The Implementation Guide is a resource for implementing this evidence-based program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Program Materials page.
Designed to increase colorectal cancer (CRC) screening among adults who are overdue for screening, this intervention implemented by health care providers with electronic health records uses a stepped-intensity approach (i.e., first usual care, then automated care, next assisted care, and last navigated care) consisting of patient education, mailings, brief telephone assistance from medical assistants, and patient navigation by registered nurses. The study showed, for each step up in intensity, a higher percentage of receiving any CRC screening and of being current for screening.
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Colorectal cancer (CRC) is the third most commonly diagnosed cancer among men and women in the United States. The lifetime risk of developing colorectal cancer is about 1 in 21 (4.7%) for men and 1 in 23 (4.4%) for women. Screening rates among adults aged 50-75 remain low, with only 1 in 3 adults in this age group complying with recommended CRC screening. Recommendations for ongoing screening and follow-up are aimed to prevent colorectal cancer and not simply to identify it early for treatment. Several screening tests are available, including flexible sigmoidoscopy (recommended every 5 years), colonoscopy (recommended every 10 years), or high-sensitivity fecal occult blood test (FOBT) or fecal immunochemical test (FIT) (recommended each year). Interventions that increase adherence to colorectal cancer screening are needed. Interventions that reduce structural barriers, provide one-on-one education, leverage electronic health record (EHR) data, and use a stepped-intensity approach for hard-to-reach patients may help increase screening and follow-up rates.
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.
The intervention is guided by two models. The chronic care model aims to improve and integrate six domains of care— evidence-based guidelines for CRC screening and follow-up decision support, information systems, delivery design and processes of care, self-management support and informed decision making, health care policy, and community resources—to address systemic deficiencies in care and improve clinical care for chronic health conditions. The preventive health model aims to increase a patient's intent and action to screen; based on the health belief and theory of reasoned action models, the preventive health model describes moderators (e.g., patient demographics) and mediators (e.g., patient's perceived susceptibility and worry) related to the patient's intent and action toward completion of CRC screening.
SOS begins by identifying patients due or overdue for screening. The four stepped-intensity levels of care are described below:
-- Usual Care. Usual care includes patient handouts and an annual "birthday letter" containing completion dates and due dates for chronic care tests and prevention activities (e.g., immunizations such as influenza shots, screening tests such as CRC screening). In addition, medical assistants or nurses check EHRs for overdue tests prior to each patient's clinic visit. A patient overdue for CRC screening is given an FOBT test kit during his or her visit unless he or she prefers colonoscopy or sigmoidoscopy.
-- Automated Care. In automated care, EHRs are used to identify patients due or overdue for CRC screening and automatically generate patient mailings. These patients receive a letter about the need for CRC screening and an informational pamphlet about the different CRC screening tests. Patients are also informed that FOBT cards will be mailed or that they may call the SOS telephone line if they prefer an alternate screening test (i.e., colonoscopy, sigmoidoscopy). Patients are mailed FOBT kits and a postage-paid return envelope if they do not request a different type of test. If patients do not complete an FOBT after 3 weeks, they receive a reminder letter.
-- Assisted Care. Patients who request an alternate screening test or do not undergo screening within 3 weeks of the FOBT test kit mailing receive assisted care. Medical assistants make up to three attempts to contact each patient by phone to determine the patient's screening intent (e.g., plans to do the FOBT soon, prefers colonoscopy or sigmoidoscopy, does not want to complete screening) and encourage the patient to complete screening. During the brief telephone session, the medical assistant reviews education materials sent to the patient previously to assist him or her in making a choice or completing FOBT testing. If the patient chooses a colonoscopy or sigmoidoscopy, the request is forwarded to his or her primary care physician, and the medical assistant follows up with the patient to discuss the decision and instructions.
-- Navigated Care. Patients who do not undergo screening after receiving assisted care receive navigated care. A registered nurse contacts patients who prefer a colonoscopy or sigmoidoscopy instead of an FOBT, need assistance in making a screening choice, intend to do the FOBT but do not have FOBT results within 3 weeks of talking with the medical assistant, or could not be contacted by the medical assistant during assisted care. The nurse assesses each patient's CRC risk; reviews procedural risk; provides motivational counseling to bolster the patient's intent to undergo screening; creates a screening action plan; assists with referrals, appointments, and preparation for endoscopy; and tracks testing completion. If the nurse is unable to reach the patient, a letter or secure e-mail is sent to the patient to reiterate the importance of CRC screening and provide the nurse's contact information.
Community Preventive Services Task Force Finding
-- Medical assistants receive 2 half-days of training, one 2-hour refresher, and one 30-minute monthly conference call to discuss the intervention
-- Nurse navigators receive 3 half-days of training, a 30-minute conference call every other week, and direct observations of patient communications quarterly
-- Time for a programmer to build an EHR-linked ACCESS database
-- Administrative staff time to prepare and mail letters and materials (approximately 25 minutes for 100 participants)
-- Administrative staff time to monitor the SOS telephone line
-- Approximately 6 hours weekly for medical assistants to deliver the assisted intervention and 4 hours weekly for the registered nurse to deliver the navigated intervention
The intervention targets adults aged 50‒75 years.
The intervention can be used by health care providers with an EHR system.
