finding best practices in chronic disease prevention
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Finding Best Practices in Chronic Disease Prevention. Sally Honeycutt, MPH, CHES Evaluation Team Lead Emory Cancer Prevention & Control Research Network (CPCRN). - PowerPoint PPT PresentationTRANSCRIPT
Finding Best Practices in Chronic Disease Prevention
Sally Honeycutt, MPH, CHESEvaluation 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
Expert Review & Recommendations
Site Visit
Document Review 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
The Langdale Company and TLC Benefits
Descriptive Case Study
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 & MethodsHow 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 strategiesThe Community Guide to Preventive Services: Intervention Categories Recommended for Colorectal Cancer Screening2
Intervention Category Evidence for Method Used by CCSP
Provider Assessment & Feedback Sufficient: FOBT
Provider Reminder & Recall Systems Strong: FOBTSufficient: 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/
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
EligiblePopulation
Non-RandomizedAssignment
CCSP4 clinics
No CCSP9 clinics
Colonoscopy No Colonoscopy
Colonoscopy No Colonoscopy
• Quasi-experimental design– 2 conditions– No randomization to condition
• 18-month study period– Nov. 1, 2009-Apr. 30, 2011
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
Blue stars = CCSP Intervention ClinicsGreen stars = Comparison Clinics
Setting: All 13 FQHCs in region
FQHC: Federally Qualified Health Center
Southwest GA Federally Qualified Health Centers
• Four FQHC Systems– 13 total clinics
• Provider/Patient Ratio– Mean: 0.0039– Range: 0.0015-0.0087
• % Uninsured Patients– 0-25%: 6 clinics– 25-50%: 7 clinics
# Patients seen (2010)
# Clinics
< 1,000 1
1,001 – 2,000 5
2,001 – 3,000 2
3,001 – 4,000 4
> 4,000 1
Sample Size
• Intervention– 4 clinics– Serve 3,009 patients– 1,267 eligible patients– Take 25%– 350 charts to review
• Comparison– 9 clinics– Serve 11,001 patients– 2,506 eligible patients– Take 25%– 625 charts to review
975 patients
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 FindingsEvaluation 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 FindingsAre rates of colonoscopy screening among uninsured/ underinsured patients age 50-64 at the four intervention clinics significantly higher than at the nine comparison clinics?
Note. Statistics not yet adjusted for clustering within clinics˄ Among patients due for colonoscopy during study† Among all eligible patient* p < .0001
Outcome Intervention Comparison Total c2
Had colonoscopy referral during study
No 108 (42.0%) 388 (76.1%) 496 (64.7%)86.738*
Yes 149 (58.0%) 122 (23.9%) 271 (35.3%)Had a colonoscopy exam during study
No 167 (65.0%) 477 (93.5%) 644 (84.0%)103.439*
Yes 90 (35.0%) 33 (6.5%) 123 (16.0%) Total ˄ 257 510 767 Compliant on any test No 166 (57.4%) 464 (89.2%) 630 (77.9%)
108.962*Yes 123 (42.6%) 56 (10.8%) 179 (22.1%)
Total† 289 520 809
Preliminary Findings
What is the degree of CCSP effectiveness towards improving colonoscopy screening behavior?
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
Outcome Wald (c2) Odds Ratio
Had colonoscopy referral during study (among due) 75.447* 4.260˄Had colonoscopy exam during study (among due) 79.669* 7.708†Compliant on any test 89.448* 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
AcknowledgmentsCCSP Staff, Stakeholders & Local TeamCancer Coalition of South GA: Denise Ballard, MEd
Diane Fletcher, RNRhonda GreenJames Hotz, MD
Medical College of GA: Alex BruederShavonda ThomasJennifer Yam
SW GA Family Medical Residency: Teri Stapleton, MD TSTC Health IT program: Aisha Viquez
Langdale Staff, Stakeholders & Local TeamThe Langdale Company: Barbara Barrett
Mark WilsonLowndes County Partnership for Health: Alan Powell
John SparksTLC Benefits Solutions, Inc.: Kate Waagner Doctor’s Direct Health Care: Tina Wise, RN
* Evaluability assessment or evaluation project leader † Expert Review Committee Member
Emory University CPCRNKimberly Jacob Arriola, PhD, MPH*†
Lucja Bundy, MEd, MAMichelle Carvalho, MPHCam Escoffery, PhD, MPH†
April Hermstad, MPHSally Honeycutt, MPH Michelle Kegler, DrPH, MPH†
Joseph Lipscomb, PhD†
Natasha Ludwig-Barron, MPHGillian Schauer, MPH*Iris Smith, PhD, MPH†
Deanne Swan, PhD*†
Amanda Wyatt, MPHVera (Jingqi) Yang, MPH
Questions?
• Ask now, or…• Look for our posters at
the National Cancer Conference in August!