Collaborating across multiple health care institutions in an urban colorectal cancer screening program

Collaborating Across Multiple Health Care Institutions in anUrban Colorectal Cancer Screening Program

Robert Villanueva, MPA1,2; Donna Gugel, MHS1,3; and Diane M. Dwyer, MD1

BACKGROUND: Maryland, excluding Baltimore City, began public health screening for colorectal cancer in 2000. Initiating colorectal

cancer screening in Baltimore City was an objective in the Maryland Comprehensive Cancer Control Plan. The Centers for Disease

Control and Prevention’s (CDC’s) funding announcement for the “Colorectal Cancer Screening Demonstration Program” (CRCSDP)

was seen as a potential opportunity for Maryland to begin screening in Baltimore City. METHODS: The Maryland Department of

Health and Mental Hygiene (DHMH), the American Cancer Society, and five Baltimore City Hospitals collaborated to develop the fund-

ing application and model for the Baltimore City CRCSDP. After receipt of funding, between 2005 and September 2009, screening

sites collaborated with the DHMH to implement the multi-site colorectal cancer screening program in Baltimore City. RESULTS: Close

collaboration across organizational boundaries enabled the funding, formation, and implementation of the CRCSDP in Baltimore City.

The Baltimore City CRCSDP illustrates the complexity of establishing a functional public health screening program. The program over-

came expected and unexpected fiscal, programmatic, and clinical challenges to successfully perform 709 colonoscopies screening

cycles among 696 people and detect three cancers during the 38 months of screening. CONCLUSIONS: Partnerships among the state

and local health department, the American Cancer Society, and hospitals in Baltimore City enabled the implementation of this suc-

cessful program. Lessons learned from the collaborative planning process and the program implementation may facilitate similar col-

laborations in other geographic areas. Cancer 2013;119(15 suppl):2905-13. VC 2013 American Cancer Society.

KEYWORDS: colorectal cancer; screening; health care partnerships; program planning; collaborations; colon cancer screening; lessons

learned.

In 1998, as part of Maryland’s portion of the multistate Master Settlement Agreement with the tobacco industry, theCigarette Restitution Fund (CRF) program was created by the Maryland General Assembly and signed into law by thegovernor.1 The major goals of the program were to reduce cancer mortality and to lessen cancer disparities among ethnicand racial minorities in Maryland. The statute called for each of Maryland’s 24 jurisdictions (23 counties and Baltimorecity) to form Community Health Coalitions and solicit stakeholder input into the direction of the CRF programs at thelocal level. Colorectal cancer was the second-leading cause of cancer death among men and women nationally and inMaryland in 2000.2,3 African Americans in Maryland had an age-adjusted colorectal cancer mortality rate 1.4 times thatof whites (31.1 versus 22.1 per 100,000, respectively).3

With their CRF funding in 2000, 23 of Maryland’s 24 jurisdictions prioritized colorectal cancer, developed educa-tion and/or screening programs for their populations, and focused their enrollment for colorectal screening on underin-sured and uninsured persons.4 In contrast, Baltimore city, in collaboration with its Community Health Coalition,

Corresponding author: Robert Villanueva, University of Maryland, School of Medicine, Baltimore, MD 21201; Fax: (770) 488-3230;

[email protected]

1Center for Cancer Prevention and Control, Maryland Department of Health and Mental Hygiene, Baltimore, Maryland; 2University of Maryland, School of Medi-

cine, Baltimore, Maryland; 3Prevention and Health Promotion Administration, Maryland Department of Health and Mental Hygiene, Baltimore, Maryland

The articles in this supplement were commissioned based on participation in evaluating the Centers for Disease Control and Prevention-funded Colorectal Cancer

Screening Demonstration Program.

The opinions or views expressed in this supplement are those of the authors and do not necessarily reflect the opinions or recommendations of the journal edi-

tors, the American Cancer Society, John Wiley & Sons, Inc., or the Centers for Disease Control and Prevention.

