It is my honor to introduce Dr. Jason Dominitz. He serves as the inaugural Executive Director of the Veterans Health Administration's National Gastroenterology and Hepatology Program since 2011. He also directs the VA's National Colorectal Cancer Screening Program. He is a former ASGE Governing Board Counselor and current member of the U.S. Multi-Society Task Force on Colorectal Cancer. Jason co-chairs a 16-year VA cooperative study comparing screening with annual fit to colonoscopy in over 50,000 veterans. He received his medical degree from the University of Maryland and is currently a professor at the University of Washington. Thank you. I'm one of the members of the planning committee, so I want to add my thanks to everyone who came out here today to share their knowledge and comments with this group. So I'm going to be moderating this session. It gives me great pleasure to introduce Dr. Jim Hotz. He's the co-chair of the Georgia Colorectal Cancer Roundtable. He's a member of the Community Health Center Strategic Priority Team of the National Colorectal Cancer Roundtable and a co-chair of the Steering Committee of the Georgia State Cancer Plan. He helped found a community health center system in southwest Georgia that operates 30 clinical sites, which provide primary care for more than 50,000 patients. He's received many awards. He's a member of the American Cancer Society's Mission and Outcome and Health Equities Committees and he's the medical director of a CDC-supported Georgia colorectal cancer control program. Dr. Hotz has a medical degree from Ohio State. Welcome. Just one correction. That's the Ohio State. But it's good to be here and, you know, let's start talking about equity, okay? That's been my career, 5 million visits, 80% of my patients fall below poverty level. They're rural poor. And I spend most of my time trying to – I was on an IOM committee looking at the integration of public health and primary care, and what you realize, you have to have a system to make integration happen. So I was assigned the job of cancer. I said, well, let's look at colorectal, and actually said things like roundtables and states, really what's necessary. You have to build an infrastructure. In a country that doesn't have a system, you basically got to build it, got to build one for lung cancer and these other ones. So I spend a lot of my time, you know, kissing people's butts to get them to work with our patients, and who better to kiss butts to but a bunch of gastroenterologists who know that butt world really well. What I'm trying to do is give you – rapidly go through some slides about, you know, how do I sell it? What are the wow factors that really get attention? How do we add sizzle to, you know, selling this? So the first thing I do is to say, 93, you know, we know it works, 40 percent death rate just doing fecal guaiacs. Sidney Widenour showed that you remove polyps, people don't die of colon cancer. Thirty years ago, legislators, administrators, you know, were trying to convince what I call in the CF nose of the world. This is the kind of data that really shocks people. The other thing is that 76 percent of the people that die, you know, are not up to date on their screening. We know that, you know, we can reduce deaths substantially, 72 to 84 percent. So you know, what we really have is we have really a magic thing, and you know, we all talk about Oppenheimer who could do EMC squared and blow up this terrible energy. Well, timely endoscopy equals my colon cancer, and what's magic about it is it's control and cure. You know, the thought that you've got an instrument that you can stick up somebody's butt, that you can have a TV station and an operating room is unthinkable. I did the 20-centimeter rigid ones. You know, it's different. So how do you build a system? You know, well, part of what we did is we went to the Georgia Cancer Control Program, which I co-chaired. They have early detection and screening. Well, when you go into screening, there's, you know, five main cancers we screened, breast, cervical, colon, prostate, lung, and then, you know, the people that are involved in those screenings are all different, by and large, you know. So we got the Georgia Colorectal Roundtable, and we got various groups within that. And you know, we started in 2015, and what we did is we brought together a system. We brought together 200 members. You know, we had a bunch of folks that actually, the job was to get this done. And what we did is each of our work groups, there's a doc from the field, primary care doc. There's an academic, and then there's somebody who's involved in the GI world. Because what we find is you have to have people talking together. So one of the things we did is the CDC project, great project. We didn't have one in Georgia. So we went out, the Roundtable said, let's find a trusted partner. Part of the legacy of the Georgia Cancer Coalition is we take tobacco settlement dollars, built some infrastructure. One of them is the Georgia Core, Georgia Center for Research and Education. They agreed to house this thing. We took all 200 people, put it in, and said, how do we write a winning grant? And we wrote a really good grant, and it got funded, and thanks to our CDC colleagues. Because what we know, we've got stuff that works. We know what the evidence-based things are. And we now do this screening, and that area we do there, through here, is about the size of New Jersey. So we found that we can telephonically navigate all of these systems through here, and I'll show you some of the navigation success we've had. And so the work groups also are looking ahead, and so we started an ECHO project. And Dr. Jones did this, Dr. Colangio has worked on that, you did, yes. So we've had kind of the best and brightest of the Roundtable have come on, and we do this through all the community health centers, but anybody can participate. We have people as far away as Alaska doing that, and we're looking to try to expand that to every community health center. We have a platform to actually educate them through this ECHO mechanism, which has been highly successful. And then we have an access group, Dr. Owens helps chair it, she works at a community health center. And the idea is to expand this program to all the community health centers in the state, and develop also a statewide navigation. I'll talk to you about