- Email: [email protected]
1034 Variation in Colorectal Cancer Screening Rates Within a Unified Health System
unselected young-onset CRC is low, however, germline TP53 mutations account for up to 1.2% of CRC cases without family history suggestive of LFS or hereditary CRC. TP53 testing should be considered in a young subject with CRC after exclusion of other CRC hereditary syndromes. Acknowledgments: This study was funded by an AGA Translational Research Award.
1035
Purpose: Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the U.S. Randomized controlled trials have shown that CRC screening reduces CRC mortality and incidence. However, CRC screening rates are low. Recently in a randomized controlled trial, we showed that a mailed educational reminder increased CRC screening with fecal occult blood tests (FOBT) rates by 16.2% among U.S. Veterans (J Gen Intern Med 2009;24:1192-7). The objective of this study is to assess the costs and cost-effectiveness of the mailed educational reminder on adherence with FOBT-type screening. Methods: In a blinded, randomized, controlled trial, 775 U.S. Veterans who had agreed with FOBT screening were randomly assigned to the usual care group (n=386) or the intervention group (n=389). Ten days after distribution of the guaiac-based FOBT kits (3 cards/kit), a 1-page reminder with information related to CRC screening was mailed to the intervention group only. Primary outcome was proportion of returned FOBT cards after 6 months. The costs and incremental cost-effectiveness ratio (ICER) of the intervention were calculated. Costs per person screened were calculated for use with both FOBT and immunochemical FOBT (IFOBT) kits (3 tests/kit). Sensitivity analyses were based on varying costs of labor and supplies. Results: 6 months after card distribution, 64.6% (250/389) of patients in the intervention group returned the cards compared with 48.4% (185/386) in the control group (P<0.001). The total cost of the intervention was $1,037 or $2.67 per patient, and the ICER was $16 per additional person screened for CRC ($14 to $18 in a sensitivity analysis). The cost per patient screened with FOBT was $4.80 in the control group versus $7.89 in the intervention group. If the more expensive IFOBT were used, the costs per patient screened would be $51.32 versus $42.75 in the intervention group. Conclusion: A simple mailed educational reminder significantly improved FOBT card return rates for CRC screening. The costs and ICER associated with this patient-directed intervention was markedly lower than most analogous screening promotion interventions, and would be highly relevant if applied to the more expensive IFOBT that is increasingly being adopted. This effective and easy to implement intervention is low cost to cost saving per patient screened, and should be considered for implementation and routine practice. Incremental cost-effectiveness (Intervention cost per person screened)
1033 Genetic and Epigenetic Features in Synchronous Colorectal Cancer Cases Versus Solitary Cancers, Utilizing 1243 Colorectal Cancer Patients From Two Large Prospective Cohort Studies Katsuhiko Nosho, Shoko Kure, Yoshifumi Baba, Kaori Shima, Edward Giovannucci, Charles S. Fuchs, Shuji Ogino Background & Aims: Synchronous colorectal cancers refer to two or more primary colorectal carcinomas detected in a single individual at the time of the first diagnosis of colorectal cancer. Synchronous neoplasias, which arise in a background of common etiologic (genetic or environmental) factors, can provide a unique model to examine molecular aberrations. Previous studies have reported several molecular features in synchronous colorectal cancers. However, in all of these studies, control solitary cases were retrospectively selected, thereby subject to potential selection bias. In this study, we analyzed data collected from 32 patients with synchronous colorectal cancers and 1211 solitary cancers (controls) in 2 well-characterized, large prospective cohort studies. Methods: Tumor tissue specimens were analyzed for methylation in LINE-1 and 16 CpG islands (CACNA1G, CDKN2A [p16], CRABP1, IGF2, MLH1, NEUROG1, RUNX3, SOCS1, CHFR, HIC1, IGFBP3, MGMT, MINT1, MINT31, p14 [CDKN2A/ARF], and WRN); microsatellite instability (MSI) status; CpG island methylator phenotype (CIMP) status; KRAS, BRAF, and PIK3CA mutations; and expressions of DNA methyltransferase-3B (DNMT3B) and JC virus T-antigen (JCVT). Results: BRAF mutations were significantly more common in synchronous cancers (30%=9/30; p=0.0080) than in solitary cancers (13%=158/1198). Likewise, synchronous cancers were more commonly CIMP-high (p=0.047) and MSI-high (p=0.030), compared to solitary controls, whereas no association was found between tumor synchronicity and other molecular markers. Considering the confounding effect by age, we constructed a logistic regression model including age, BRAF mutation, CIMP-high, MSI-high and synchronicity status as an outcome variable. As a result, the association between BRAF mutation (p=0.010), CIMP-high (p=0.038), MSIhigh (p=0.033) and tumor synchronicity persisted, while age was no longer associated with tumor synchronicity. Among the 32 synchronous cancer cases, 12 synchronous cases could provide cancer tissues from both of two cancers in synchronous pairs. We found that methylation levels of LINE-1 (Spearman r=0.76; p=0.0062) and levels of CpG island methylation (p<0.0001) correlated between synchronous pairs from the same individuals. Conclusions: Compared with solitary cancers, synchronous colorectal cancers more commonly show BRAF mutations, CIMP-high, and MSI-high. In addition, synchronous colorectal cancer pairs exhibit a significant correlation of LINE-1 methylation levels and concordance in CpG island methylation. Our study may be an important one step forward to elucidate clinical and molecular characteristics of synchronous colorectal cancers.
