Organizational Change: A Way to Increase Colon, Breast and Cervical Cancer Screening in Primary Care Practices
Abstract and Introduction
Abstract
Screening tests for colon, cervical and breast cancer remain
underutilized despite their proven effectiveness in reducing morbidity
and mortality. Stone et al. concluded that cancer screening is most
likely to improve when a health organization supports performance
through organizational changes (OC) in staffing and clinical procedures.
OC interventions include the use of separate clinics devoted to
prevention, use of a planned care visit, designation of non-physician
staff for specific prevention activities and continuous quality
improvement interventions.
Objectives To identify specific elements of OC interventions that
increases the selected cancer screening rates. To determine to which
extent practices bought into the interventions.
Methods Eleven randomized controlled trials from January 1990 to
June 2010 that instituted OC to increase cancer screening completion
were included. Qualitative data was analyzed by using a framework to
facilitate abstraction of information. For quantitative data, an outcome
of measure was determined by the change in the proportion of eligible
individuals receiving cancer screening services between intervention and
control practices. The health prevention clinic intervention
demonstrated a large increase (47%) in the proportion of completed fecal
occult blood test; having a non-physician staff demonstrated an
increase in mammography (18.4%); and clinical breast examination
(13.7%); the planned care visit for prevention intervention increased
mammography (8.8%); continuous quality improvement interventions showed
mixed results, from an increase in performance of mammography 19%,
clinical breast examination (13%); Pap smear (15%) and fecal occult
blood test (13%), to none or negative change in the proportion of cancer
screening rates.
Conclusions To increase cancer screening completion goals, OC
interventions should be implemented tailored to the primary care
practice style. Interventions that circumvent the physicians were more
effective. We could not conclude whether or not continuous quality
techniques were effective. Further research is needed to evaluate
cost-effectiveness of these interventions.Background




According to the latest National Center for Health Statistics in
2010, cancer is the second leading cause of death in the United States
for men and women (US).^[1]
Among men of all ages, the leading causes of cancer death are lung,
prostate, colorectal and liver cancer and the most commonly diagnosed
cancers are prostate, lung and colorectal cancer. Likewise, among women
of all ages, the leading causes of cancer death are lung, breast and
colorectal cancer and the most commonly diagnosed are breast, lung and
colorectal cancer.^[2]
Although screening is not indicated or available for all cancer types,
timely screening for colorectal, breast, and cervical cancer can reduce
morbidity and mortality.
The US Preventive Services Task Force, major health organizations and
expert panels have published guidelines and made recommendations for
cancer screening.^{[1, 3, 4]}
Despite improvements over recent years, screening rates for colon are
below targeted goals and screening rates for breast and cervical cancer
remain suboptimal among minorities and other special populations,
partially due to the failure in the delivery of cancer screening
services in clinical practice.^{[5, 6]}

To improve cancer screening delivery in clinical practice, wide
arrays of interventions aimed at cancer screening promotion have been
tested.^{[7, 8]}
Because of the diversity of the interventions and findings, it has been
difficult to identify the key elements necessary for clinical practices
to implement in order to improve cancer screening delivery. Recently,
Stone et al. evaluated the effectiveness of the diverse approaches used
to promote preventive care activities such as cancer screening and adult
immunizations. By using a conceptual framework, Stone assessed the
effectiveness of seven interventions and conclude that "cancer screening
is most likely to improve when a health care organization supports
performance of such activities through organizational changes in
staffing and clinical procedures". Stone found that organizational
change (OC) was the most effective intervention at improving adult
immunizations, cervical cytology, and colon cancer screening services
and was the second most effective intervention at improving the use of
mammography.^[8]

In order for practices to translate effective interventions from
these trials into patient care, specific details of organizational
change interventions are necessary. This review builds on the work of
Stone and colleagues by identifying specific elements of OC
interventions that have been implemented to try to increase breast,
colon and cervical cancer screening in primary care settings. Our
purpose was to determine whether we could identify specific elements or
groups of elements that were related to effective interventions. We also
evaluated studies to determine if interventions were adopted by the
practices and the extent to which practices bought into the
intervention.Methods