other people that have had success. So this can be done. So here's the Roundtable. And if you think about the Roundtable and King Arthur, there's been more English literature written about the Knights of the Roundtable, Camelot, than any other thing in the English language. So there's something magical about this Roundtable. And what are, well, 12 seats, each person has input. So we just don't have a gastroenterologist, you know, we have a public health person in the field. So we had somebody who could tell what the commoners were doing, who could tell you how to transport, who got horses. So when they went in to do combat, you know, what they did is they had, you know, intelligence and not just one person making decisions. That's what a Roundtable does. The Knights Code, which was unique, to protect the weak and defenseless, Song of Roland. So that was very unique, you know, the serfs didn't get protected. You know, they said, we're going to wrap this around everybody. And they also had the invincible weapon, Excalibur, that in the hands of a worthy master, they could wield this weapon and it was unbeatable. So here's the weapon today. You may recognize it. So who does endoscopy here? Raise your hand. Okay. I'm going to dub you the King of the Roundtable, okay, because that is what we're trying to get in everybody at the proper time, the E sub T. But unfortunately, you know, these are BRFSS data, and we know it's probably, you know, we look for our insurance data, we know it's probably 65 percent. Progress is slow. But for community health centers, UDS, we report fully electronically every year what goes on. So this is an underestimate, but we're at 42 percent. So I think this is a real proxy. You talk about health equity, 32,000 people sitting in health centers, you know. If you want to know who's not getting screened, these are the people who need a partnership. And we also know that if you're not insured, it's 30 percent. If you're under 55, it's 48 percent. Less than high school, 42. Recent immigrant, less than 10 years, 26 percent. So we actually know who the weak and defenseless are, okay? Health disparities develop when you have highly effective technology like timely endoscopy and it's not evenly distributed. So when we have maldistribution, we're going to have death rates that are going to get worse. So the major focus of you guys, the American Society of Gastrointestinal Endoscopy, is like the Knights of the Roundtable, to protect the weak and defenseless. Isn't that what you do in Kentucky, you know? That's basically what we're doing. Now, this is not new stuff. In 2012, the community health centers I represent, National Association of Community Health Centers, we got together with the big health systems who've got to be part of this whole thing because we've got to have the health system involved in this. We met and, you know, basically said, you know, we can do it. Here's a paper we did, Dr. Joseph's on there, Dr. Brooks is on there, myself. And what we knew were there were strategies to do it. So this is 10 years old stuff. We also knew Lynn Butterly, who was head of GI at Dartmouth who did this, showed that you could actually navigate and you could get high rates of show. So none of this is new. The navigation is difficult. We've got to get you into you guys' office. We then, you know, if it's positive, we've got to get surgery, other dots, X-rays, CT scans. All these things can make the system fall apart. We've got a cancer center, we've got oncology. So you've got to basically develop a relationship with the CF nose of all of these folks. We put together a program where we actually did navigation. We got open doors to all of these things. And here's what you've got to get people through. You know, we published this in Cancer in 2012, and you had a colonoscopy, did an exam during the study, you know, seven times more likely if you got navigated. This is the other thing we did is early on we actually brought a student in and we started putting reminders. This is, you know, 20 years ago in the chart, put reminders. We did a jog sheet like you used to have in pediatrics where we developed a jog sheet and presented it at the CDC Prevention Conference. And what we showed that, you know, if you used the jog sheet, your rate could go up to 46 percent, if not, it was 21 percent. But if you had no insurance, and Dr. Anita Mohanty, who's on the faculty at the University of Chicago now, was my student who did this, and we found that every person didn't get through the door. We presented this to the GI group. We said, that's true. We see everybody in the hospital for you. You have bleeders. You take care of a lot of shit. And then you see stuff for us. And I said, yeah, that's true. But when they go to your door, they need $200 to get past. They had no idea what was going on. We broke down this barrier. The GI guys agreed each one would do one a month. They liked it so much, they said one a week. And when the hospital brought them out, they said, we're going to do 500 free ones, okay? And then we got the hospital backing up, saying if a cancer is found, and it's a COC hospital. So 3,200 colonoscopies, 16 cancers detected, about that 2 percent you were talking about, 35 percent no-show rate, 2 percent, good bowel prep, 96 percent. This is South Georgia, which looks a lot like Mississippi, except we have a better football team. And we bumped our numbers up big time. We got in the CDC project with COVID. You know, our denominator just blew out. And our CDC projects, we've really done it. But it's a team sport. Just to let you know, it's not just us. There's this crazy guy in South Carolina, Dr. Brian Green, a gastroenterologist. And GI guys are the best people for us to work with. He put together this thing. They looked at a navigation project. He sold this to folks. And back to why we went into medicine, I've heard a lot of people say, this is why I did it. You know, I didn't want to leave people behind. I didn't want to create this health inequity. So he now has all of these 115 community health center clinics, 11 pathologists. He wanted pathologist anesthesia and said, hey, I'm giving my time. Can't you give yours? I give you a lot of business. And what they did is they realized that the numbers aren't huge. But they did provide this. And I think this is a model that we could roll into other states. And