This program would not have been possible without the cooperation and participation of the following individuals from the DHMH CCSC: Barbara Andrews,

Marsha Bienia, Carmela Groves, Annette Hopkins, Kitty Musk, Eileen Steinberger, Vicki Varsalone; the following individuals from the participating hospitals: Mary

Austin, Jennie Boyer, Kira Eyring, Michael Farrier, Nancy Goldstein, Christine Hendrix, Alva Hutchison, Myra James, Jin Lee, Marylu Manning, Eileen Marks, Candace

Shaffer, Eden Stotsky, Toby Tighe, Linda Wieczynski; and the participating colonoscopists: Richard Baum, Sudhir Dutta, Anthony Kalloo, Gopal Kowdley, Robert

Mathieson, Patrick Okolo, Justin Somerville, and Rakesh Vinayek.

This article is dedicated to the memory of Eileen Marks. Her wisdom, compassion, and commitment were instrumental to the success of the program.

DOI: 10.1002/cncr.28153, Received: October 10, 2012; Accepted: October 12, 2012, Published online July 18, 2013 in Wiley Online Library

(wileyonlinelibrary.com)

Cancer August 1, 2013 2905

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selected prostate, oral, breast, and cervical cancer as prior-ity areas for screening and outreach rather than colorectalcancer. As a result, underserved residents of Baltimore citycontinued to lack access to no-cost colorectal cancerscreening services.

In 2003, a “Colorectal Cancer Collaborative” com-mittee of the Baltimore City Community Health Coali-tion was formed under the leadership of a representativeof the American Cancer Society (ACS). The ColorectalCancer Collaborative included representatives from theMaryland Department of Health and Mental Hygiene(DHMH), the Baltimore City Health Department, majorcity hospitals, Johns Hopkins Medical Institutions, andthe University of Maryland, Baltimore. With limitedresources, the Colorectal Cancer Collaborative initiatedcolorectal cancer education and awareness activities inBaltimore city.

At the same time, the Maryland ComprehensiveCancer Control Plan was developed, and members of theColorectal Cancer Collaborative who served on this groupensured that the plan included a specific objective, stating,“Increase funding for colorectal cancer screening amonguninsured, low-income Maryland residents, especially inBaltimore City.”

An opportunity to realize this objective emergedin April 2005, when the Centers for Disease Controland Prevention (CDC) offered a funding opportunitysupporting an organized colorectal cancer screeningprogram. The goal of the program, the ColorectalCancer Screening Demonstration Program (CRCSDP),was to assess the practicality of varied screening deliv-ery models in differing geographic settings, includingcosts of the models.

The objectives of this article are to describe: 1) theplanning and development of a multisite, multiorganiza-tional collaborative screening program in Baltimore,Maryland, an urban setting; and 2) the implementationand operation of the program, including fiscal, organiza-tional, programmatic, and clinical challenges and suc-cesses, as well as screening outcomes.

Program Planning and DevelopmentDeveloping the funding application and theprogram model

In response to the CDC funding announcement, the Mary-land DHMH approached the Baltimore City ColorectalCancer Collaborative. Given mutual interest, the chair ofthe collaborative, a strong “champion” of colorectal cancerscreening from the American Cancer Society, convened aseries of planning meetings that included several Baltimore

city hospitals, local nonprofits, academic medical institu-tions, and other groups all interested in the initiative.

Several decision points were addressed during theinitial stakeholders’ meeting, including those related tofiscal leadership, colorectal cancer screening test selection,level of organizational centralization, and screening sitelocations.

1. Identifying the primary applicant for the funding.

The primary applicant would have ultimate responsibilityfor the project—serving as the fiscal agent for the grant,coordinating the screening program, and communicatingand reporting to the CDC. Potential agencies to fulfillthis role included the DHMH, the Baltimore City HealthDepartment, an academic medical center, a hospital, anda nonprofit agency. Factors affecting the choice of theapplicant organization included costs and requirements ofthe funding announcements and related agency capacity.

The fiscal implications of identifying an academicmedical center as the grant recipient were considered,including the amount of the award funds that would becommitted to indirect costs (up to 60% of the award).DHHM staff contacted nonprofit groups and thought thatthe Maryland chapter of 1 large, national nonprofit wouldbe the perfect applicant; however, the fiscal, clinical, anddata reporting requirements of the award were an obstacleto that agency’s ability to serve as the primary applicant.

