Becker's Hospital Review

32 Executive Briefing Sponsored by: A ccording to the American Cancer Society 1 , colorectal cancer is the second leading cause of cancer-related deaths in the United States. In 2020, approximately 53,200 Americans are expected to die from colorectal cancer. The good news is that several colorectal cancer (CRC) screening options exist, and early detection can translate into better patient outcomes 2 . Despite the existence of effective screening options, colorectal cancer has the dubious distinction of being the easiest to prevent yet least prevented form of cancer. When colorectal cancer is detected early at stage I or II, the 5-year survival rate for patients is 90 percent, according to the American Cancer Society 3 . Still, screening numbers remain well below current public health goals, and most colorectal cancer isn't identified until it has progressed 4 to the later stages of the disease. Becker's Hospital Review recently spoke with Jay Zdunek, DO, CMO at Austin (Texas) Regional Clinic, Robert Tracy, MD, medical director of quality at Kentucky-based St. Elizabeth Physicians, and Allison Church, manager of quality transformation at St. Elizabeth Physicians, about strategies for improving CRC screening rates. They discussed how shared decision-making, in combination with a portfolio of different CRC screening options, is helping more patients complete this very important preventive testing. Implementation of shared decision-making approaches to CRC screening may impact stagnant screening rates. Shared decision- making offers patients a voice in their own care journeys and is a key component of patient-centered care. For CRC screening, providers can offer patients multiple screening options, which could increase the likelihood of a patient being screened by 23 percent, according to the National Colorectal Cancer Council Roundtable 5 . Choice ignites change Today's patients have more access to information about their health and healthcare providers than ever before, meaning many patients are eager to have more sophisticated healthcare interactions. Rather than relying solely on what providers tell them to do, many patients want to have a conversation about options. "We all are more likely to buy into decisions when we have a stake in how they are made," Dr. Zdunek said. "It's no different in healthcare. The patient needs to be engaged in decisions. That's paramount for higher levels of cooperation and commitment." Education about colorectal cancer is an essential part of the shared decision-making process. Some patients are reluctant to participate in screening because they fear that tests will identify a problem. "We educate people about the progression of colorectal cancer which begins with pre-malignant polyps," Dr. Tracy said. "By finding these polyps during screening, we can prevent patients from undergoing a lot of additional testing, surgery and possibly chemotherapy. Once people understand how screening works, it helps reduce the resistance." The ability to offer different options for CRC screening is another component of share decision making. Austin Regional Clinic, for example, offers traditional colonoscopies, fecal occult blood (FOBT) tests and multi-target stool DNA (MT-sDNA) tests. St. Elizabeth Physicians has also expanded its CRC testing alternatives to include colonoscopies, MT-sDNA and FIT tests. "There's no single approach to CRC testing that will work for all patients," Dr. Zdunek said. "At the end of the day, it's about finding which alternative will work best for the individual and enable them to feel comfortable completing the process." The time commitment required for a colonoscopy is another barrier to getting tested, since it means taking time off work and some people have concerns about the bowl preparation process. "The discussions and shared decision-making about MT-sDNA and FIT are what have helped move our needles with regard to CRC screening," Dr. Tracy said. "Some folks who have said they would never do a colonoscopy are willing to be screened using a different method." Dr. Zdunek added, "It used to be a bigger fight when the only options were flexible sigmoidoscopy and colonoscopy. Overall, we've seen much improved acceptance for CRC screening due to the advent of DNA testing." Beyond meeting patient desires for more choice, offering multiple options for CRC screening may translate into more screenings, and more screenings means better outcomes. In a study of nearly 1,000 patients published in the Archives of Internal Medicines 6 , participants whose providers exclusively recommended colonoscopy completed screening at a rate of 38 percent. The participants that were given a choice between FOBT and colonoscopy completed CRC screening at a rate of 69 percent. Adherence in FOBT-only arm was no different than in choice arm. Randomized study of adults aged 50-79 at average risk of CRC conducted in a single-site safety-net health care system. Without organizational commitment, CRC screening rates won't improve To address gaps in CRC screening, organizational focus is essential. Individual physicians can't singlehandedly increase CRC screening rates. If health system leaders and administrators don't support this goal, it's unlikely to be successful. Improving the rates of cancer screening across populations requires leadership and widespread individual ownership among clinicians. Austin Regional Clinic is using a top-down approach to achieve improvements in its CRC screening rates. According to Dr. Zdunek, "We have a commitment that flows through our medical home, IT department, scheduling department, primary care offices and the GI and surgery departments. Across the board, multiple levels of the organization are working together to increase the ease of The best colorectal cancer screening test is the one patients complete — How shared decision-making is improving colorectal cancer screening rates

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