*EMBARGOED All research presented at the 2019 ACG Annual Scientific Meeting and Postgraduate Course is strictly embargoed until Monday, October 28, 2019, at 8:00 am CDT.
P3025 “Go Before You Go”: Interim Analysis of a Quality Improvement Project to Improve Colorectal Cancer Screening in a Safety Net Primary Care Clinic
Author Insight from Shida Haghighat, MD, MPH, LAC+USC Medical Center
What’s new here and important for clinicians?
In our safety-net clinic, the Fecal Immunochemical Test (FIT), a low-cost stool test, is the primary means of colorectal cancer screening. Our reports indicated a poor FIT return rate of 20% at the end of a six-week period which was far below the national average for time to FIT completion. So, we set out to ask “Why is the FIT return rate so low? And how can we increase the FIT return rate?” How did we do this? We did something that’s rarely done – we asked the patients themselves!
Before our intervention, patients completed their FITs in the privacy of their own homes and either dropped them off in person at the lab or mailed them in (less likely the latter). In addition, patients were not given a deadline for FIT return, thus many patients were returning their FITs between 3-6 months after they were ordered.
Many things we do as physicians come from a top down approach. In other words, the doctor tells the patients what to do and the patients are expected to comply. Unfortunately, it has not become common practice to involve the patient in the discussion of how we can best suit their needs. In a low-resource, safety net clinic that delivers care to an underserved population like ours, it Is imperative to engage the community – the patients – in how we can make things easier for them, in this case returning a simple FIT test.
For this reason, we applied the basic principles of community based participatory research (CBPR) in an endeavor to learn how we can improve colorectal cancer screening rates in our unique population. The main tenet of CBPR is to engage the community (in our case, the patients) at its core and to ask them, “Hey, how can we make it easier for you to return your FIT test?” CBPR emphasizes forging collaborative relationships with all stakeholders in an equitable process. The stakeholders in our process were many: the patients, the clinic leadership, the nursing staff, and the resident physicians. In whole, by engaging each of these stakeholders in a meaningful way we aimed to disseminate our results to all of our partners for an ultimately shared goal that attends to health disparities.
Put simply, our goal was to collect knowledge (by way of surveys and personal interviews) to inform an intervention ultimately to increase the FIT return rates at our clinic. We surveyed 126 patients and had a few surprising findings. It was disconcerting to learn that of those who completed a FIT test, 22% did NOT know why they were doing it. Even more alarming was learning that 33% of our patients reported that their provider had never spoken to them about the FIT. With that said however, we found that lack of awareness or lack of provider communication did not affect whether or not the patient completed their FIT. As for our main finding, when we asked patients how returning the FIT could be made easier, 22% preferred to complete the FIT on the same day as their clinic visit. This was definitely surprising to us. Can that many people actually “poop on demand?” Well, we set out to find out the answer to exactly this question. We thus implemented the “Go Before You Go” (alternative and less kosher name: Poop on Demand) intervention.
The intervention included meeting separately with our various stakeholders and sharing these exciting/surprising results. Clinic leadership and nursing staff were informed of the plan to “Go Before You Go” and were fully on board. Resident physicians were informed of the survey findings and were counseled to encourage this policy at weekly lectures. They were also sent weekly text-reminders of the intervention. In addition, television monitors in the clinic waiting room displayed ads for “Go Before You Go.” We even had two bathrooms in the clinic designated specifically for this purpose.
Interim analysis of data one month after the introduction of the intervention demonstrated an overall improvement in the FIT return rate. Our same day FIT return rate more than doubled from 5.0 to 12.7%. Our one-week FIT return rate nearly doubled from 11.1 to 20.1%, and our four-week return rate increased from 20.6 to 29.9%. The intervention has continued to show promising results. An important lesson to take away from the “Go Before You Go” initiative is that most of the time we just need to listen to our patients. Engaging patients in the decision-making process and in policy design can be a simple key to innovation.
What do patients need to know?
Patients should know about universal colon cancer screening guidelines and that there are different options for screening. Specifically however, at our safety-net institution we utilize the FIT test, a low cost, convenient screening tool. The FIT test can detect hidden blood in the stool, which can be an early sign of colon cancer. Patients should know that the FIT test is not the conventional “stool in a bottle” test. Rather, the FIT test only requires you to brush your stool with a provided brush and insert it into a tube, and voila – you’re done for the year!
Author Contact
Shida Haghighat, MD, MPH, LAC+USC Medical Center
Sh_346 [at] usc [dot] edu
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