Measuring and improving cervical, breast, and colorectal cancer screening rates in a multi-site urban practice in Toronto, Canada

Abstract

Our Family Health Team is located in Toronto, Canada and provides care to over 35 000 patients. Like many practices in Canada, we took an opportunistic approach to cervical, breast, and colorectal cancer screening. We wanted to shift to a proactive, population-based approach but were unable to systematically identify patients overdue for screening or calculate baseline screening rates. Our initiative had two goals: (1) to develop a method for systematically identifying patients eligible for screening and whether they were overdue and (2) to increase screening rates for cervical, breast, and colorectal cancer. Using external government data in combination with our practice's electronic medical record, we developed a process to identify patients eligible and overdue for cancer screening. After generating baseline data, we implemented an evidence-based, multifaceted intervention to improve cancer screening rates. We sent a personalized reminder letter to overdue patients, provided physicians with practice-level audit and feedback, and improved our electronic reminder function by updating charts with accurate data on the Fecal Occult Blood Test (FOBT). Following our initial intervention, we sought to maintain and further improve our screening rates by experimenting with alternative recall methods and collecting patient feedback. Screening rates significantly improved for all three cancers. Between March 2014 and December 2016, the cervical cancer screening rate increased from 60% to 71% (p<0.05), the breast cancer screening rate increased from 56% to 65% (p<0.05), and the overall colorectal screening rate increased from 59% to 70% (p<0.05). The increase in colorectal screening rates was largely due to an increase in FOBT screening from 18% to 25%, while colonoscopy screening remained relatively unchanged, shifting from 45% to 46%. We also found that patients living in low income neighbourhoods were less likely to be screened. Following our intervention, this equity gap narrowed modestly for breast and colorectal cancer but did not change for cervical cancer screening. Our future improvement efforts will be focused on reducing the gap in screening between patients living in low-income and high-income neighbourhoods while maintaining overall gains.

Mailed Letter Versus Phone Call to Increase Uptake of Cancer Screening: A Pragmatic, Randomized Trial

“…We identified potentially eligible patients as of March 31, 2015 using data from a provincial registry and our practice EMR as described previously. 12,15 Eligibility determination was consistent with provincial guidelines. 16 Women aged 21 to 69 years and 50 to 74 years were eligible for cervical and breast cancer screening, respectively.…”

“…Our practice has previously noted that patients living with a low income 15 or in a low-income neighborhood 12 were less likely to be up-to-date on screening. We hope to reduce this disparity.…”

“…Early efforts focused on accurately identifying patients who were overdue for screening and in the summer of 2014, testing a multifaceted intervention that included personalized mailed reminder letters, physician audit and feedback, and enhanced point-of-care reminders in the electronic medical record (EMR). 12 The intervention was launched in the context of an existing population-based screening program organized by Ontario's provincial cancer agency. 13 Six months following our intervention, screening rates increased for all 3 cancer types.…”

“…We based our sample size calculations on estimates of effectiveness from previous studies 8 and our own previous work. 12 We estimated 903 patients in each arm to detect a 5-point difference (15% vs 20%) between the 2 interventions, with a 5% type I error and 80% power. We included all trial-eligible patients from our practice in the study and estimated this would provide a sufficient sample to stratify patients by sex.…”

“…The trial was pragmatic and built on existing quality improvement efforts in our practice that have resulted in a sustained improvement in overall screening rates. 12 Our interventions integrated outreach for all 3 cancer screening tests recommended for the general primary care population. We performed an equity analysis and also examined the effect of the intervention separately on FOBT and colonoscopy uptake.…”