We're now going to hear the primary care perspective from Dr. Frank Colangelo. Dr. Colangelo is a primary care internist with Premier Medical Associates, a large multi-specialty group in the Pittsburgh area. It's part of the Allegheny Health Network. Dr. Colangelo serves on the National Colorectal Cancer Roundtable Steering Committee. And it's worth noting that Premier Medical Associates has been honored with a National Achievement Award from the NCCR for its efforts to increase CRC screening rates. Dr. Colangelo has a medical degree from Jefferson Medical College. Come on up. Thank you, Brian, for the introduction. Thank you to the summit for asking me to speak. I'm giving one primary care doctor's outlook at the difficulties that we sometimes face having patients who have a positive fit test go on to complete their colonoscopy to complete the screening. So, you know, I'm part of Premier Medical Associates. We're part of the Allegheny Health Network, which is the organization between Highmark Health, the local Blue Cross and Blue Shield affiliate, and the provider. I'm the Allegheny Health Network in Western Pennsylvania and Western New York. And Premier itself, I've been fortunate over time, I've worked there. Seven primary care offices, very busy. We've touched about 100,000 lives in the eastern suburbs of Pittsburgh. And it's very convenient because we're within a 15-mile radius. So when we want to roll something out, it's easy for us to get everyone together to talk. We're going to do this. We're going to work. So it's been beneficial for the work that we've done over time. But over the last 10 years, this is what my journey has felt like with many ups and many downs. So, and I'll explain what I mean by that. So this is efforts over the last decade. It's an agenda what I'm going to talk about today. So, you know, we started January 1st, 2013 was when we kicked off our efforts to improve overall screening rates. We were in the high 50% at that time. Many of my primary care partners, colonoscopies, the gold standard, I'm only offering colonoscopies. We had to convince doctors they had to offer a patient's choice in screening if they wanted to have better screening rates. We leveraged transparent provider reporting. I've shared this with Jim Hutz before. The, you know, every single month was the graph as to how doctors were doing with their screening rates with the 80% goal rate and the people at first when we started doing it who were below 80% screened bloody murder that we were hurting their self-esteem, but we kept using this and it worked to improve overall screening rates. And it took us until October of 2016 to hit that 80% screening rate. And we also worked on improving our follow-up completion of colonoscopies after a stool-based test and then the pandemic hit and there have been numerous changes that have happened to the practice since then. Now, early March of 2013, I was doing some chart reviews. We were trying to find colonoscopy gaps to submit to an insurer to close gaps because they didn't know someone had new coverage. And I noticed several of my partner's patients who had a positive fit that never had a positive colonoscopy and said to the lab, give me all the positive fits for the last year and did a chart review. And again, it was about 57% of those patients had completed a colonoscopy. And I remember getting on the phone with Rich Wender and calling him late on a Friday afternoon, panicking, only 57% of our patients completed their screening. And he said, relax, you guys are doing better than most of the country already. But that was fun that day, but he gave me some ideas for things to do too that we implemented immediately, including doctors saying to patients, I will allow you to be screened with your fit or with your multi-target stool DNA if you promise me that you will get a colonoscopy if the result returns positive. So we do that message. In the past, our staff would call the patient and say, you had a positive test, you need to have a colonoscopy. The patient would say, I'm not doing that test. The staff would say, no, cancel the order. That was the end of it. Now the staff says to the patient, uh-uh, I'm going to be letting Dr. Colangelo know that you won't do this test, and he's going to be reaching out to you with the importance of this. We developed a positive fit registry that we track, and we do personalize letters to our procrastinators. We give them a month to schedule the test. If they haven't, we send them a letter from their primary care doctor saying, you had a positive test. You really do need to go ahead and complete your screening with a colonoscopy. So did this effort help? I had compiled this slide several years ago. From March of 2020 to almost March of 2019, almost 89% of our patients with a positive fit completed a colonoscopy. Now I didn't say three months or six months. I gave them credit if they did it two years after their test in that 88.7% number, but we did a breakdown. Almost 80% of those patients had their colonoscopy completed within 90 days, so we were happy with that. Now we had it rolling then. With our primary care base of about 40 providers, we had two full-time gastroenterologists that were part of our multi-specialty group, and, you know, we did the order. They got the patients. They got them in. They took care of them. They did things, and then right about this time, one of those two gastroenterologists left the practice, so there started being more strain, and, you know, this gentleman was a workhorse. I mean, he did a lot of stuff, but he was one guy doing the job of two, and then this fellow hit and threw everything upside down, so. But in spite of that, just from our work we did with AMGA, we were in some collaborative learning with them, at the end of 2021, for that entire year, 83% of our patients who had been screened that year were current with screening, so the pandemic didn't hurt our overall screening rate, so we were pleased