1036 Low Adherence to Fecal Occult Blood Testing Over Time: Why CrossSectional Performance Measures May Overestimate Colorectal Cancer Screening Rates Ziad F. Gellad, Karen M. Stechuchak, Deborah A. Fisher, Maren K. Olsen, Jennifer R. McDuffie, Truls Ostbye, William S. Yancy
1034 Variation in Colorectal Cancer Screening Rates Within a Unified Health System Jennifer Weiss, Sally Kraft, Grace Flood, Lauren M. Fiedler, Perry J. Pickhardt, Maureen A. Smith, Patrick Pfau
BACKGROUND: Screening asymptomatic individuals with yearly fecal occult blood tests (FOBT) has been shown to decrease mortality from colorectal cancer (CRC). Adherence over time is necessary to ensure programmatic effectiveness. Thus, cross sectional measures of screening rates, such as HEDIS and the Veterans Affairs (VA) Performance Measure, may overestimate the success of a screening program in the setting of low adherence. METHODS: We conducted a retrospective study of veterans with one or more visits to 136 VA outpatient clinics in the United States in the year 2000. We limited our analysis to veterans age 5075 whose first screening test in the study period was an FOBT. We excluded those with a diagnosis of CRC or who died at anytime during the study period. Using VA administrative data, we assessed the receipt of subsequent screening by FOBT or other recommended CRC screening tests (barium enema [BE], flexible sigmoidoscopy and colonoscopy) over five years of follow-up. We defined “adequate CRC screening” over the 5 year period as receipt of at least four FOBT tests (each separated by at least 8 months) and/or receipt of a single BE, sigmoidoscopy or colonoscopy. We performed multivariable logistic regression analyses to identify predictors of adequate screening, including age, race, marital status, insurance coverage, primary care enrollment, service connection, Charlson comorbidity index, body mass index and geographic region. RESULTS: The sample included 555,281 men and 16,263 women. 40.5% of men and 44.4% of women underwent adequate CRC screening during the study period. Of those with adequate screening, only 24.1% of men and 19.8% of women achieved adequate screening because of repeated FOBT. In fact, in a subgroup of patients (N = 384,527 men and 10,469 women) who received FOBT but no other CRC testing, only 14.1% of men and 13.7% of women completed FOBT in 4 out of 5 years. The likelihood (OR and 95% CI) of adequate screening was lower in the West (OR 0.86, 0.850.87 for men and OR 0.75, 0.69-0.81 for women), Midwest (OR 0.90, 0.89-0.92 for men and OR 0.84, 0.76-0.93 for women) and Northeast (OR 0.92, 0.90-0.93 for men and OR 0.98, 0.88-1.09 for women) as compared to the South. Patients without outside insurance were also less likely to receive adequate screening (0.91, 0.90-0.92 in men and 0.88, 0.820.94 in women). CONCLUSIONS: In patients engaged in an FOBT screening program within the VA, adherence to yearly FOBT is low. Quality measures should consider longitudinal assessment of adherence when calculating colorectal cancer screening rates, particularly if FOBT is a common screening modality.