The stakeholders’ group determined collaborativelythat the DHMH would be the strategic and appropriategrant recipient given the DHMH’s experience with CDCgrant applications and management.

2. Colorectal cancer screening test selection. In select-ing a primary screening test to be used for the program,the collaborative gave primacy to screening the largestnumber of people in the most efficient manner. In makingthis decision, the collaborative first sought guidance fromthe larger, Maryland CRF colorectal cancer screening pro-gram, which had been conducting colorectal cancerscreening using various screening tests for almost 5 years.For the CRF program, colonoscopy was preferred becauseit provided screening, diagnosis, and primary preventionthrough polypectomy; there was sufficient capacity forcolonoscopy; and a resultant screening interval of 10 yearsfor average-risk clients simplified patient support servicessuch as case management. Moreover, CRF programs inMaryland that first selected fecal occult blood tests(FOBTs) with sigmoidoscopy switched to colonoscopyduring the initial 3 years because of the above reasons.4,5

A second factor influencing test selection was the

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2906 Cancer August 1, 2013

influence of hospital gastroenterologists involved in theplanning who recommended colonoscopy. Consequently,the collaborative chose colonoscopy as the primary screen-ing test for the program while also allowing individualscreening sites to use FOBTs (either guaiac-based or im-munochemical) with or without flexible sigmoidoscopyfor asymptomatic average-risk patients who refusedcolonoscopy.

3. Level of organizational centralization. Two potentialscreening models, one decentralized and the other central-ized, were considered.

In the decentralized model, the primary applicant(DHMH) would serve as the fiscal agent and would havea central coordinator who would oversee the program andbe the liaison with the CDC. The fiscal agent would thencontract with screening sites and distribute grant funds foreach site to perform the colonoscopies and case manage-ment activities including contracting with endoscopists,facilities, and laboratories for services; recruiting patients;determining patient eligibility; navigating/managingpatients through screening and beyond; paying providers;and entering data.

In the centralized model, the primary applicant(DHMH) would serve as the fiscal agent, hire central staffto coordinate all program activities, and perform thescreening case management activities of contracting withproviders, recruitment, and case management of screen-

ing, and the screening sites would only perform endos-copy under contract to the DHMH.

The members of the collaborative selected a decen-tralized model (Fig. 1) based on both administrative issuesand problems of mission conflict with a centralizedmodel. Specifically, a decentralized model was selectedgiven the following: 1) the difficulty of the DHMHrecruiting and quickly hiring nursing staff for case man-agement, 2) the difficulty of the DHMH establishing con-tracts with providers for clinical services, 3) the fact that itwas not the mission of the DHMH to be a primary casemanager, and 4) the desire of the screening sites to havetheir own staff recruit and manage their patients andinteract with their providers.

4. Identifying screening sites. Criteria for screening siteselection included the ability to accept a grant from theDHMH, hire staff, establish contracts for clinical services,and accomplish all the clinical and technical requirementsset forth by the CDC CRCSDP and the DHMH. SeveralBaltimore city hospitals and academic medical centersexpressed interest. High indirect costs precluded 1 aca-demic medical center from participating.

Five sites were selected for participation: HarborHospital and Union Memorial Hospital (both of MedStarHealth), Johns Hopkins Medical Institutions, St. AgnesHospital, and Sinai Hospital. To prepare the budget pro-posal for the CDC application, each site was given a

Figure 1. Model of Baltimore City Screening Demonstration Program.

Colorectal Cancer Program Collaborations/Villanueva et al


preliminary dollar figure and asked to develop a budgetthat would support staff and fund as many colonoscopiesas possible.

The chair of the collaborative asked each site to deter-mine its cost for colonoscopy. This created a sense of friendlycompetition among the sites to reduce staffing and clinicalcosts and to make them roughly comparable by changingsome items (eg, fringe benefits, pathology laboratory costs,precolonoscopy physical exams) into in-kind donations tothe program. The DHMH prepared its budget, whichincluded the costs for a program coordinator and for somecentral office operations. The DHMH contributed its exist-ing CRF program client database so that screening sitescould directly enter client data required by the CDC.

After collecting final budgets from each of the sites,the DHMH submitted its application to the CDC, whichcontained 90% of funding for the sites and 10% for theDHMH.