their number is 3,000 polyps. So they do a good job. Many lives saved. And here's him. So the South Carolina model can be replicated. You can do it. You have this somebody from a similar background that takes about eight calls. We also navigate fits back at about 70% rate. So we've been out there doing it for over 10 years in a very challenging population. And we think one of the missing things is resources necessary to develop a statewide navigation. They did this in South Carolina. And obviously, Kentucky's done that. So when you look at the health centers, they're everywhere in the state. These are the COC hospitals. And interesting, you talk about opportunities. Well, there are 1,500 COC hospitals. The new standard says they have to identify barriers to care. And the navigation is able to overcome them. So it satisfies that. And our hospital at Phoebe Putney in Albany does this. They have to have a cancer screening event. Why not colon cancer? There are 1,600 nonprofits. And the IRS states that they have to show. Now, they're getting hammered because they're not showing that they provide as much as tax benefit they get. When you give 500 colonoscopies at $2,000 a shot, that's a million bucks that anybody would say is extraordinarily important. And then there's a CDC cancer plans in every state that you can plug into. Schedule H requirements says that they have to do this. So when you talk with your hospital, there's actually something in for them. And our hospital administrator has spoken nationally. And several other hospitals in our system in South Georgia have now done it. These are the hospitals. You basically have like eight health systems in Georgia, and you could actually cover the whole state. This is the number of encounters in health centers. They're booming. You know, COVID really, we kept open and did vaccines and, you know, a bunch of visits. And as, you know, numbers were still sitting at the 31, 32. Medicaid non-expansion states are really difficult because you have to put together these links to care. And here's a slide, 35% no health insurance were publicly screened. Probably worse than that, that 50%. But here's what we, our latest numbers through our CDC project, 95% show rate, 94% good to fair prep, and 60 to 70% fit return rate. So here's the other theory of relative ET equals MC squared by cancer control, but it's a relatively complicated process to do. And it requires system construction to do that. But you have CDC, you have other things to construct the system, and roundtables are great vehicles. And a lot of states have roundtable equivalents. And, you know, with the CFO, we, the National Collective Roundtable has this needs calculator, so you can actually plug in. So my daughter's an internist at Savannah. They're looking at expanding there, you know, so you have two COC hospitals. If we went from 21% to 60%, how many cancers will we detect this year? Six cancers, but four of them are fully insured. And two of them have probably come through the emergency room anyway. We'd say $1.7 million. The local GI group wants to donate their services, but, you know, basically would take, you know, each of that 12-man group doing one a month. But the problem is, is they now have a handler who says, we need a Medicaid denial letter. Federally qualified health centers have a federally vetted sliding scale. And if you're in that, and if you lie about it, you can go to jail, and people have. So why wouldn't you just use that? Well, you know, it's kind of like redlining and the old, you know, where people can live. Well, that's the secret redlining that's out there. Or they say, my anesthesia group will charge $1,500. But, you know, we've been able to work through this some, but I think that's one of the big challenges to get health systems involved in doing this stuff. But this is a very nice tool. Can it calculate? You can do it. And the National Roundtable has a ton of information, but this is one of the more effective tools. And this is what we concluded, is that this links to care thing is incredible. I can, my navigator can pull somebody through this complex chain, but every one of those links has to be strong. You know, a 30-grade chain can pull 1,500 pounds. A 100-grade can do 15,000 pounds. But you know, if you've got a one-grade, it's only 50 pounds. Or if you have nothing in there, it doesn't move through. So when you look at doing this project, what you need to be certain is all of these people are lined up. You know, the colonoscopy guy's got their buddies. The oncology wants you to go over there, have their things. And then we can pull through if those doors are open. I got a young doctor working with me, and he did this. I didn't do this myself. I want you to know that. But I think, you know, prior to my career, and I'm 73 years old, why I do this, I could have retired 10 years ago. Some doctors retire to, you know, build furnitures. Other people retire to plant. I would like to retire, even though I'm working full-time, my hobby is building a health system. Around this. And President Kennedy, when I was 12 years old, said we're going to be in the mood. So having a stretch goal is important. I think what we're talking about here is a stretch goal. How do we get this for everybody? We choose not because it's easy, but because it's hard. It requires everybody working together, a limited time frame. A hard goal, but an important one. So if you look at what we can do with our CDC project, we have it established. We have a track record. We have high-need demographics. We have full continuum of care that we can put together. We have guys willing to do it. And then the other thing is the ability to navigate patients throughout the entire links to care. The most important reason we do this, 1946. This guy married that gal, and that person was the best man. I was one of the products of this connection. They produced five kids and 18 grandkids that he never saw because he died at age 60 of colon cancer. Uncle Barney made it to 62 before he died of colon cancer and didn't see his eight grandkids. Every year, if we got to 80% in Georgia, which I think is our stretch goal for every community, we'd save 468 lives. So thank you. That's my story, and I'm sticking to it.

colorectal cancer screening

timely endoscopy

health disparities

navigation programs

collaboration

system-level approaches