Wednesday, July 12, 2017

Whitesburg clinic shows rural lag in colon-cancer screening can be erased by overcoming the reluctance to talk about it

Screening for colorectal cancer isn't as common in rural areas as it is in metropolitan areas, partly because rural people seem to have trouble talking about it. Whatever the reason, the rural death rate from it is higher, and the disease is more common in Kentucky than any other state.

Dr. Van Breeding talks with a patient. (WEKU-FM photo)
When Dr. Van Breeding of Whitesburg found that only 19 percent of patients at Mountain Comprehensive Health Corp. had been screened, he said, "That's horrible! We've got to do better than that!" reports Dr. Kay Miller Temple for The Rural Monitor's Rural Health Information Hub: "He said their effort started with everyone in their clinic talking about it, from check-in personnel to lab team members to providers — everyone started talking about colorectal cancer screening." Breeding told her, "We got everyone who had contact with the patient to talk about it, starting with a simple question: ‘Have you ever been screened for colon cancer?’" Breeding says the rate is now 73 percent, in "an area where its incidence and death rates are the highest in the country," Temple notes.

Temple reports that a similar approach was used at Clearwater Valley Hospital and Clinics and St. Mary’s Hospital and Clinics in Idaho. "Using an electronic record indicator, providers were reminded to talk to unscreened patients during any appointment scheduled for any reason," Temple reports. "In addition to talk, they mailed reminders to patients" and did community outreach.

The screening rate at the Idaho facilities was much better, 52 percent, but their quality-improvement director, Heather Hodges, said their goal was 70 percent. They are now at 69 percent and have set a new goal of 75 percent. The national rate is 60 percent; the rural rate is 58 percent and the metro rate is 63 percent. Kentucky's statewide rate is 68 percent. The National Colorectal Cancer Roundtable’s 2018 goal is 80 percent, which acknowledges that some patients will always choose not to be screened.

"Hodges said the subject of CRC screening is a bit distasteful, but this can’t prevent healthcare organizations from doing community outreach," Temple reports. Such outreach includes a much-latger-than-life-size colon, through which people can walk. Here's a video:

“Screening rates are lower in rural areas, where geography causes barriers like lack of access to providers and lack of specialists or access to those specialists,” Dr. Djenaba Joseph, medical director for the federal Centers for Disease Control and Prevention’s Colorectal Cancer Control Program, told Temple. “In some states, there are hundreds of miles between the patient and the nearest endoscopist. But, regardless of location, I tell everyone, rural and urban, you can improve rates by knowing your population. Know the number of endoscopists in your area, know the population you are trying to reach, know the income limits, and know insurance status.”

Temple writes, “A recent American Cancer Society survey showed that 'nearly all unscreened people knew they should be screened.' Many who hadn’t completed screening assumed if they had no family history, they were at no risk for the disease. Others perceived the test was expensive, complicated, painful, embarrassing, and only needed for worrisome symptoms. With information like this, many providers feel that talking about CRC screening seems not only delicate, but time-intensive in order to dispel myths about screening, especially when discussions around other cancer screenings are often as simple as 'It’s time for you to make an appointment for a pap smear, mammogram or prostate check.'”

In Whitesburg, "as the CDC’s Joseph suggested, success came from knowing the population," Temple reports. "Breeding said they talked to their area insurance carriers about ensuring colonoscopy coverage. They also discovered that patients without insurance could get assistance from the health department due to the area’s high risk. Next, the local hospital decided to improve the endoscopy area, and the area’s surgeons, who performed the colonoscopies, immediately accommodated a structured approach to direct screening. Mondays and Fridays became designated testing days to accommodate prep and recovery times."

Breeding told Temple that one of the most powerful factors in his clinic's huge increase in screening "was a new dynamic that emerged in their tight-knit community: when community members looked into the face of a family member, a friend, a neighbor, and realized that person was living in an area of high colorectal cancer incidence and death rates, they encouraged one another to get screened. With this effort, Breeding shared that more than 30 lives have been saved. Their new screening goal — their community’s goal? It’s now 100%. Among the many lessons learned in this effort was patients’ understanding that the clinic was not just a place to come when sick, but a place to come to get, and stay healthy."

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