Required resources to implement the program include the following:
-- SOS Auto Continued (Group 2) Work Flow
-- SOS MA Electronic Medical Records Training
-- SOS MA LPN and RN Work Flow Diagram
-- SOS Assisted (Group 3) Work Flow Diagram
-- SOS Updated MA_LPN Protocol
-- SOS MA LPN and RN Work Flow Diagram
-- SOS Nurse Navigation (Group 4) Work Flow
-- SOS RN Motivational Interviewing Training
-- SOS RN General Overview of Counseling
-- SOS Updated RN Protocol
-- SOS Quality Assurance for Positive FOBT-FIT Completion of Diagnostic Testing and Follow-up
Automated, Assisted, and Navigated Care
-- SOS ICD Codes
-- SOS Preferred Language
-- SOS Updated FIT Instruction Sheet
-- SOS Intervention Letter mailed with FOBT kit
-- SOS Follow-up Letter
-- SOS Updated Screening Options Brochure
For costs associated with this program, please contact the developer, Beverly Green. (See products page on the RTIPs website for developer contact information.)
About the Study
A 2-year randomized trial was conducted with participants aged 50‒73 years recruited from 21 primary care clinics of Group Health Cooperative, a large non-profit health care delivery system in Washington State. The study assessed the effect of three levels of support or usual care alone on CRC screening uptake. Patient EHRs were used to identify patients aged 50‒73 years who were due or overdue for CRC screening (i.e., they had not undergone colonoscopy within 9 years, flexible sigmoidoscopy within 4 years, or FOBT within 9 months). Those with prior colorectal cancer, inflammatory bowel disease, or serious chronic or life-threatening conditions were excluded. Contacted patients who confirmed eligibility and willingness to participate provided verbal consent followed by written consent via a consent statement mailed to them. A computer program generated random allocation sequences to stratify participants by clinic, age group (aged 50‒64 and 65‒73 years), and self-reported previous CRC testing. Participants in the assisted group only received the assisted level of care if they did not receive screening after the automated intervention. Likewise, participants in the navigated group only received the navigated level of care if they did not receive screening after the automated and assisted interventions.
A total of 4,664 patients were included in the analysis as follows: 1,166 in the usual care group, 1,169 in the automated group, 1,159 in the assisted group, and 1,170 in the navigated group. Participants were 54.5% women and 45.5% men. Further, 85.2% were aged 50‒64 and 14.8% were aged 65‒73; 80.1% were White, non-Latino; 5.1% were Asian; 4.9% were African American, non-Latino, 3.3% were Latino; and 6.0% self-identified as "other."
The primary outcomes were (1) completion of any CRC screening (i.e., colonoscopy, flexible sigmoidoscopy, FOBT) in year 1 or 2 of the study and (2) being current for CRC screening in years 1 and 2 of the study. Current for CRC screening was defined as receipt of a colonoscopy or flexible sigmoidoscopy in year 1, FOBT in years 1 and 2, or FOBT in year 1 and flexible sigmoidoscopy or colonoscopy in year 2. Primary outcomes were based on evidence from the EHR or claims data of CRC test completion.
- All intervention groups had a significantly higher percentage of participants receiving at least one screening compared with the usual care group, with significant incremental increases in percentage with each level of the intervention (p<.001 for all comparisons).
- All intervention groups had a significantly higher percentage of participants being current for screening in years 1 and 2 compared with the usual care group, with significant incremental increases in percentage with each level of the intervention (p<.001 for all comparisons except the assisted vs. automated group, p=.001).
Green BB, Wang CY, Anderson ML, Chubak J, Meenan RT, Vernon SW, Fuller S. (2013). An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial. Annals of Internal Medicine, 158 , 301-311.
Green BB, Wang CY, Horner K, Catz S, Meenan RT, Vernon SW, Carrell D, Chubak J, Ko C, Laing S, Bogart A. (2010). Systems of support to increase colorectal cancer screening and follow-up rates (SOS): design, challenges, and baseline characteristics of trial participants. Contemporary Clinical Trials, 31 (6), 589-603.
Green BB, Anderson ML, Chubak J, Fuller S, Meenan RT, Vernon SW. (2016). Impact of continued mailed fecal tests in the patient-centered medical home: Year 3 of the Systems of Support to Increase Colon Cancer Screening and Follow-Up randomized trial. Cancer, 122 (2), 312-321.
Green BB, Anderson ML, Chubak J, Baldwin LM, Tuzzio L, Catz S, Cole A, Vernon SW. (2016). Colorectal Cancer Screening Rates Increased after Exposure to the Patient-Centered Medical Home (PCMH). Journal of the American Board of Family Medicine: JABFM, 29 (2), 191-200.
Meenan RT, Anderson ML, Chubak J, Vernon SW, Fuller S, Wang CY, Green BB. (2015). An economic evaluation of colorectal cancer screening in primary care practice. American Journal of Preventive Medicine, 48 (6), 714-721.
Murphy CC, Vernon SW, Haddock NM, Anderson ML, Chubak J, Green BB. (2014). Longitudinal predictors of colorectal cancer screening among participants in a randomized controlled trial. Preventive Medicine, 66 , 123-130.
Green BB, Anderson ML, Wang CY, Vernon SW, Chubak J, Meenan RT, Fuller S. (2014). Results of nurse navigator follow-up after positive colorectal cancer screening test: a randomized trial. Journal of the American Board of Family Medicine: JABFM, 27 (6), 789-795.
Green BB, Bogart A, Chubak J, Vernon SW, Morales LS, Meenan RT, Laing SS, Fuller S, Ko C, Wang CY. (2012). Nonparticipation in a population-based trial to increase colorectal cancer screening. American Journal of Preventive Medicine, 42 (4), 390-397.