Case Study | Quality Improvement

Dell Medical School: A low-cost approach to increasing colorectal cancer screening in vulnerable patients

Case Study | Quality Improvement

Dell Medical School: A low-cost approach to increasing colorectal cancer screening in vulnerable patients

  • Dell Medical School at The University of Texas at Austin partnered with a community health center network on a colorectal cancer screening initiative that, in 18 months, more than doubled the percentage of patients being screened.
  • The potential savings from cancer prevention and improved outcomes is substantial.
  • This low-cost model of improving preventive care is easily scalable to serve a larger geographic area or a bigger patient population. 

Until recently, fewer than one-third of underserved residents in Travis County, Texas, home to Dell Med, received routine screening for colorectal cancer. Meanwhile, uninsured patients with symptoms or increased risk for colon cancer faced long waiting lists to receive colonoscopies.

Michael Pignone, MD

That’s why we at Dell Med partnered with CommUnityCare (CUC), a federally qualified health center network that serves nearly 100,000 patients in Travis County, on a colorectal cancer screening initiative.

In late 2017, just 18.4% of CUC’s eligible patients — individuals ages 50 to 75 with average risk of colorectal cancer — were up-to-date on colorectal screening. Our goal was to close this gap in cancer prevention. After two years the screening rate has increased to 40%.

Our relatively low-cost program involves mailing test kits to patients’ homes and reaches people who have not previously had access to screening. One of the most exciting things about the program is that it can be scaled up to a larger geographic area or a bigger patient population. For that reason, it is a particularly promising type of intervention for people who are not easily reached through conventional care.

How the program works

We developed and implemented the program with support from the Cancer Prevention Research Institute of Texas. The at-home test kit includes a fecal immunochemical test (FIT), a validated alternative to a screening colonoscopy. 

Patients provide a stool sample and return it to us by mail. Patients who test positive are connected with a bilingual patient navigator, who helps them schedule a colonoscopy. Those whose FIT is negative repeat the test the following year.

In the two years since its inception, the program has mailed over 28,000 tests. More than 5,560 patients have completed the tests, with 202 undergoing follow-up colonoscopies.

Clinical evidence indicates a substantial ROI

Like most population health initiatives, this one requires an upfront investment and ongoing efforts to increase screenings. Also, the return may not be realized for several years. But if you trust the evidence showing that FIT-based screening leads to a reduction in cancer cases and deaths, the ROI of this program is significant.

Each packet costs about $5, which includes all the assembly and mailing expenses. For each person who returns a kit, conducting the test and returning the results costs about $20. Meanwhile, every cancer that is prevented will save at least $25,000 — and sometimes $100,000 or more, depending on the stage at the time of diagnosis. More importantly, this type of intervention saves lives.

For health systems, this program also is a low-cost way to meet the screening-rate thresholds needed to earn quality bonuses in value-based contracts. In a health system that serves a typical insured population, about 60% to 70% of patients probably are receiving appropriate colorectal cancer screenings. This program is likely to boost that number by 5 to 10 percentage points.

Tips for implementing the program

Mailed test kits get used only if the recipient opens the envelope. Based on our past work, we knew the mailing needed to come from a trusted party. We’ve embedded this initiative within the CUC system to ensure the mailings come from patients’ primary care providers.

The materials are co-branded as CommUnityCare and Dell Med, and the mailing includes a letter from the CUC medical director explaining the importance of the screening test.

Other tips from our experience:

Materials need to be easy to read. We made sure that instructions in both English and Spanish were written at a basic reading level. The letter explains that, according to our records, the patient may be due for a screening test. If we are wrong, the patient is asked to return a postcard (included in the packet) to let us know he or she already has been screened.

For those who need the screening, we explain how to send in the test, how we report the results back to patients and their physicians and how we help with follow-up if necessary. Access to a patient navigator allows patients to ask questions if they are unsure how to take the FIT.

The program requires infrastructure. Implementation takes several steps for each patient, so a team needs to be assigned to send out packets, send out reminders, track positive screens so that those patients can be connected with a navigator to schedule and attend their colonoscopy screening, and conduct any other needed follow-up. As part of this initiative, we built a colonoscopy registry to ensure we know when a patient’s subsequent colonoscopy is due.

Make it sustainable. The FIT screening method requires an annual test, so the program needs to be designed as an ongoing service.

Overall, our experience with this program shows that innovative outreach approaches can increase the use of preventive services, support value-based care initiatives and, most importantly, save lives.

About the Author

Michael Pignone, MD, MPH,

is chair of the Department of Internal Medicine and director of cancer prevention and control for the LIVESTRONG Cancer Institutes, Dell Medical School at The University of Texas, Austin (pignone@austin.utexas.edu).

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