BACKGROUND: In 2006, 17 health systems across Wisconsin voluntarily reported quality measures in colorectal cancer (CRC) screening, published on-line by the Wisconsin Collaborative for Healthcare Quality. UW Health ranked 11 out of 17. CRC screening rates overall in Wisconsin were above the national average (~40-43%), however there was considerable variability across the state (56.9% to 69.3%). AIM: To examine the variation in CRC screening practices within our institution at both the clinic and the provider levels as a first step in designing targeted interventions to improve CRC screening rates. METHODS: Billing and electronic medical record data from July 2005 to June 2008 were used to identify patients within the UW Health system who were eligible for and had completed CRC screening within the current recommended guidelines. In our system, virtual colonoscopy is covered by all major third party payers and was considered among the available CRC screening modalities. Data collection was limited to age appropriate patients (50-79 yo) who received primary care services within our health system and for whom CRC screening data was available. Overall CRC screening rates of eligible patients were analyzed by clinic as well as number of patients screened by each individual provider. In addition, breakdown of CRC screening modalities ordered per provider were recorded. RESULTS: 37,511 patients were identified as being eligible for CRC screening and receiving primary care within our system. These patients were seen at 19 primary care clinic sites. Average overall CRC screening rates at our institution was 64.9% but ranged by clinic from 42.3% in the lowest performing clinic to 78.7% in the highest performing primary care clinic. CRC screening rates by provider ranged from 38.4% to 86.6%. Within clinics there was also significant variation in screening rates between providers. The largest variation of patients screened within a clinic was 39.3% [39.4-78.7] compared to the smallest spread represented by 1.0% [59.460.4]. Overall pattern of CRC modality choice was optical colonoscopy (82.7%), virtual colonoscopy (8.7%), and FOBT (5.5%). Use of flexible sigmoidoscopy and DCBE as CRC screening methods was negligible. CONCLUSIONS: 1. Significant variation in CRC screening practices exists between different primary care clinics within the same unified health system with major insurance coverage for virtual colonoscopy. 2. Significant variation in CRC screening exists between individual providers within clinics. 3. Targeted interventions to improve CRC screening within a health system need to be directed at both the system and the provider level.
S-151
AGA Abstracts
AGA Abstracts
Cost-Effectiveness of a Mailed Educational Reminder to Increase Colorectal Cancer Screening Jeffrey K. Lee, Erik J. Groessl, Theodore G. Ganiats, Samuel B. Ho
1035
Purpose: Colorectal cancer (CRC) is one of the leading causes of cancer-related deaths in the U.S. Randomized controlled trials have shown that CRC screening reduces CRC mortality and incidence. However, CRC screening rates are low. Recently in a randomized controlled trial, we showed that a mailed educational reminder increased CRC screening with fecal occult blood tests (FOBT) rates by 16.2% among U.S. Veterans (J Gen Intern Med 2009;24:1192-7). The objective of this study is to assess the costs and cost-effectiveness of the mailed educational reminder on adherence with FOBT-type screening. Methods: In a blinded, randomized, controlled trial, 775 U.S. Veterans who had agreed with FOBT screening were randomly assigned to the usual care group (n=386) or the intervention group (n=389). Ten days after distribution of the guaiac-based FOBT kits (3 cards/kit), a 1-page reminder with information related to CRC screening was mailed to the intervention group only. Primary outcome was proportion of returned FOBT cards after 6 months. The costs and incremental cost-effectiveness ratio (ICER) of the intervention were calculated. Costs per person screened were calculated for use with both FOBT and immunochemical FOBT (IFOBT) kits (3 tests/kit). Sensitivity analyses were based on varying costs of