To identify relevant articles, we used the National Library of
Medicine on-line database to identify Randomized Controlled Trials
(RCT), meta-analysis and systematic reviews related to OC strategies in
primary care practices. We searched Pubmed using combinations of the
search terms neoplasm, prevention and control, mass screening,
organizational innovation, organizational objectives, preventive health
services, organization and administration. Dates of this initial search
were from January 1990 to May 2006. In addition, we reviewed the
references of these articles for relevant studies. We updated our
original search using the same search terms and dates from May 2006 to
June 2010.
We included RCT published in English language between January 1990
and July 2010. We selected articles in which OC interventions were
carried out by practice staff (no research staff) and were aimed to
increase cancer screening for colorectal, breast and cervical cancer. We
defined OC using Stone et al.^[8]
definitions, "Changes in the work processes in a medical care
organization that can facilitate improved performance of preventive
services. Changes could include addition or redesign of jobs, changes in
clinical procedures or changes in facilities or infrastructure". For
colorectal cancer we assessed test completion for flexigmoidoscopy (FS),
colonoscopy and fecal occult blood test (FOBT), for breast cancer we
assessed test completion for mammography and clinical breast examination
(CBE) and for cervical cancer we assessed test completion for Pap
smear. Information abstracted from selected articles was recorded on an
excel worksheet and included author and year of publication, main
outcome of measure, study setting and population, type of practice, type
of organizational change, study timeframe and results. In order to
abstract information regarding the type of OC we used the classification
proposed by Stone et al.^[8]
in which OC was grouped into four main categories: the designation of
specific prevention responsibilities to non-physician staff, the use of
continuous quality improvement (CQI), the use of a planned care visit
for prevention, the establishment of a separate clinic devoted to
screening. For RCT using CQI we created a framework that facilitated a
detailed abstraction of information related to the elements of the
quality improvement cycle. We considered whether these practices had
performed an initial assessment of their ongoing cancer screening
practices (A = Assessment), had designed an intervention or plan (P =
Plan), had given feedback to staff participating in the study (F =
Feedback), and had facilitated the implementation or not (F* =
Facilitation).
For quantitative data, an outcome of measure was determined by the
change in the proportion of eligible individuals receiving cancer
screening services between intervention and control practices over a
period of time. Another outcome of measure was the percentage difference
in the completion of cancer screening between intervention and control
practices among previously unscreened individuals. Results were manually
coded subtracting baseline and post-intervention absolute data,
statistical significance of the difference was also specified. We
considered the clinical importance of a change in screening as none if
the difference between the control and the intervention result was less
or equal to 5%, moderate change between 5–15% and large change if more
than 15%. Article selection, abstraction of relevant information and
results was performed by two researcher physicians working
independently. Disagreements were resolved by consensus.Results




We found 11 RCT that fulfilled our inclusion criteria. Three RCT
studied the designation of specific prevention responsibilities to
non-physician staff,^[9–11] one RCT studied the use of a separate clinic devoted to screening and prevention activities,^[12] one RCT studied the use of a planned care visit for prevention^[13] and six used continuous quality improvement (CQI) based techniques.^[14–19]
These interventions introduce practice changes by involving personnel
in planning and executing processes aimed to improve health care
quality.^[20]



