Colorectal cancer (CRC) is the third most common cancer among men and women in the U.S. and ranks second among cancer death causes. Over 2,000 cases are diagnosed in VA patients each year. Recent studies have demonstrated that CRC screening is effective in the prevention and early detection of CRC. Despite the strength of the evidence, less than one-third of CRCs are found at an early stage. Nationwide only about 20% of the U.S. population over the age of 50 years has had a fecal occult blood test (FOBT) each year and only about one-third of men and one-quarter of women have had a sigmoidoscopy or proctoscopy in the past 5 years. In VHA, the Office of Quality and Performance (OQP) has reported a national average of 32% of patients over age 52 with three or more visits in a given year failing to receive timely CRC screening, while VISN-level screening failure rates range from 22% to 44% (CRC-QUERI Strategic Plan, 2002). To date, VA policy makers and health care managers lack needed information about the determinants of these variations in CRC screening across the VA health care system.
OBJECTIVES: The purpose of this study was to conduct secondary analyses of existing data to elucidate the environmental, organizational, practice and patient level predictors of colorectal cancer (CRC) screening performance among VA medical centers nationwide.
Simple frequencies and histograms of the variability in CRC screening in VA settings were analyzed and presented for overall variation assessments. The outcome variables of interest included overall screening penetration rates (any screening modality). We then conducted multivariate analyses to examine the organizational characteristics independently associated with CRC screening rates in VA practices. We used simple linear regression, using different approaches to address the distributional characteristics of CRC screening rates, and hierarchical linear regression, assessing the contribution of organizational factors adjusting for the patient-level characteristics and potential clustering of patients within practices.
CRC screening rates were stable for FY01 and FY02 with screening rates of 62.6% and 61.0% respectively. Significant geographic variations in CRC screening exist, with the South/East regions performing significantly lower than other regions. CRC screening does not vary, however, by the location of the facility in a metropolitan vs. non-metropolitan area. Facility size is a strong predictor of CRC screening (i.e., smaller facilities perform better than larger facilities), while facilities with an academic affiliation are significantly less likely to perform CRC screening, even after adjusting for the size of the facility. The degree of primary care leader practice autonomy was significantly and positively associated with the delivery of CRC screening, even after adjusting for size and academic affiliation. The level of primary care resource sufficiency was also a significant independent predictor of CRC screening, even after adjusting for facility size and academic affiliation. Provider mix was significantly and positively associated with delivery of CRC screening. Primary care practice-level characteristics accounted for a much higher percentage of the variance than patient-level characteristics.
Among patient characteristics, female gender and lower income were significantly associated with a lower likelihood of screening whereas older age was significantly and positively associated with a higher likelihood of screening. Patient characteristics (i.e., age, race, gender, frequency of primary care visits) were not predictive of receipt of a follow-up exam after a positive fecal occult blood test.
VA health policymakers and health care managers lack needed information about the determinants of variations in CRC screening across the VA healthcare system to design evidence-based quality improvements. This study represents the first empirical demonstration of the contribution of discrete primary care practice organizational features on prevention performance in VA settings, pointing to mutable attributes that ought to be considered in intervention design.
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- Soban L, Yano EM, Parkerton PH, Lanto AB. The Impact of Primary Care Resources on Colorectal Cancer Screening. Paper presented at: VA QUERI National Meeting; 2003 Dec 10; Washington, DC.
Cancer, Quality assurance, improvement, Screening