labor and supplies. Results: 6 months after card distribution, 64.6% (250/389) of patients in the intervention group returned the cards compared with 48.4% (185/386) in the control group (P<0.001). The total cost of the intervention was $1,037 or $2.67 per patient, and the ICER was $16 per additional person screened for CRC ($14 to $18 in a sensitivity analysis). The cost per patient screened with FOBT was $4.80 in the control group versus $7.89 in the intervention group. If the more expensive IFOBT were used, the costs per patient screened would be $51.32 versus $42.75 in the intervention group. Conclusion: A simple mailed educational reminder significantly improved FOBT card return rates for CRC screening. The costs and ICER associated with this patient-directed intervention was markedly lower than most analogous screening promotion interventions, and would be highly relevant if applied to the more expensive IFOBT that is increasingly being adopted. This effective and easy to implement intervention is low cost to cost saving per patient screened, and should be considered for implementation and routine practice. Incremental cost-effectiveness (Intervention cost per person screened)
1033 Genetic and Epigenetic Features in Synchronous Colorectal Cancer Cases Versus Solitary Cancers, Utilizing 1243 Colorectal Cancer Patients From Two Large Prospective Cohort Studies Katsuhiko Nosho, Shoko Kure, Yoshifumi Baba, Kaori Shima, Edward Giovannucci, Charles S. Fuchs, Shuji Ogino Background & Aims: Synchronous colorectal cancers refer to two or more primary colorectal carcinomas detected in a single individual at the time of the first diagnosis of colorectal cancer. Synchronous neoplasias, which arise in a background of common etiologic (genetic or environmental) factors, can provide a unique model to examine molecular aberrations. Previous studies have reported several molecular features in synchronous colorectal cancers. However, in all of these studies, control solitary cases were retrospectively selected, thereby subject to potential selection bias. In this study, we analyzed data collected from 32 patients with synchronous colorectal cancers and 1211 solitary cancers (controls) in 2 well-characterized, large prospective cohort studies. Methods: Tumor tissue specimens were analyzed for methylation in LINE-1 and 16 CpG islands (CACNA1G, CDKN2A [p16], CRABP1, IGF2, MLH1, NEUROG1, RUNX3, SOCS1, CHFR, HIC1, IGFBP3, MGMT, MINT1, MINT31, p14 [CDKN2A/ARF], and WRN); microsatellite instability (MSI) status; CpG island methylator phenotype (CIMP) status; KRAS, BRAF, and PIK3CA mutations; and expressions of DNA methyltransferase-3B (DNMT3B) and JC virus T-antigen (JCVT). Results: BRAF mutations were significantly more common in synchronous cancers (30%=9/30; p=0.0080) than in solitary cancers (13%=158/1198). Likewise, synchronous cancers were more commonly CIMP-high (p=0.047) and MSI-high (p=0.030), compared to solitary controls, whereas no association was found between tumor synchronicity and other molecular markers. Considering the confounding effect by age, we constructed a logistic regression model including age, BRAF mutation, CIMP-high, MSI-high and synchronicity status as an outcome variable. As a result, the association between BRAF mutation (p=0.010), CIMP-high (p=0.038), MSIhigh (p=0.033) and tumor synchronicity persisted, while age was no longer associated with tumor synchronicity. Among the 32 synchronous cancer cases, 12 synchronous cases could provide cancer tissues from both of two cancers in synchronous pairs. We found that methylation levels of LINE-1 (Spearman r=0.76; p=0.0062) and levels of CpG island methylation (p<0.0001) correlated between synchronous pairs from the same individuals. Conclusions: Compared with solitary cancers, synchronous colorectal cancers more commonly show BRAF mutations, CIMP-high, and MSI-high. In addition, synchronous colorectal cancer pairs exhibit a significant correlation of LINE-1 methylation levels and concordance in CpG island methylation. Our study may be an important one step forward to elucidate clinical and molecular characteristics of synchronous colorectal cancers.
