Michael Potter, MD, is a professor in the Department of Family and Community Medicine at the University of California, San Francisco. He is a graduate of Harvard Medical School and the family medicine residency program at San Francisco General Hospital. For the past 20 years, he has divided his time evenly between patient care, teaching, and research. Dr. Potter is Director of the San Francisco Bay Area Collaborative Research Network, which is UCSF's primary health care practice based research network. In this role, he works within UCSF's Clinical and Translational Sciences Institute to promote and lead collaboration between UCSF researchers and community health providers on research projects that can improve primary care systems and clinical outcomes. He is also active within the National Colorectal Cancer Roundtable, having completed 4 years of service on the NCCRT steering committee, and he is currently co-chair of the NCCRT's Professional Education and Practice Committee. Dr. Potter is the developer of the Flu-FIT Program, which is a primary care intervention that focuses on increasing access to colorectal cancer screening by offering annual stool tests to eligible patients during annual flu shot campaigns. The development and dissemination of the Flu-FIT Program has been supported with grants from the American Cancer Society, Centers for Disease Control and Prevention, the HMO Cancer Research Network, and others. The Flu-FIT Program has been featured on the AHRQ, Research to Reality and RTIPS websites, actively promoted by the ACS and many state cancer programs, and has been implemented in many different iterations across the United States. Dr. Potter received the 2013 Annual Prevention Laurel awarded jointly by the Prevent Cancer Foundation, the National Colorectal Cancer Roundtable, and the American College of Obstetricians and Gynecologists. He was a member of NCI's TIDRH faculty in the summer of 2012 and presented his work in the fall of 2013 at NCI-sponsored conferences in Buenos Aires and Paris.
Questions & Answers
Our original idea was the Flu-FOBT and Flu-FIT Programs would be ideal for community health centers that rely on home stool testing for colorectal cancer screening and that had lower than desired colorectal cancer screening rates. Many of these clinics organize teams each year to do flu shot clinics, and it seemed natural to add the offering of FOBT or FIT to eligible patients as part of these activities.
In our initial American Cancer Society (ACS) funded study, we found that nurse-run “flu shot clinics” were an excellent venue to offer colorectal cancer screening, too. In a subsequent CDC-funded study, we learned that Flu-FOBT and Flu-FIT activities can be adapted for primary care in community health centers, as well. For example, nurses can be given standing orders to offer flu shots and colorectal cancer screening to eligible patients during routine primary care visits each fall.
Coupling the activities provides the message that getting colorectal cancer screening is as important as getting a flu shot, and that stool tests must be done every year. In a subsequent ACS study we adapted the Flu-FIT Program for mass vaccination clinics at a large HMO (Kaiser Permanente), and showed that it can work there, too. Finally, we did a pilot study of the program in commercial pharmacies that provide annual flu shots, and we found that many customers are interested in learning about and gaining access to colorectal cancer screening through their pharmacists.
At present, working in pharmacies is more challenging, however, because pharmacies often lack the space to offer preventive counseling, because it is difficult to assess eligibility for colorectal cancer screening without access to electronic health records, and because pharmacies may lack the ability to connect patients to primary care for follow up of abnormal test results. In addition, it may be difficult for pharmacies to capture reimbursement for providing FOBT or FIT in pharmacies. That said, pharmacies within integrated healthcare systems may turn out to be ideal locations for Flu-FOBT Programs (e.g. at Kaiser), since many of these barriers do not exist in these settings.
I have been asked if I thought a Flu-FIT programs could work in community health settings, such as a flu shot clinics run at community health fairs, in churches, or in rural areas for migrant health workers. My response is that these can be excellent settings for education about colorectal cancer screening, but they are problematic for providing screening unless follow up of abnormal tests with colonoscopy can be assured. There is no benefit to screening without being able to assure appropriate follow up with treatment, if needed.
Hopefully many of these barriers will ultimately be overcome with health reform.
In my experience, Flu-FOBT and Flu-FIT Programs are most likely to be successful in environments where there are strong leaders with strong incentives to increase colorectal cancer screening rates, where a high value is placed on teamwork that brings medical assistants and nursing staff to bear on preventive health, where electronic health records can provide accurate information about eligibility for colorectal cancer screening, and where follow-up of abnormal tests with colonoscopy can be assured. As more and more health settings are developing these characteristics, I am optimistic that Flu-FOBT and Flu-FIT Programs will become feasible in an increasingly large number of settings. Practical considerations that can make the implementation process easier are to start with a stool test that is easy to explain, and easy for patients to complete. Nowadays, that almost always means using FIT (fecal immunochemical test) instead of traditional guaiac FOBT. FIT requires no dietary medication changes, and typically has a higher return rate than guaiac FOBT. Just like planning a flu shot clinic, preparations should usually begin in the summer, and time needs to be allotted to advertise the program, review and select patient education materials, and for staff training and supervision. Follow-up phone calls are an effective way to remind patients to complete tests that are dispensed, and attention needs to be given to review test results and navigate appropriate patients to colonoscopy. Much of this detail can be found on the http://flufit.org website
Flu-FOBT and Flu-FIT Programs are only one of several ways to address colorectal cancer screening, and that is as it should be. Before initiating a Flu-FOBT or Flu-FIT Program, practitioners and healthcare organization leaders should evaluate their baseline screening rates and assess other activities they are already doing to support colorectal cancer screening. If there are no resources to follow-up on abnormal screening (i.e. either to contact patients or to get them colonoscopy), then the program should not be attempted. In environments with little experience with teamwork or with offering colorectal cancer screening, one should not expect immediate success – but the yield of the program can be high over time, both because the program itself can work, and because the process of implementing the program serves to educate clinic staff and patients about the importance of colorectal cancer screening. In environments where screening rates are already high, Flu-FIT Programs may not lead to tremendous absolute increases in screening rates, but they can help reinforce institutional messages about the importance of screening and they can reach a significant number of patients that have not responded to other forms of colorectal cancer screening outreach. Just as trial and error over several seasons may be needed to establish effective systems to implement annual flu shot campaigns, the same sustained effort over several seasons may be important to establish a successful Flu-FOBT or Flu-FIT Program. And finally, Flu-FOBT and Flu-FIT Programs can inspire other innovations, such as year-round activities to support colorectal cancer screening that did not previously exist, or expansion of Flu-FOBT and Flu-FIT Programs to include other preventive services, such as mammograms or referrals for other preventive services. Therefore short term outcomes like reach and changes in clinic wide screening rates may not be as important initially as outcomes like staff knowledge and competence in offering testing, and whether the systems implemented are sustainable for future flu shot season. The approach to program evaluation will vary greatly based on the baseline levels of screening, resources for implementation, and goals of the program in the context of other programs or healthcare activities. But to answer the question more briefly, we do have interview guides based on the RE-AIM Framework that we used in our evaluation work at the San Francisco Department of Public Health primary care clinics and at Kaiser Permanente’s flu shot clinics. These are available on request.
I direct a practice-based research network, called the San Francisco Bay Area Collaborative Research Network. Our mission is to promote the collaboration of academic researchers and community-based health care leaders to develop, implement, evaluate, and disseminate interventions that can improve primary health care outcomes. In my own research, I continue to work on Flu-FOBT and Flu-FIT dissemination, but I am also involved a variety of other research projects relating to relatively simple and scalable practice changes that can make a difference in primary care.