the program
Study Team: The core of the study team has worked together for over two years to develop and use the registry. Our provisional team includes:
Ena Mahapatra, MD, MS, Director of the Colon Cancer Screening Program (CCSP) and the principal investigator for this project; Dr. Mahapatra has oversight of the screening program and is a local expert on colon cancer screening. As the principal investigator, Dr. Mahapatra will have responsibility over the organization of the project; will be involved in all aspects of oversight of the grant including design, data collection, analysis and reporting, staffing, and administration.
William Trick, MD, Division Chair of the Collaborative Research Unit; Dr. Trick oversees the team that developed the Colon Cancer Screening registry and has vast experience in medical informatics applications. He will continue to support Information Technology specialists and data analysis necessary to carry out the project.
Thomas Mason, MD, Medical Director of Woodlawn Clinic; Dr. Mason plays a formative role in the IT applications of the EMR for primary care. Dr. Mason is new to the study team. His participation will align the study efforts with plans for our ambulatory network.

Michael Davidovich, MD, Co-Director of GMC; Dr. Davidovich plays an important administrative role in the GMC Patient Centered Medical Home initiative and the resident practice. Dr. Davidovich is new to the study team. His participation will support communication efforts between the Colon Cancer Screening Program and the clinical staff of providers (Aim #3).
Kyungran Shim, MD, Member of the Colon Cancer Screening Program and primary care endoscopist (FS).
Cathy Rowell, BSN, Nurse Clinician of Colon Cancer Screening Program
David Goldberg, MD, Director of the Section of Preventive Medicine. Dr. Goldberg was the PI of the IDPH, whose support helped us develop and initiate the registry.
Implications and Conclusion: Clinical registries are an important clinical tool; their value depends on their remaining current and accurate. The registry may serve as an interface with patients or may serve as an interface with providers. Both interfaces may be tools to for care improvement. With this application, we propose to study three focused and complementary aspects of a colon cancer screening registry; (1) the epidemiology of change in screening status for a population based upon readily available clinical data and assessment, (2) the interface of the registry with a subset of screen eligible patients and not up to date (those who completed a flexible sigmoidoscopy and are due screening per USPSTF recommendations) to complete screening, and (3) the interface of the registry with physician providers through data reports from the registry.
The findings of this study will guide other program toward successful development and maintenance of colon cancer screening registries. It will show the utility of the registry to guide care and facilitate communication between programs and providers. In our role as a safety net organization, the findings of this study may further guide how disparities can be addressed in health care delivery.

PERSONAL BUDGETS
A; PERSONNEL

NAME TITLE %TIME
REQUIRED SALARY REQUESTED FRINGE BENEFITS TOTAL REQUESTED  
OLIMPIA TELESPHOR ARSEN (MD) DIRECTOR OF CANCER PROGRAME 19% In –kind In- kind In- kind  
Davis john ochola  MPH DIVISION CHAIR COLLABORATIVE SCREENING UNIT 2.5% In- kind In- kind In- kind  
Dorice achieng  MD MEMBER COLON CANCER SCREENING PROGRAM 10 In- kind In- kind In- kind  
MATHEW PETER NURSE CLINICAL 20 In- kind In- kind In- kind  
OSCAR JOHN WANGWE DIRECTOR SECTION OF PREVENTIVE  MEDICINE 5 In- kind In- kind In- kind  
MUSSA SHADRACK MEDICAL DIRECTOR IN CLINICAL 2.5 In- kind In- kind In- kind  
DR. Philemon okech ASSOCIATE MEDICAL DIRECTOR 3 2280 889 3169  
Dr. lilian polo DATA ANALYSIST 3 2790 1088 3878  
TDB RESEARCH ASSISTANT 25% 7500 1350 8850  
TDB RESEARCH ASSISTANT 25% 7500 1350 8850  
B; CONTRACTED SERVICES  
Richard Christopher  data consultant $ 5000  
C; SUPPLIES  
General office suppliers  postage $250  
TOTAL 30,000






Justification:
Ms. Manjula Srinivasan will support the project in her capacity as the Data Manager for the Collaborative Research Unit. She has worked with the registry and has previously linked the registry with other available data from the electronic medical record. She will cross-tabulate the registry with GMC registration data. She will download EMR lists of colonoscopy of the clinic patients within the specified time period. She will provide Dr. Mahapatra and the Research Assistants with work-lists and ―datasets‖ for the described process to update the registry and perform the relevant analyses.
Mr. George Markowski will support the project in his capacity as a health information technology specialist. Mr. Markowski created the web-based registry. He has worked closely with Dr. Mahapatra to enhance the data fields and decision rules within the registry. He will work with Dr. Mahapatra to insure that all updates to the registry are captured in a way that allows us to report the findings. Mr. Markowski will also place the provider questionnaire on a web-based form to allow data collection.
1 Maciosek, M. V.; Solberg, L. I.; Edwards, N. M., et al. Colorectal cancer screening. Technical report prepared for the National Commission on Prevention Priorities, 2006
2 Screening for colorectal cancer: recommendation and rationale. Ann Intern Med 2002 Jul 16;137(2):129-31.
3 Trombold J, Farmer RW, McCafferty M ,The impact of colorectal cancer screening in a veteran hospital population. Am Surg. 2013 Mar;79(3):296-300.
4 Healthy People.gov available at http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=5
5 C A. Richardset al. Increased Screening Colonoscopy Rates and Reduced Racial Disparities in the New York Citywide Campaign: An Urban Model. Am J Gastroenterol 2011;106:1880
Ms. Helen Zhang will support the analysis of the project. She will work with Dr. Mahapatra and Ms. Srinivasan to insure that the appropriate data for each Aim is pulled from the registry. She will then work with Dr. Mahapatra and Dr. Trick to complete the analyses.
Research Assistants – TBD – will support the project by completing chart reviews to complete the registry entries. They will perform updates of the registry based upon their reviews of colonoscopy and pathology reports, interval updates of patients in the Work Up in Progress or Indeterminate categories, and from clinical information from the primary care physicians.
We anticipate that the supplies will be used for mail correspondence with patients.
References
1 Maciosek, M. V.; Solberg, L. I.; Edwards, N. M., et al. Colorectal cancer screening. Technical report prepared for the National Commission on Prevention Priorities, 2006
2 Screening for colorectal cancer: recommendation and rationale. Ann Intern Med 2002 Jul 16;137(2):129-31.
3 Trombold J, Farmer RW, McCafferty M ,The impact of colorectal cancer screening in a veteran hospital population. Am Surg. 2013 Mar;79(3):296-300.
4 Healthy People.gov available at http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=5
5 C A. Richardset al. Increased Screening Colonoscopy Rates and Reduced Racial Disparities in the New York Citywide Campaign: An Urban Model. Am J Gastroenterol 2011;106:1880
6 Maciosek MV et al ,Priorities Among Effective Clinical Preventive Services: Methods. Am J Prev Med 2006 Jul.
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