with that, but look what it did. Nothing changed in the practice. We had the same things that we did, but in that 21-and-a-half-month period of time, only 55% of those patients who had a positive fit completed their colonoscopy. Patients were afraid to go and get their colonoscopy. They were afraid they were going to get COVID as opposed to getting colon cancer, but we didn't give up. We kept working that list. Over another year, we kept up, and eventually, almost 80% of those patients did a colonoscopy, so we didn't give up on them. We kept reminding them, it's safer to come out now. You can go ahead and get your testing done, and they agreed with that. So then, at the beginning of 2022, our 2.0 FT gastroenterologist decided to retire also, and we had to rely on our Allegheny Health Network parent GI organization, and our staff, it was kind of, I hope you know what, we'll get back to their stays in this room, we complained about them, but we had the thing where we would put the order in the electronic health record, our MAs would print out the order, would fax it directly to their office, say this person had a positive fit, this person needs colon cancer screening. We did it, and when we had our own GI division, they used to freak out if there were over 1,000 colonoscopy orders that hadn't been scheduled yet. They would call people into work weekends and work the list. In May of this year, when I realized in preparation for AMGA screening collaborative that we're getting involved with, that there were 3,900 open colonoscopy orders in our EHR, in our screening rated job, and we reached out to them, and they said, oh, we don't do anything with those faxes, we wait for the patients to call us, we just threw them away. And it's like, okay, we've been sending you 300 orders a month for the last 10 months, don't you think you could have picked up the phone and said this isn't the way we do things? So now I'm real happy to be working with these people for our colon cancer screening, but at the same time, during COVID, in our marketplace, almost every provider stayed at home in their jammies and did nothing but virtual visits because they were afraid to be exposed to their patients. We stayed open in a safe, socially distanced fashion, and patients loved this. Patients heard this. Patients came roaring into our doors as new patients because they still wanted to see providers. So we had a huge influx of new patients, but I had 40 adult primary care doctors who had completely closed panels because they were busy doctors. So who took on all these new patients? It was the 10 or 15 APCs that we had recently hired for the practice who hadn't been indoctrinated in this decade-long process that we did. So it's interesting to see all the changes and shifts that had happened. We added the extra five years of patients who needed to be screened, and then we had the planning for the collaborative that Elizabeth mentioned earlier. So we had to turn in our information, where 80% of our patients used to have their follow-up colonoscopy within three months. We're now in the mid-30s. Now, we stretched that out to six months, even though the collaborative didn't want to know that. We're in the 60% to 70% range, so a little bit down from where we were. But we have some work to do to do this. Now, we did break this down because we were required with the health equity part of the project to break it down by race, ethnicity, by financial class, by age brackets. And there really weren't. In many of those quarters, our Medicaid patients had a better completion rate than our commercially insured patients did. It was like all over the place. There was nothing consistent. The one health equity thing that we decided to work on was just our overall screening rate. Our Medicaid patients in the past year had a 48% screening rate. Our commercially insured patients, it was 66%, and our Medicare patients, 76%. We're going to work on getting our Medicaid screening rates over the next year back to the commercial, or hopefully up to the Medicare rates for the practice. We put on our quality improvement hats. What are we going to do for the collaborative? How are we going to improve things? Just had a meeting last week. I've got all the primary care doctors, including the new APCs. We're going to mentor them, work on this, break out the posters from a decade ago to hang on the walls in the practice saying that we have to get screened for colon cancer. And now we are on EPIC, where I'm no longer faxing the thing. So we just had an EPIC go live on June 6th of this year. So I've been working closely with the parent Allegheny Health Network GI department. So the orders can go in. They're giving priority scheduling for our patients who have positive stool-based testing. And they also are using us as a pilot site for what they're calling direct primary care scheduling of colonoscopies. In EPIC, they have eight evidence-based questions that a medical assistant or nurse at our offices can fill out based on the patient's history, their BMI, do they have sleep apnea, do they have heart disease. And based on those things, it will decide if this patient does need to have that pre-visit for clearance by the GI, if they need to be scheduled in a hospital, or if they can safely be scheduled in an ASC. So this is something we are going to be rolling out beginning September 1st. And I'm hoping, me not worrying about a fact or an order getting lost by them. We're lucky the medical assistant who used to do the scheduling for our GI division still works for us. So this is going to be her job because she's very comfortable with it. And we're really hoping that this is going to energize our efforts and get us back up to that 80% or above completion rate within a quick period of time. So I think that's my last one. So picture of downtown Pittsburgh in the Highmark office building. So thank you.

challenges

colonoscopy

screening rates

COVID-19 pandemic

completion rates