A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics

Emily M. Mader, MPH, MPP; Chester H. Fox, MD; John W. Epling, MD, MSEd; Gary J. Noronha, MD; Carlos M. Swanger, MD; Angela M. Wisniewski, PharmD; Karen Vitale, MSEd; Amanda L. Norton, MSW; Christopher P. Morley, PhD

Disclosures

J Am Board Fam Med. 2016;29(5):533-542. 

In This Article

Abstract and Introduction

Abstract

Background: Despite the current evidence of preventive screening effectiveness, rates of breast, cervical, and colorectal cancer in the United States fall below national targets. We evaluated the efficacy and feasibility of combining practice facilitation and academic detailing quality improvement (QI) strategies to help primary care practices increase breast, cervical, and colorectal cancer screening among patients.

Methods: Practices received a 1-hour academic detailing session addressing current cancer screening guidelines and best practices, followed by 6 months of practice facilitation to implement evidence-based interventions aimed at increasing patient screening. One-way repeated measures analysis of variance compared screening rates before and after the intervention, provider surveys, and TRANSLATE model scores. Qualitative data were gathered via participant focus groups and interviews.

Results: Twenty-three practices enrolled in the project: 4 federally qualified health centers, 10 practices affiliated with larger health systems, 4 physician-owned practices, 4 university hospital clinics, and 1 nonprofit clinic. Average screening rates for breast cancer increased by 13% (P = .001), and rates for colorectal cancer increased by 5.6% (P = .001). Practices implemented a mix of electronic health record data cleaning workflows, provider audits and feedback, reminder systems streamlining, and patient education and outreach interventions. Practice facilitators assisted practices in tailoring interventions to practice-specific priorities and constraints and in connecting with community resources. Practices with resource constraints benefited from the engagement of all levels of staff in the quality improvement processes and from team-based adaptations to office workflows and policies. Many practices aligned quality improvement interventions in this project with patient-centered medical home and other regulatory reporting targets.

Conclusions: Combining practice facilitation and academic detailing is 1 method through which primary care practices can achieve systems-level changes to better manage patient population health.

Introduction

Screening for breast, cervical, and colorectal cancers can detect disease at an early stage, when it is most amenable to treatment, effectively reducing mortality and morbidity.[1] The colorectal cancer (CRC) screening methods of high-sensitivity stool tests, flexible sigmoidoscopy, and colonoscopy; breast cancer screening through mammography; and cervical cancer screening through Papanicolaou tests have been identified by the US Preventive Services Task Force (USPSTF) as effective preventive measures for the early identification of CRC, breast cancer, and cervical cancer.[2] However, rates of screening for these cancers remain below the national Healthy People 2020 targets in the United States.[3] In addition, large segments of the population (including the uninsured, rural residents, Hispanics/Latinos, African Americans, Native Americans, and those with low education levels and low socioeconomic status) have been shown to be significantly less likely to receive appropriate cancer screening and will likely experience a higher burden of cancer because of suboptimal screening.[4–9]

A variety of factors present challenges to the effective provision of cancer screening in primary care, including numerous guideline recommendations, patient reluctance or refusal, and resource constraints.[10–13] Primary care practices can benefit from interventions and techniques to address barriers to the effective provision of population health maintenance services, including cancer screening. One potential intervention to achieve this goal is the use of practice facilitation and academic detailing.

Practice facilitation involves the work of trained quality improvement (QI) professionals who assist primary care practices in research and QI activities.[14–16] Assistance includes data collection, feedback on provider and practice performance, and the facilitation of systems-level changes to improve practice processes. Academic detailing is modeled based on the communication approach of pharmaceutical industry detailers and involves trained experts visiting health care professionals in their own setting to provide tailored education on specific health topics and evidence-based guidance on best practices.[17–19] The goal of combined practice facilitation and academic detailing is to help primary care practices align their work with evidence-based best practices to improve patient care and outcomes.[14,20]

The purpose of the project detailed in this article was to evaluate the efficacy and feasibility of combining practice facilitation and academic detailing to help primary care practices increase patient breast cancer, cervical cancer, and CRC screening in 3 regional practice-based research networks (PBRNs) in Central and Western New York: the Studying-Acting-Learning-Teaching Network (Syracuse, NY), the Upstate New York PBRN (Buffalo, NY), and the Greater Rochester PBRN (Rochester, NY). This evaluation investigated the impact of this grant-funded intervention on cancer screening rates, as well as how components of the intervention were implemented across varying practice structures.

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