In June 2005, the CDC notified the DHMH thatBaltimore city was selected as 1 of 5 sites in the countryfor the 3-year grant award that would begin on September1, 2005. However, based on available funding at CDC,the funds awarded were less than what the DHMH hadrequested in their proposal.

Given the actual funding award, adjustments in pro-gram design and staffing were required. Leveraging otherprogram funds, the DHMH identified 1 of its federallyfunded coordinators for the Maryland ComprehensiveCancer Control Plan as a half-time coordinator for theCRCSDP. The DHMH also provided in-kind staff forprogram and grant management, database design andimplementation, clinical input, quality assurance, anddata collection of screening costs. These contributions onthe part of the DHMH allowed for the majority ofCRCSDP funds to support direct screening services andstaff at the clinical sites.

The Baltimore City CRCSDP began operations onSeptember 1, 2005, with 5 screening sites projected toperform 260 colonoscopies each year.

Collecting and analyzing data

The CDC proposed and modified the required clinicaldata elements that were to be reported to the CDC fromeach site.6 In Maryland, the DHMH modified its existingclient database to add the additional CDC-required varia-bles, to obtain a data extract, and to recode data to meetthe CDC requirements. Each hospital screening siteentered data on patients screened through the CDCSDPinto the database, a centralized, SQL, intranet-based cli-ent database housed at the DHMH and accessed through

a virtual private network. The number of patientsscreened and their clinical outcomes were available to theDHMH through direct views of the input data, databasereports, and downloaded data.

Program Implementation and OperationContracting with sites and providers

The 5 screening sites (Fig. 2) were located throughoutBaltimore city. In the decentralized model, the DHMHwas spared the responsibilities of hiring, contracting withcolonoscopy providers, and direct patient management;however, the DHMH had to establish contracts with eachof the 5 screening sites (in a process that took up to 5months) and then to monitor the contracts. To receivefunding, each screening site had to agree to the program-matic, billing and data reporting requirements and toagree to give the DHMH a copy of every clinical invoicereceived for each client screened so that the DHMH couldmeet the CDC requirement for cost assessment data.

Each screening site then had to establish contractswith its providers who would perform colonoscopies, anes-thesiology, and pathology testing within the facilities wherecolonoscopies would be performed. In these clinical con-tracts, providers had to agree to follow guidelines developedfor the program by the CDC and by the DHMH Mary-land Colorectal Cancer Medical Advisory Committee. TheMedical Advisory Committee for the CDCSDP was com-posed of gastroenterologists, surgeons, a medical oncolo-gist, and a pathologist who were on the existing statewidecommittee, to which was added an endoscopist from eachBaltimore city screening site. The committee reviewed andapproved the Baltimore city program policies and proce-dures and clinical eligibility. Each hospital screening sitethen had to establish policies and procedures that reflectedits own staffing and operations within these guidelines.

Identifying and enrolling eligible clients

The ACS offered to have their 1-800-ACS-2345 cancerhotline number advertised as a central number for clientintake and eligibility determination for the 5 sites. Mary-land houses the ACS South Atlantic Division’s fullystaffed cancer information “call center,” located 10 milesnorth of Baltimore city. The call center is staffed by cancerinformation specialists who answer calls, E-mails, andother inquiries from cancer patients, families of cancerpatients, or those seeking information on cancer topics.The service is free to all who call.

Normally when individuals contact the call center,their names are entered into a central database used forfundraising. Because of privacy and other concerns, the

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DHMH had to ensure that clients who called the call cen-ter and were interested in the CRCSDP would have theiridentifying information kept separately and not be soli-cited for ACS donations in the future. The ACS workedwith the DHMH to establish an internal logging system

to keep these callers out of the ACS database. The log alsoallowed the DHMH to track call data. DHMH stafftrained call center staff about SDP eligibility by residence,age, income, and insurance. Call center staff did not deter-mine risk factors, prior screening, or clinical eligibility,

Figure 2. Map of Baltimore city (shown in blue) and locations of the 5 hospitals participating in the Colorectal Cancer ScreeningDemonstration Program.



which was done by the screening sites. Call center staffknew which of the screening sites were currently enrollingnew clients, asked the potential clients which available sitethey preferred, and faxed intake information to the sitethat the client selected.