Non-physician Staff


Three RCTs studied the designation of specific prevention responsibilities to non-physician staff (Table 1).
This intervention mostly showed a large increase in the completion of
screening services among unscreened individuals. Herman,^[10]
showed a large change in obtained mammography (18.4%) and moderate
change in offered CBE (13.7%) after the designation of specific
prevention responsibilities to prevention teams consisting of providers,
nurses and other ancillary staff who in addition to providing patient
education, expedited the performance of preventive services. Results
were assessed 3 months after the intervention was implemented. Mohler^[11]
reported a large increase (32%) in the percentage of mammograms
obtained after telephone calls done by a medical assistant who besides
calling patients to encourage mammography completion, counseled patients
about necessity, discomfort and costs of the procedure. The medical
assistant also helped patients to schedule mammogram appointments at the
time of the phone call. Results were obtained 2 months after the
intervention was implemented.^[11]
Binstock in 1997 demonstrated a large increase (18.8%) in the
completion of Pap smears among eligible women without a Pap smear in the
previous 3 years. In his study, participants were randomly assigned to
one of five groups: a telephone call to the member, a letter to the
member, a memo to the member's primary provider, a chart reminder
affixed to the outside of the member's medical record, and a control
group that received no interventions. Increase was large for the phone
call group (18.8%) and moderate for the letter to patient (10.1%),
provider memo (9.2%) and use of chart reminder (7.6%). These activities
were carried out by a practice clerk.^[9]



CQI Based Techniques


Six studies addressed changing screening processes through CQI based techniques (Table 2). Three studies showed improvements while three showed no increase in the proportion of screening services. Dietrich et al.^[18]
showed a large increase in the proportions of eligible female patients
who reported receiving a mammography (19.0%), a moderate increase in the
performance of Pap smear (15.0%), FOBT (13.0%), CBE (13.0%) and no
change in the proportion of FS (2.0%) after 1 year of the intervention.
Dietrich's intervention used methods consisting of education activities
for providers (MD and staff members) and an office system intervention
that used a project facilitator who assisted practices in the design and
implementation of office routines supporting provision of early
detection and preventive services. The same author in 1998 showed only a
moderate increase in the proportion of patients who received a CBE
(9.0%), no change in the proportion of received mammography(3.0%) and
FOBT(0.0%) and a negative value for the proportion of received Pap smear
(−6.0%) and FOBT (2.0%).^[19] Kinsinger^[16]
showed a moderate increase in the proportion of completed CBE (6.0%)
and no change in the proportion of reported mammograms (1.3%) after 1
year of the intervention. Solberg et al.,^[14] Goodwin et al.^[17] and Ruffin^[15] failed to increase cancer screening rates in community based primary care practices.Key Elements of CQI based Techniques



Initial Assessment and Feedback of Current Screening Practices


When we examined the key elements of studies that used CQI processes,
we found that five of the six studies reported assessment of current
screening procedures.^[14–18]
Most of the interventions assess the practices current processes in
regards to cancer preventive services; however, some performed the
evaluation with the practices and others did not. Three of the practices
that performed an assessment of current screening procedures reported
giving feedback to the practice^[15–17] at the beginning of the study. Of these, only one study reported a small positive change in screening rate for breast cancer.^[16] Only one study reported providing feedback to the practice every 6 months^[17] and two provided feedback at the end of the study.^[15,16]
The reported contact with the intervention practices varied across the
six studies. A minimum of two visits were made to each practice. Ruffin
reported at least monthly contact with a key contact among the office
staff during the entire study.^[15]
Besides on-site visits, practices received ongoing support which was
described primarily as being available for phone calls. Solberg reported
phone contact every 6 weeks with more than 750 calls over the 1.5 years
of the study.^[14]



Office System


All six studies reported using practice tools to facilitate
screening. These included tracking tools (e.g. flow sheets), and
reminders (e.g. chart prompt, posters). For five of the studies a menu
of these tools was offered and the practices chose among to create their
own system.^[15–18] Four of six studies reported some type of education provided to the staff and or physicians.^{[14, 16, 18]}
Education sessions consisted of workshops and informative sessions on
the use of practice tools and adoption of current cancer screening
recommendations. Solberg's study was unique in that it focused on
education about continuous quality improvement techniques. Education to
physicians was the only component that was consistently present in three
of the studies that showed positive result.^{[16, 18]}



