Best Practices Detail

A Community-Based Model for Promoting Long-Term Utilization of Screening Sigmoidoscopy By Primary Care Providers.

Date: 10/25/2002
Category: Screening
Source: Paul C. Schroy III, M.D., M.P.H., Boston Medical Center, E201

Background:
The aims of the project was to (1) assess the impact of “academic detailing” in the form of an outreach educational seminar combined with implementation of on-site sigmoidoscopy services performed by university-based gastroenterologists on provider utilization of screening sigmoidoscopy (SS); (2) determine whether the sustained presence of outside, university-based gastroenterologists performing on-site (SS) maintains long-term utilization; and (3) whether the provision for on-site SS services was an effective venue for training interested PCPs to perform flexible sigmoidoscopy. Nine urban (Boston) community health centers participated in a controlled trial that began in 1996. Four centers were selected as intervention sites (54 PCPs) and 5 as control sites (28 PCPs). The two groups were balanced with respect to annual adult patient visits, patient and provider demographics, and on-site resources. Primary care providers (PCPs) practicing at one of the participating health centers were the target population.

Methods: A quasi-randomized controlled clinical trial was conducted to evaluate the impact of a community-based model for promoting provider utilization of screening sigmoidoscopy. The model was designed as a four-phase program projected over a 36 month time period. Phase I included a pre-education baseline survey of provider attitudes and practice patterns and a didactic seminar on the current status of colorectal cancer screening. Phase II (12 months) included the academic detailing and implementation of on-site flexible sigmoidoscopy services performed by university-based gastroenterologists. Phase III (12-24 months) included procedural training for one to six interested providers per site. Phase IV culminated with the inception of a self-standing screening sigmoidoscopy program staffed exclusively by PCPs.

Four centers were selected as intervention sites (54 PCPs) and 5 as control sites (28 PCPs). Control sites received only the didactic seminars. The two groups were balanced with respect to annual adult patient visits, patient and provider demographics, and on-site resources.

Results/Conclusions:
Primary outcomes included PCP utilization of SS and number of PCPs trained on-site who continued to perform SS independently; secondary outcomes included number of patients referred for SS and factors influencing participation in the on-site flexible sigmoidoscopy training program (intervention sites only). Data collection methods included surveys at baseline, Year 1 and Year 3, and quarterly review of SS referrals using appointment logs.

Overall self-reported utilization of SS increased by 61% (baseline, 24%; Year 1, 60%; Year 3, 85%) for the intervention group versus only 25% (baseline, 19%; Year 1, 26%; Year 3, 44%) for the comparison group (p= .001). There was substantial agreement between self-reported compliance and documented referrals (k=.66). The total number of SS referrals increased from 134 in Year 1 to 264 in Year 2 to a near-maximum capacity of 344 in Year 3, but remained low (< 50 per annum) for control sites. On-site SS services were not an effective venue for training PCPs to perform flexible sigmoidoscopy. Only 2 providers (2.4%) completed on-site training and continued to perform SS independently. Lack of interest, time constraints, concerns about technical proficiency, and lack of need due to on-site availability were cited as major reasons for nonparticipation.

Conclusions: (1) “Academic detailing” in the form of an outreach educational seminar combined with implementation of on-site sigmoidoscopy services is an effective strategy for enhancing provider utilization of screening sigmoidoscopy; and (2) maintenance of on-site screening sigmoidoscopy services performed by an outside gastroenterologist promotes long-term utilization but fails as venue for training primary care endoscopists.

Future studies are needed to assess the cost-effectiveness of our<