Potential clients also came from existing programsthat had established patient populations:

� Two of the sites were screening sites for the CDC-funded breast and cervical cancer screening programthat served women of the same income and insuranceeligibility.� One site managed the prostate cancer screening program

for the Cigarette Restitution Fund in Baltimore city.� Other sites partnered with Federally Qualified Health

Centers with whom they were affiliated.

Nursing staff hired as case managers at each site (0.5full-time equivalents at each site) completed standardforms to determine eligibility by obtaining family andpersonal risk history, symptoms, and prior colorectal can-cer screening history to assure that these met programrequirements for eligibility.

Establishing procedures and communicating withand monitoring sites

The DHMH provided template materials for each site foreducation and outreach, policies and procedures, guide-lines, result letters, data collection forms, and trainingmaterials that had been modified from the CRF colorectalcancer screening program.7 Training was held to familiar-ize the staff with colorectal cancer, the client database andhow fields should be completed, billing and the require-ment to reimburse at Medicare rates for colonoscopy andpathology, and the fiscal requirements of the grant withthe DHMH. DHMH staff reviewed the final 5 “site man-uals” and made them available to CDC staff before anysite was approved to begin screening. Screening beganwithin 9 months of the CDC award, 3 months longerthan initially anticipated.

DHMH staff performed site visits to each screeningsite after the first few colonoscopies were completed andperiodically thereafter. The DHMH provided feedbackon case management, data entry, and billing accuracy andcompleteness. Monthly teleconferences were held amongstaff of the DHMH and the 5 sites to review progress andto communicate new information or answer questions.Data quality review was ongoing and proceeded as fol-lows: sites entered data and DHMH staff compared textwith coded data to assure accuracy and completeness; the

DHMH received data submission feedback reports on theclinical data elements submitted quarterly to IMS, Inc.,the data contractor retained by CDC to help manage theflow of clinical data; and the DHMH worked with sitestaff to correct problems identified such as missingrequired information, duplicates, errors in coding of find-ings, and recall recommendations that deviated from theCRCSDP-required national standards.

Managing fiscal, programmatic, and clinicalchallenges

Over the course of the development and implementationof the Baltimore City CRCSDP, several challengesemerged with the screening model. None of these provedinsurmountable, but they did cause DHMH, the screen-ing sites, and partners to adapt to the challenges of thestart-up of a new program.

Because of initial budget constraints and fear thatinterest in the program would overwhelm the resour-ces, the Baltimore CRCSDP reduced originallyplanned outreach and education activities. Having lim-ited funding allocated for outreach and educationactivities meant that clinical case managers assumedthese responsibilities, including recruitment of individ-uals to colorectal cancer screening.

The ACS provided its literature, which included itscentralized call center number, and the CDC provided in-kind Screen for Life materials. Except for the part-time co-ordinator funded under the CDC Comprehensive CancerPlan grant, DHMH staff for central program manage-ment was in-kind.

Recognizing and managing intersite differences

Rather than 1 program with 5 screening sites, the Balti-more city CRCSDP functioned as 5 separate minipro-grams, which the DHMH treated as individual entitiesand managed for CDC reporting. This posed challengesfor program implementation such as differing contractapproval processes by each hospital, differing contract-ing methods between hospitals and their providers, andvarying methods to track invoices and bill the DHMH.The DHMH considered the demonstration project pub-lic health implementation and not research and did notseek institutional review board (IRB) approval; however,we required that the hospital staff present the programto their respective institutional review boards (IRBs).Four hospital IRBs decided that the program was notresearch and exempted the program, whereas 1 hospitalIRB required that all participants sign an additional

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consent form for participation in the program beforescreening.

Meeting CDC program requirements

During the program start-up and early implementation,evolving policy and requirements required flexibility andresulted in some unexpected costs.

The CDC finalized the required Colorectal CancerData Elements 3 months into implementation, and theDHMH modified its existing DHMH database there-after. The delay in Office of Management and Budgetclearance for sites to submit line-listed patient data (with-out identifiers) to the CDC led the CRCSDP to require asupplemental aggregate data report to monitor site screen-ing activities in the interim. This monthly report requiredadditional effort and continued for 2 years into the SDP.