Evidence of Intervention Implementation


Four of the six studies reported some measure of whether or not there
was uptake of the intervention. The methods of these measures and
reporting varied. Dietrich 1992 mentioned "Practices implemented only
those tools that met their specific perceived needs".^[18] In 1998, the same author reported only 39% of the intervention centers initiated a new flow sheet.^[19]
Kinsinger 1998 reported a several process measures: 49% of the
intervention practices had a written policy about preventive services,
30% physician use of flow sheets, and 17% staff recommended mammography.
Solberg 2000 reported 59% of the practices had implemented the
intervention after 20 months.^[16]



Planned Care Visit for Prevention


One RCT evaluated the effect of a planned care visit for prevention
along with a patient initiated system for preventive health care (Table 3).
Williams et al. in 1998 studied the effectiveness of a patient
initiated touch sensitive computer system for improving cancer screening
rates for different type of cancer. He found a moderate increase in the
completion of screening mammography (8.8%), and CBE (8.3%) particularly
in women who had a health maintenance examination during the year of
the study. He found no change in the completion of Pap smear (2.7%),
FOBT (1.0%) and FS (1.3%).^[13]



Health Prevention Clinic


One RCT assessed the effect of the establishment of health prevention clinic on cancer screening (Table 3). Belcher^[12] showed a large increase in the proportion of completed FOBT (47.0%) after 5 years that the intervention had began.Discussion




In this review we detailed specific elements of OC interventions that
have been implemented in RCT designed to increase breast, colon and
cervical cancer screening in primary care settings. Like Stone et al.,
we found that interventions that circumvented the physicians were the
most effective at increasing the use of screening services. When we
examined OC interventions that used CQI based techniques, we were unable
to identify specific elements of groups of elements that were related
to effective interventions, perhaps because the overall effect of these
interventions was mixed. Furthermore, we found limited evidence that
these or aspects of these interventions were implemented in the
intervention practices making it difficult to ascertain which aspects of
the interventions could be effective. However, our work contributes to
the current body of knowledge by detailing key elements common in CQI
processes that have been incorporated into intervention studies.
This review may guide primary care physicians and practices to
improve their current cancer screening completion by implementing
evidence-based interventions found to be the most effective, saving them
from the trial and error common type of approach.
Using a separate clinic devoted to prevention demonstrated the greatest increase in cancer screening. Belcher^[12]
had the longest follow-up period all the studies to test the
intervention (5 years). In this study, patients were mailed a
description and invited to self-refer to the clinic, two additional
phone calls were made to contact nonparticipants and repeat the offer;
the clinic was run by two part time nurse practitioners trained to
recommend screening, provide health counseling, coordinate follow-up
care and apply referral protocols tailored to participant's risk
factors. These measures translated in colorectal cancer screening
through FOBT of 47% increase. Reasons for this success may include that
patients are willing to self refer to health maintenance clinics,
obtaining more services while evading clinic barriers. Although this was
an encouraging result, no other studies using the same type of
intervention is available for comparison.
Non-physician staff interventions^[9–11]
showed large increase in the completion of screening services among
unscreened individuals. The included studies accounted for the shortest
follow up periods amongst all the studies (2 months to 1 year). They
demonstrated a large increase in preventive services for mammogram and
Pap smear.^{[9, 10]}
This approach along with the dedicated prevention clinic did not rely
on physicians, yet they demonstrated a large increase in cancer
screening completion rates. These studies suggests that, the needed
array of clinic processes to execute the cancer screening tests are more
effective when carried out by non-physician staff: reminding and
counseling patients on the upcoming or overdue tests, for which
non-physician staff may devote more time, providing administrative
support such as appointment-scheduling, linking patients with community
resources and helping patients navigate through the health care system.
Phone-calls or face-to-face encounter were more encouraging to patients
than letters due to their interactive nature.
Studies using CQI based techniques methods showed mixed results: from large increase (19%) for mammograms^[18] to negative change in the proportion of completed cancer screening tests (−16%) Pap smear,^[19] (−13%) FOBT.^[15]
Understanding the characteristics of CQI intervention is critical when
comparing studies; the lack of detail presented in the studies in
describing the processes such as the extent of the implementation, staff
acceptability and readiness to change, did not allow such comparison.
We could not clearly identify a CQI framework used by the practices;
however, we could abstract elements that were consistent in CQI
processes: practice assessment and feedback, plan, and evidence of
intervention implementation. By assessing these elements, we did not
find major similarities/differences across the six studies that could
explain differences in outcomes. None of the aforementioned elements
common CQI processes could be single out as being the most effective in
increasing cancer screening rates. In fact, education to clinic
personnel and physicians, which was present in four out of the six
studies translated into a positive result only in three of them. Another
drawback was the lack of evidence of long term maintenance of positive
results in the studies. Ruffin 2004 in a 3 year follow study showed
negative results as result of the intervention.^[15] Indeed, after the year 2000 studies consistently showed little or no change when a CQI model was used.^{[14, 15, 17]}

