Smart Options for Screening (SOS) is an intervention designed to encourage adherence to CRC screening recommendations. Implemented by health care providers with electronic health records (EHRs), the intervention uses a stepped-intensity approach consisting of various components—including patient education, mailings, brief telephone assistance by medical assistants, and patient navigation by registered nurses—for patients who are due or overdue for CRC screening. SOS allows patients to receive up to four levels of care: usual care, automated care, assisted care, and navigated care. Patients receive the least intensive level first and are moved up to a more intensive level at scheduled times if they do not undergo screening.
We used some specific evaluation tools that would be appropriate for practitioners when they evaluate this program. We used codes to distinguish mailed kits from those handed out in clinic. We also tracked completion rates of fecal testing by patient characteristics so we could identify groups of individuals who were less likely to respond to the intervention. Tracking HEDIS colon cancer screening scores over time is an easy way to see if the program makes a difference on overall CRC screening rates.
Adaptations could be tested as part of a “Plan, Do, See, Act” (PDSA) cycle. For example, you could test a change to the FIT instructions (such as highlighting the area where patients put in the completion date, which is important because blood in the stool deteriorates over time) and determine the percent of individuals entering a date before and after the PDSA activity.
We are conducting the following additional studies:
- SOS was awarded a continuation (5RO1CA121125, Green) to study long-term adherence to CRC screening. Participants in the active intervention groups in years 1 and 2 of the study were randomized, with some continuing to receive ongoing mailed interventions and others returning to usual care (at our organization all primary care clinics are patient centered medical homes). We will test whether exposure to the SOS centralized CRC screening program (i.e., a centralized program with mailed FITs and nurse navigation for those still not completing screening) leads to better long-term adherence to screening (up to 10 years) than clinic-based care. We will also look at long-term health outcomes and the cost-effectiveness of the program.
- STOP CRC in Priority Populations (5UH3CA188640, Coronado, Green) is an NIH Common Fund Collaboratory pragmatic cluster randomized trial that is being conducted in 26 safety-net clinics in California, Oregon, and Washington. It is testing whether an electronic-health record-embedded registry with linked mailings of FIT kits increases CRC screening uptake and decreases screening disparities. Mailed interventions are similar to those used in the SOS study but tailored for patients who receive care in safety-net clinics and materials are in Spanish and English.
- BeneFITs for Increasing CRC Screening in Priority Populations (CDC SIP 14-012, Co-PIs Baldwin, Coronado, and Green). For this implementation study we are working with two Medicaid health insurance plans, Care Oregon in Oregon and Molina in Washington State, to implement a mailed FIT program.
I appreciate that many R2R community members are working to increase colorectal cancer screening rates and I would welcome your perspectives on using EHRs and your evaluation approaches.
And, of course, I hope you will learn more about SOS on RTIPs.