Other adjustments were made based on CRCSDPreimbursement policies. Some hospital sites absorbed thecost for standard precolonoscopy tests that were not reim-bursable through the program. Individuals presentingwith colorectal symptoms were not eligible for CRCSDPscreening. Maryland was initially interested in acceptingclients into screening who had minor gastrointestinalsymptoms, but the CRCSDP required a provider to cer-tify that the symptoms were not suggestive of colorectalcancer and did not reimburse for this provider visit.

During the program start-up and early implementa-tion, the Baltimore City CRCSDP adapted to changes inCDC program requirements.

Covering the cost of colonoscopy in Maryland

Hospital rates in Maryland are regulated by the Health-care Services Cost Review Commission (HSCRC),8 andrates change frequently. All payers, including Medicareand the Baltimore City CRCSDP, must pay the rates thatthe HSCRC sets. For the CRCSDP, this includedHSCRC rates for colonoscopy facility fees, which werehigher than the Medicare rates published for nonregulatedfacilities. This unavoidable cost meant that for theamount of funding awarded, fewer clients could bescreened than might have been expected if paying pub-lished Medicare rates for Maryland.

Billing DHMH for reimbursement

Three of the 5 sites had not worked under the provisionsof a DHMH contract before and were not familiar withthe level of reporting required under this CDC award.When sites invoiced the DHMH for costs associated withthe program, some sites submitted invoices with an inac-

curate or disallowed billing procedure code charge, requir-ing the DHMH to reject payment.

To address this, DHMH staff reiterated that wecould only reimburse for specified procedures listed in theprogram manual. If a site or 1 of its providers wished toperform procedures not on the list, the site needed priorapproval from the DHMH, which then had to seek ap-proval from the CDC. Also, the DHMH visited the sitesto meet with clinical and hospital billing staff to reviewbilling procedures and approvals.

Using the CDC Cost Assessment Tool

Obtaining and reporting cost data were burdensome. TheCDC required completion of a cost assessment tool thatsummarized the costs at the site for personnel, administra-tive costs, and in-kind contributions.9 In addition, theCDC required reporting of line-listed billing data forevery invoice on each client. To comply, the DHMH col-lected each invoice from the screening sites and enteredthem into a database. Screening sites found that copyingand submitting to the DHMH each bill on hundreds ofclients was burdensome, yet they recognized that omittingbills would lead to underestimates of cost.10 The DHMHassumed the responsibility of entering each invoice into adatabase, a complex task that was undertaken in-kind.

Collecting clinical data and adhering to guidelines

The DHMH reviewed the quality of the data that wereentered by the screening sites into the central databaseaccording to its usual procedures that assure accuracyand completeness of the fields. The DHMH performedsite visits to the 5 screening sites to assure that the clinicaland billing procedures and records met program stand-ards of accuracy, completeness, and clinical acceptability.In addition, the CDC contractor, IMS, Inc., providedquality assurance feedback on the screening data that theDHMH submitted quarterly. These feedback reportsenabled the DHMH to review data entry and furtherassure the quality and consistency of the data by nationalstandards. The DHMH and its sites turned to the colo-noscopists and pathologists to assure that the colono-scopy and pathology reports had all the required dataand that the screening and surveillance recall intervalsagreed with the CRCSDP requirements. One majorchallenge for the program was to code in the database theadequacy of bowel preparation. Often the preparationwas reported as “excellent,” “good,” or “fair,” rather than“adequate to identify lesions �5 mm” or “inadequate,”as recommended.11 This raised several questions. Whatshould the recall interval be on an average-risk client



with no findings on colonoscopy in which a section ofthe colon was not “adequately” prepared? What did thecolonoscopist mean by “fair prep”? Should an average-risk patient with a “fair prep” and no findings return im-mediately to have a repeat colonoscopy, or wait 5 years?If the colonoscopist said “fair prep” with a 5-year recallinterval, should the prep be entered in the database as“inadequate”? These provider descriptions of bowelpreparation and recall recommendations were not cov-ered by existing national guidelines.