1036 Low Adherence to Fecal Occult Blood Testing Over Time: Why CrossSectional Performance Measures May Overestimate Colorectal Cancer Screening Rates Ziad F. Gellad, Karen M. Stechuchak, Deborah A. Fisher, Maren K. Olsen, Jennifer R. McDuffie, Truls Ostbye, William S. Yancy
1034 Variation in Colorectal Cancer Screening Rates Within a Unified Health System Jennifer Weiss, Sally Kraft, Grace Flood, Lauren M. Fiedler, Perry J. Pickhardt, Maureen A. Smith, Patrick Pfau
BACKGROUND: Screening asymptomatic individuals with yearly fecal occult blood tests (FOBT) has been shown to decrease mortality from colorectal cancer (CRC). Adherence over time is necessary to ensure programmatic effectiveness. Thus, cross sectional measures of screening rates, such as HEDIS and the Veterans Affairs (VA) Performance Measure, may overestimate the success of a screening program in the setting of low adherence. METHODS: We conducted a retrospective study of veterans with one or more visits to 136 VA outpatient clinics in the United States in the year 2000. We limited our analysis to veterans age 5075 whose first screening test in the study period was an FOBT. We excluded those with a diagnosis of CRC or who died at anytime during the study period. Using VA administrative data, we assessed the receipt of subsequent screening by FOBT or other recommended CRC screening tests (barium enema [BE], flexible sigmoidoscopy and colonoscopy) over five years of follow-up. We defined “adequate CRC screening” over the 5 year period as receipt of at least four FOBT tests (each separated by at least 8 months) and/or receipt of a single BE, sigmoidoscopy or colonoscopy. We performed multivariable logistic regression analyses to identify predictors of adequate screening, including age, race, marital status, insurance coverage, primary care enrollment, service connection, Charlson comorbidity index, body mass index and geographic region. RESULTS: The sample included 555,281 men and 16,263 women. 40.5% of men and 44.4% of women underwent adequate CRC screening during the study period. Of those with adequate screening, only 24.1% of men and 19.8% of women achieved adequate screening because of repeated FOBT. In fact, in a subgroup of patients (N = 384,527 men and 10,469 women) who received FOBT but no other CRC testing, only 14.1% of men and 13.7% of women completed FOBT in 4 out of 5 years. The likelihood (OR and 95% CI) of adequate screening was lower in the West (OR 0.86, 0.850.87 for men and OR 0.75, 0.69-0.81 for women), Midwest (OR 0.90, 0.89-0.92 for men and OR 0.84, 0.76-0.93 for women) and Northeast (OR 0.92, 0.90-0.93 for men and OR 0.98, 0.88-1.09 for women) as compared to the South. Patients without outside insurance were also less likely to receive adequate screening (0.91, 0.90-0.92 in men and 0.88, 0.820.94 in women). CONCLUSIONS: In patients engaged in an FOBT screening program within the VA, adherence to yearly FOBT is low. Quality measures should consider longitudinal assessment of adherence when calculating colorectal cancer screening rates, particularly if FOBT is a common screening modality.
BACKGROUND: In 2006, 17 health systems across Wisconsin voluntarily reported quality measures in colorectal cancer (CRC) screening, published on-line by the Wisconsin Collaborative for Healthcare Quality. UW Health ranked 11 out of 17. CRC screening rates overall in Wisconsin were above the national average (~40-43%), however there was considerable variability across the state (56.9% to 69.3%). AIM: To examine the variation in CRC screening practices within our institution at both the clinic and the provider levels as a first step in designing targeted interventions to improve CRC screening rates. METHODS: Billing and electronic medical record data from July 2005 to June 2008 were used to identify patients within the UW Health system who were eligible for and had completed CRC screening within the current recommended guidelines. In our system, virtual colonoscopy is covered by all major third party payers and was considered among the available CRC screening modalities. Data collection was limited to age appropriate patients (50-79 yo) who received primary care services within our health system and for whom CRC screening data was available. Overall CRC screening rates of eligible patients were analyzed by clinic as well as number of patients screened by each individual provider. In addition, breakdown of CRC screening modalities ordered per provider were recorded. RESULTS: 37,511 patients were identified as being eligible for CRC screening and receiving primary care within our system. These patients were seen at 19 primary care clinic sites. Average overall CRC screening rates at our institution was 64.9% but ranged by clinic from 42.3% in the lowest performing clinic to 78.7% in the highest performing primary care clinic. CRC screening rates by provider ranged from 38.4% to 86.6%. Within clinics there was also significant variation in screening rates between providers. The largest variation of patients screened within a clinic was 39.3% [39.4-78.7] compared to the smallest spread represented by 1.0% [59.460.4]. Overall pattern of CRC modality choice was optical colonoscopy (82.7%), virtual colonoscopy (8.7%), and FOBT (5.5%). Use of flexible sigmoidoscopy and DCBE as CRC screening methods was negligible. CONCLUSIONS: 1. Significant variation in CRC screening practices exists between different primary care clinics within the same unified health system with major insurance coverage for virtual colonoscopy. 2. Significant variation in CRC screening exists between individual providers within clinics. 3. Targeted interventions to improve CRC screening within a health system need to be directed at both the system and the provider level.
S-151
AGA Abstracts
AGA Abstracts
Cost-Effectiveness of a Mailed Educational Reminder to Increase Colorectal Cancer Screening Jeffrey K. Lee, Erik J. Groessl, Theodore G. Ganiats, Samuel B. Ho