The dynamics of the environment to tailor CQI processes specific to
practices are complex. Elucidated reasons for failure in CQI processes
were loss of key personnel during the first year, major building
renovations,^[15] implementation was slow or incomplete,^[14] implementation issues,^[16] medical director turnover, number of patients seen per hour by clinicians, changes in practice location or expansion,^[19] and selected highly motivated practices to participate in the intervention group.^[18]

Utilizing well–defined frameworks such as the RE-AIM framework
designed by Russ Glasgow and his associates with standardization of the
processes would facilitate the measurement of outcomes and comparison
across studies. This particular framework analyzes 5 dimensions: reach
into the target population, effectiveness or efficacy, adoption by
target settings, institutions and staff, implementation, consistency and
cost of delivery of intervention and maintenance of intervention
effects in individuals and settings over time. Paying attention to these
elements "can improve the sustainable adoption and implementation of
effective, generalizable, evidence-based interventions".^[21]

In Planned care visit for prevention approach, Williams 1998 showed
from no change to a moderate increase rates in the selected cancer
screening completion.^[13]
This model of intervention is initiated by the patient who reminds the
physician through a computer generated printed flow sheet of the due and
overdue screening tests. It is still disappointing that the results are
not better with this measure. These findings can be partly explained by
the fact that this intervention faces some of the same barriers than
CQI do, such as requirement of active physicians' actions: reviewing the
patients spread sheet, counseling process and ordering the selected
tests, as well as that it requires patients' knowledge in how to
navigate the health care system to assure tests completions.
We acknowledge some limitations in of our review. Our study is a
narrative review, not a systematic review, therefore some studies
meeting our inclusion criteria might had been missed. We found limited
number of studies for selected types of interventions up to June 2010.
Another weakness of our review is that we did not contact the authors;
any doubts that arouse from our interpretation of the studies were
resolved by consensus. When assessing the CQI interventions, we
extracted elements that seemed common to all these types of
interventions by analyzing the studies; other readers may have
disagreements with our findings. We also included some results that were
not statistically significant, accounting that they did not incur in
major flaws as per our analysis of literature.


Summary


Following the USPSTF and other health organizations' recommendations
for cancer screening completion have proven to reduce morbidity and
mortality. This should urge physicians, practices, policy makers, and
government to spare no efforts in attempting to reach screening goal
through the implementation of effective strategies.
Physicians overestimate their performance in offering preventive services,^[16]
individual effort to improve screening rates is challenging to a busy
clinician with many competing obligations. Lack of motivation and busy
schedules are also some of physicians' barriers to achieve the cancer
screening goals.
After this review, we feel that when considering reaching cancer
screening goals, having a non-physician staff in charge by offering
these services through phone calls, letters and reminders during
face-to-face visit, counseling and guiding patients through the health
system is a reasonable first choice. Designating a separate clinic
devoted to prevention should be implemented if feasible with the
practice style. Physician education should not be the only course of
action in attempting to increase cancer screening rates, since its
impact has been inconsistent. Other elements of CQI either individually
as parts of a complete program are complex, we could not conclude
whether or not these interventions are effective. CQI interventions
should use a validated framework such as RE-AIM to shine more light in
assessing the effectiveness of such intervention. Further research is
needed to assess the cost-effectiveness of these interventions.
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