We successfully implemented the SATIS-PHI/CRC intervention, mostly as intended although not in all respects. The intervention was adopted by our targeted set of primary care providers and practices and it reached our targeted patient population. Overall, although the rate of CRC screening was lower than expected, the intervention increased the likelihood of those exposed to it being screened relative to unexposed control patients' odds of being screened. The effectiveness of the intervention persisted even after adjusting the control group denominator to compensate for having less information about true eligibility of controls and even after statistically controlling for a set of patient and practice characteristics.
Due to a small number of positive stool tests requiring CDE followup, we could not determine in detail the effectiveness of SATIS-PHI/CRC in improving followup rates or behaviors. Our comparison of preintervention and postintervention surveys of participating practices indicated that the academic detailing portion of SATIS-PHI/CRC was only moderately successful in decreasing behaviors and beliefs inconsistent with current CRC screening guidelines.
Lessons Learned
A key lesson learned from our experience with SATIS-PHI/CRC is that it is important for a central entity undertaking this intervention to understand its system's capacity for implementation. This understanding is needed so that the central entity can design the details of the intervention and possibly adapt it to its specific system or setting. For example, the ability of health systems to conduct a population-based electronic record review will likely vary widely. Knowing this ahead of time, and knowing its system's capabilities, will allow the central entity to design the intervention accordingly, including adding additional personnel and time for more manual reviews as needed.
Some elements of SATIS-PHI/CRC can be time and resource intensive (e.g., conducting the patient mailings, academic detailing, or chart audits), especially if the central entity is not organized and resourced to support these elements. The central entity should be aware of the time and resources required and be prepared to provide or have access to them.
Patients are more likely to screen by stool test if sent a test kit directly in the mail rather than having to request a kit through a mail-in card. Request cards may be needed due to budget limitations, as they were for our intervention. Still, we recommend approaching multiple stool test kit suppliers early to try to procure a supplier willing to provide a sufficient number of kits to support the intervention. Alternatively, the central entity may want to consider financially supporting the procurement of sufficient test kits.
The academic detailing sessions should be designed to address the prevailing knowledge base, awareness, and behavior of the local clinicians and practices. If possible, academic detailers who conduct a preintervention focus group session should listen to practice members' comments and try to add extra emphasis where needed in the detailing. Detailers should also try to gather information about prevailing conditions before finalizing the content of the detailing sessions.
It is important to make sure that the participating practices understand what is involved in SATIS-PHI/CRC participation and what is required of them. Maintaining communication with the practices is important. It is also important to have two primary points of contact at each practice, a clinician and an office manager. The clinician can be the "clinical champion" in the practice, and the office manager can facilitate and coordinate the logistical requirements.
Transferability to Other Systems/Settings
Based on our assessment findings and our lessons learned, we believe that the SATIS-PHI/CRC can be a transferable intervention that can improve CRC screening and followup. It is most transferable to health care settings with a central entity that:
- Is motivated to take the lead in organizing and implementing the effort.
- Has easy access to up-to-date and reasonably complete electronic records.
- Understands and accepts the time and resource commitment needed to undertake the intervention.
- Has experience with large, targeted, population-based mailings to patients (either by conducting such mailings themselves or outsourcing them to reliable contractors)
- Has strong relationships with its affiliated primary care practices.
Environmental conditions most supportive of successful implementation include having a sufficient number of willing colonoscopy providers in the medical service areas participating in the intervention to accommodate any increased demand for colonoscopies resulting from the intervention. It is also key to avoid having other competing population-based initiatives occurring in the service area or at the participating practices that could detract from the support and attention needed to implement the SATIS-PHI/CRC intervention.
Our experience with SATIS-PHI/CRC also demonstrates that this intervention can be successfully implemented in a wide range of practices. These include practices that are more closely and less closely affiliated with the central entity and those that have and do not have fully functional EMR systems. However, the central entity would need to have access to sufficient other electronic records (especially claims or other evidence of medical services provided to patents) for practices without fully functional EMR systems. Successful implementation would also be enhanced if participating practices have a dedication to population-based preventive health in general and strong leadership supportive of, and a clinical champion for, the SATIS-PHI/CRC intervention effort in particular.
