Determining the Proper FIT: Strategies to Improve the Delivery of Fecal Immunochemical Tests among...
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Determining the Proper FIT: Strategies to Improve the Delivery of Fecal Immunochemical Tests among Southwest American Indian Populations, 2014, New Mexico
Determining the Proper FIT: Strategies to Improve the Delivery
of Fecal Immunochemical Tests among Southwest American Indian
Populations, 2014, New Mexico Jasmine Jacobs, MPH Prevention
Specialist Office for State, Tribal, Local and Territorial Support
Centers for Disease Control and Prevention PHAP/PHPS Summer
Training June 2, 2015 Centers for Disease Control and Prevention
Office for State, Tribal, Local and Territorial Support
Slide 2
BACKGROUND Colorectal cancer & how it affects American
Indians and Alaska Natives
Slide 3
Polyps in the colon may develop into colorectal cancer if not
removed. Colorectal Health Education Flip Chart, Albuquerque Area
Southwest Tribal Epidemiology Center
Slide 4
Routine Screening for Colorectal Cancer (U.S. Preventive
Services Task Force and CDC) Criteria Asymptomatic Ages 50-75 years
Average-risk Tests Colonoscopy every 10 years (many health
professionals consider it the GOLD STANDARD) Sigmoidoscopy every 5
years + fecal occult blood test every 3 years Fecal occult blood
test (FOBT) every year Guaiac-based fecal occult blood test (gFOBT)
Fecal immunochemical test (FIT) Recommendation Summary. U.S.
Preventive Services Task Force. October 2008.
http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/colorectal-cancer-screening
Slide 5
If colonoscopies are so effective, why doesnt everyone just get
them?
Slide 6
Comparison of Colorectal Cancer Screening Tests
ColonoscopygFOBTFIT Cost $2,000~ $5-7 No. of SamplesN/A31-3
Clinician Requirements Specially-trained mid- to high-level
providers Primary care providers and technicians Preparation Heavy
laxatives 1 gallon of water Clear liquid or low- residue diet Avoid
vitamin C, red meat, broccoli, turnips, oranges, mushrooms, apples,
iodine, boric acid, Aspirin, Ibuprofen None Procedure Conscious
sedation Invasive procedure May require missed work/school May
require travel Must have companion None
Slide 7
Colorectal Cancer Issues for American Indian & Alaska
Native Populations Low colorectal cancer screening rates among
AI/AN populations (Government Performance and Results Act, 2014)
Government Performance and Results Act, 2014
http://www.ihs.gov/crs/documents/gpra/2015/2014EndofYearDashboard.pdfhttp://www.ihs.gov/crs/documents/gpra/2015/2014EndofYearDashboard.pdf
Perdue DG, Haverkamp D, Perkins C, Daley CM, Provost E. Geographic
variation in colorectal cancer incidence and mortality, age of
onset, and stage at diagnosis among American Indian and Alaska
Native people, 1990-2009. Am J Public Health,. 2014 Jun;104 Suppl
3:S404-14. Colorectal cancer second leading cause of cancer death
among American Indians/Alaska Natives (AI/ANs)
Slide 8
Disparities in Colorectal Cancer Incidence and Death Rates
Perdue DG, Haverkamp D, Perkins C, Daley CM, Provost E. Geographic
variation in colorectal cancer incidence and mortality, age of
onset, and stage at diagnosis among American Indian and Alaska
Native people, 1990-2009. Am J Public Health,. 2014 Jun;104 Suppl
3:S404-14. * = Statistically significant (P < 0.05) Rates per
100,000 persons
Slide 9
METHODS An attempt to improve colorectal cancer screening
rates
Slide 10
Methods Randomized controlled trial Setting 3 Indian Health
Service or tribally-operated health facilities in New Mexico
Participants Ages 50-75 Not up-to-date with CRC screening No
history of CRC or total colectomy Study groups Group 1: Usual care
Group 2: Mail-out Group 3: Mail-out + Community Health
Representative (CHR) outreach
Slide 11
Slide 12
Why Community Health Representatives? Trusted and familiar
faces in community Liaisons between community members and health
clinics Vast majority members of same tribe they work with Already
interact with many community members
Slide 13
RESULTS Which delivery mechanism worked best?
Slide 14
Distribution of Participants, by Facility GroupFacility
1Facility 2Facility 3TOTAL Usual Care25795214566 (43.9%)
Mail-out13395133361 (28.0%) Mail-out + CHR13395133361 (28.0%)
TOTAL523 (40.6%)285 (22.1%)480 (37.3%)1288
Slide 15
Group Distribution of FIT Kits, by Return Outcome
GroupYESNOTOTAL Usual Care36 (6.4%)530 (93.6%)566 (43.9%)
Mail-out*61 (16.9%)300 (83.1%)361 (28.0%) Mail-out + CHR 68
(18.8%)293 (81.2%)361 (28.0%) TOTAL165 (12.8%)1123 (87.2%)1288
*Significant difference compared to usual care (P < 0.01)
Significant difference compared to usual care (P < 0.01), but no
significant difference compared to Mail-out (P=0.44)
Slide 16
DISCUSSION What can we take away from this study?
Slide 17
Limitations CHRs could not carry out all intended outreach due
to staff turnover, competing priorities, etc. We cannot determine
if significant differences between the mail-out group and mail-out
+ CHR outreach group would have resulted, had CHRs performed all
outreach Results should not be generalized to all American Indian
populations
Slide 18
Take-Away Messages Directly mailing FIT kits to individuals
eligible for CRC screening increases completion and access to CRC
screening. If used widely, this strategy could increase the
percentage of AI/ANs who are up-to-date with CRC screening,
potentially affecting CRC morbidity and mortality.
Slide 19
Acknowledgements Community health representatives, laboratory
directors, and all others who contributed to the project from the 3
participating tribes Kevin English, DrPH Director, Albuquerque Area
Southwest Tribal Epidemiology Center (Principal Investigator)
Amanda Tjemsland PHAP Class of 2013 Donald Haverkamp, MPH
Epidemiologist, CDC Division of Cancer Prevention and Control (PHPS
Alumnus) David Espey, MD Medical Officer for Tribal Affairs, CDC
National Center for Chronic Disease Prevention and Health Promotion
*This project was realized with funding from the Centers for
Disease Control and Prevention, in cooperation with the National
Indian Health Service Division of Epidemiology and Disease
Prevention.
Slide 20
For more information, please contact CDCs Office for State,
Tribal, Local and Territorial Support 4770 Buford Highway NE,
Mailstop E-70, Atlanta, GA 30341 Telephone: 1-800-CDC-INFO
(232-4636)/TTY: 1-888-232-6348 E-mail: [email protected]:
http://www.cdc.gov/[email protected]://www.cdc.gov/stltpublichealth
The findings and conclusions in this presentation are those of the
authors and do not necessarily represent the official position of
the Centers for Disease Control and Prevention. Jasmine
Jacobs-Wingo [email protected] 505-232-9908 Centers for Disease
Control and Prevention Office for State, Tribal, Local and
Territorial Support
Slide 21
Video: Procedures to complete an iFOBT (e.g., Polymedco OC
Light) Albuquerque Area Southwest Tribal Epidemiology Center