Monitoring outcomes of screening

Table 1 shows the screenings performed in the BaltimoreCity SDP by hospitals with the outcomes of screening. Atotal of 696 people received 1 or more screenings in theBaltimore City SDP. Of these, 597 (86%) were of minor-ity race or ethnicity, and 190 (27%) were men. Success inreaching minority clients was because of the recruitmentfrom existing cancer screening programs that serve mostlyminorities, the patient populations seen at these hospitals,and the outreach and education efforts to communities inBaltimore city, which has a predominantly minoritypopulation.

There were a total of 709 colonoscopy cycles with744 colonoscopies performed. Of these, 139 colonoscopiesdetected 1 or more adenomas (19%), and 2 found adeno-mas with high-grade dysplasia. As a result of screening, can-cer was detected in 3 people, 1 with adenocarcinoma and 2with rectal carcinoid tumors. Unplanned events during orfollowing colonoscopy included 5 colonoscopies with post-polypectomy bleeding (1 requiring emergency room visitwith repeat colonoscopy), 3 cardiopulmonary events (2with arrhythmia, 1 with hypertension), 3 drug-related reac-tions, and 12 gastrointestinal complaints.

Per CDC program policy and guidelines, paymentfor cancer treatment was not covered by the CDC SDP.12

The stage III adenocarcinoma was treated by the hospital

as charity care. The 2 carcinoids did not require treatmentbeyond colonoscopy, which was covered in the program.Costs of the Baltimore SDP are summarized in otherarticles in this monograph.9,10

Conclusions

Through its participation in the CRCSDP, Baltimore cityachieved unprecedented collaboration across multiplecompeting health care systems throughout the city. Thelessons learned through this demonstration helped posi-tion Maryland to successfully compete for future federalcolorectal cancer funds.

The CRCSDP award brought additional funds tothe Maryland DHMH, and this provided an opportunityto contract with 5 Baltimore city hospitals for colorectalcancer screening services, case management, and dataentry in the city. The hospitals used template contracts,case management procedures, a screening database, andquality assurance procedures modified from the existingstatewide CRF colorectal cancer screening program toprovide infrastructure to manage and implement theCRCSDP at the local level.

There were fiscal, programmatic, and organizationalchallenges that the Baltimore city program encounteredand surmounted, and overall the CRCSDP was an unqua-lified success. Clinically, from 2005 to 2009, theCRCSDP provided access to screening to individuals whowould not have had access without this program, namely,the program performed 744 colonoscopies, detected 3cancers, and found and removed adenomas in 139individuals.

From a collaborative partnership perspective, staffsof 5 hospital sites that had previously not interacted witheach other on a regular basis formed a cohesive screeningprogram across Baltimore city. The sites demonstratedtheir commitment to the partnership and their belief inthe public health mission in Baltimore city through thiscollaboration. The successes of the Maryland CRCSDP

TABLE 1. Colonoscopy Screenings Performed in the Baltimore City Screening Demonstration Program byHospital and Outcome

ScreeningHospital

PeopleScreened

Minority Raceor Ethnicity (%) Men (%)

Number ofColonoscopy Cyclesa

Adenoma DetectionRate

Hospital 1 105 80% 16% 108 29%

Hospital 2 119 83% 18% 121 15%

Hospital 3 123 84% 28% 125 31%

Hospital 4 172 85% 41% 176 11%

Hospital 5 177 93% 26% 179 13%

Total 696 86% 27% 709 19%

a Seven hundred nine colonoscopy “cycles” in which 744 colonoscopies were performed (eg, repeat colonoscopy because of inadequate bowel preparation or

not reaching the cecum).

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and the ongoing CRF colorectal screening program led toMaryland’s successful new funding under the federalColorectal Cancer Control Program in 2009.

FUNDING SOURCESThe Colorectal Cancer Screening Demonstration Program eval-uated in this supplement was funded by the Centers for DiseaseControl and Prevention Funding Opportunity Number: RFAAA030. This study was also supported by the Centers for DiseaseControl and Prevention CDC) Colorectal Cancer ScreeningDemonstration Program Cooperative Agreement U55/DP325046, CDC National Comprehensive Cancer Control Pro-gram Cooperative Agreement U58DP000827, the State of Mary-land, and the Maryland Cigarette Restitution Fund.

CONFLICT OF INTEREST DISCLOSURESThe authors made no disclosures.

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