Feldman Joshua, Davie Sam, Kiran Tara
St. Michael's Hospital, Canada.
BMJ Qual Improv Rep. 2017 Apr 27;6(1). doi: 10.1136/bmjquality.u213991.w5531. eCollection 2017.
Our Family Health Team is located in Toronto, Canada and provides care to over 35 000 patients. Like many practices in Canada, we took an opportunistic approach to cervical, breast, and colorectal cancer screening. We wanted to shift to a proactive, population-based approach but were unable to systematically identify patients overdue for screening or calculate baseline screening rates. Our initiative had two goals: (1) to develop a method for systematically identifying patients eligible for screening and whether they were overdue and (2) to increase screening rates for cervical, breast, and colorectal cancer. Using external government data in combination with our practice's electronic medical record, we developed a process to identify patients eligible and overdue for cancer screening. After generating baseline data, we implemented an evidence-based, multifaceted intervention to improve cancer screening rates. We sent a personalized reminder letter to overdue patients, provided physicians with practice-level audit and feedback, and improved our electronic reminder function by updating charts with accurate data on the Fecal Occult Blood Test (FOBT). Following our initial intervention, we sought to maintain and further improve our screening rates by experimenting with alternative recall methods and collecting patient feedback. Screening rates significantly improved for all three cancers. Between March 2014 and December 2016, the cervical cancer screening rate increased from 60% to 71% (p<0.05), the breast cancer screening rate increased from 56% to 65% (p<0.05), and the overall colorectal screening rate increased from 59% to 70% (p<0.05). The increase in colorectal screening rates was largely due to an increase in FOBT screening from 18% to 25%, while colonoscopy screening remained relatively unchanged, shifting from 45% to 46%. We also found that patients living in low income neighbourhoods were less likely to be screened. Following our intervention, this equity gap narrowed modestly for breast and colorectal cancer but did not change for cervical cancer screening. Our future improvement efforts will be focused on reducing the gap in screening between patients living in low-income and high-income neighbourhoods while maintaining overall gains.
我们的家庭健康团队位于加拿大多伦多，为超过35000名患者提供护理服务。和加拿大的许多医疗机构一样，我们对宫颈癌、乳腺癌和结直肠癌筛查采取了机会主义的方法。我们希望转向一种积极主动、基于人群的方法，但无法系统地识别逾期未筛查的患者或计算基线筛查率。我们的举措有两个目标：（1）开发一种系统识别符合筛查条件的患者及其是否逾期的方法；（2）提高宫颈癌、乳腺癌和结直肠癌的筛查率。我们将外部政府数据与本医疗机构的电子病历相结合，开发了一个识别符合癌症筛查条件和逾期未筛查患者的流程。在生成基线数据后，我们实施了一项基于证据的多方面干预措施，以提高癌症筛查率。我们给逾期未筛查的患者发送了个性化提醒信，向医生提供机构层面的审核和反馈，并通过在图表中更新粪便潜血试验（FOBT）的准确数据来改进我们的电子提醒功能。在我们最初的干预之后，我们试图通过试验替代召回方法并收集患者反馈来维持并进一步提高我们的筛查率。所有三种癌症的筛查率都有显著提高。在2014年3月至2016年12月期间，宫颈癌筛查率从60%提高到71%（p<0.05），乳腺癌筛查率从56%提高到65%（p<0.05），总体结直肠癌筛查率从59%提高到70%（p<0.05）。结直肠癌筛查率的提高主要是由于FOBT筛查从18%增加到25%，而结肠镜检查筛查相对保持不变，从45%变为46%。我们还发现，居住在低收入社区的患者接受筛查的可能性较小。在我们的干预之后，乳腺癌和结直肠癌筛查方面的这种公平差距略有缩小，但宫颈癌筛查方面没有变化。我们未来的改进工作将集中在缩小低收入和高收入社区患者之间的筛查差距，同时保持总体成果。
