All right, so we're going to move into the second session of the morning. Dr. Brian Jacobson is the Director of Program Development for Gastroenterology at Massachusetts General Hospital and an Associate Professor of Medicine at Harvard Medical School. Dr. Jacobson's research focuses on several aspects of colonoscopy quality and effectiveness. He has co-authored several guidelines and standards of practice for the GI community and has served in leadership roles within several leading gastroenterological organizations. From 2014 to 2020, he was the Medical Director of the Boston Accountable Care Organization. That ACO included 120,000 beneficiaries, the majority being insured through Medicaid and involved more than 1,000 providers spread over 21 organizations, including many federally qualified health centers. Dr. Jacobson has a medical degree from the Albert Einstein College of Medicine. Thank you. Thanks for those who came back from break early. So we'll get the next session going. The first speaker is Dr. Janava Joseph, who is a Captain and Epidemic Intelligence Service Officer with the CDC Division of Cancer Prevention and Control. She served as a Medical Director of CDC's Colorectal Cancer Control Program from 2019 to 2021. She was the Chief Medical Officer at the Arcadia Community-Based Outpatient Clinic in the Atlantic VA Medical Center Medical System from 21 to 22. Dr. Joseph has a medical degree from the University of Michigan Medical School and will be speaking to us on CDC's Colorectal Cancer Control Program, the challenges of follow-up colonoscopy. All right. Well, good morning. I was an Epidemic Intelligence Service Officer many years ago. That was 2005. Done with that, however. So I'm going to talk to you a little bit about CDC's Colorectal Cancer Control Program. I know many faces in here have heard about this program more times than they probably care to think about. So I'm going to try to whiz through some of the background information to sort of get to the end, which is where I talk about more about our challenges with follow-up colonoscopy. So for those of you who don't know, this program has been around in some sort of form, shape, or form since 2005. It initially started as a demonstration project, which was actually based on our National Breast and Cervical Cancer Early Detection Program, which provides breast and cervical cancer screening to un- and underinsured women. So they pay for the mammogram, the Pap test, you know, and all the things that come up to it, come after it, right up to treatment. So that demonstration project was modeled after that, just to see if it could be done with colorectal cancer screening. So that was done in five state, county, city, and universities. And we found it seemed to work. So we moved on to a full program, and that was from 2009 to 2015, which folks, again, focused on delivering colorectal cancer screening services. So any USPSTF-approved screening test on, obviously, follow-up colonoscopies, we did not, we do not pay for treatment, you know, if they are diagnosed with cancer. So they had to arrange for, to partner with someone to provide that service. We started to introduce that element of population outreach into this program, because the CDC director at that time was much more interested in reach, because our funding is limited and we can only reach by X many people if we actually pay for the screening, right? So we would need a lot more money to make a bigger dent if we paid for all the screening tests. So that led to the next iteration of the program in 2015 to 2020, where we had 30 grantees. And really, this is when we started to partner with health systems, health systems being primary care clinics, to implement evidence-based interventions to increase colorectal cancer screening. So really, the tenets are to really try to integrate public health and primary care, to focus on high-need populations, so the clinics we're partnering with are inevitably federally qualified health centers or community health centers, establish lots of partnerships with other organizations to support implementation, and obviously, data, data, data, because we can't modify or do anything if we don't know what's going on. So basically, the idea is grantee partners with a whole variety of people. Sometimes it's American Cancer Society, primary care associations in the state, could be anybody. They do an initial assessment of the primary care clinic they're proposing to work with to see if they're even ready to even try to do some of this stuff. We implement the EBIs. We found this was not originally intended, but we found that if we didn't do some work with the EHRs in the primary care clinics, like trying to figure out screening rates, follow-up rates, anything, was almost impossible. So this was kind of unintended, but this is the problem we ran into. And then they report that data to us, and then we get to say, yay, increased screening rates. So here are the evidence-based interventions we focus on. So patient reminders, provider reminders, provider assessment and feedback, and reducing structural barriers. So that's things like patient transportation. A lot of people will say, if they need a colonoscopy, I don't have someone to take me. Those sorts of things. And then what we call supporting activities. So that's small media. So those are like educational pieces you can hand out to patients, or even the wider community. Patient navigation, which started out small and has gotten much bigger, has been really key to support a lot of this stuff. That overlaps a lot with community health workers. And then, of course, provider education. So our 2015 to 2020 program, we partnered with these 264 health systems, which turned into 836 clinics, and we wound up reaching, which served collectively, 1.3 million adults between the ages of 50 and 75. So pretty good reach. Of the clinics we partnered with, 71% were federally qualified health centers. Between all of them, about 26% of the patients they served were uninsured, and 17% were in a non-metropolitan location. So rural-ish, I would say. So we had good success to start. We had a 38% baseline across all of those clinics collectively. And then with each every year, each consecutive year, the screening rate went up. Mean screening rate, 251%, until COVID came along, and then it stopped going up and kind of went backwards. So we're still trying to recover from some of that. So that cycle actually ended in 2020. So then we have to re-compete, and we get a whole new bunch of grantees, which means a whole new bunch of clinics, which means we basically have to start over. So we got this question a lot when we moved from paying for screening to doing this partnership evidence-based implementation approach about why the switch. This is why we screened about 83,000 over the course of those two earlier programs, so from 2005 to 2015, as opposed to reaching 1.3 million in five years. There's some pros and cons to that that if you really want to know, I can tell you about. I won't get into all of them right now, but that was largely the impetus. This is our current program. We have 35 award recipients. They can be states, universities, tribal organizations, or what we call other. So we have AltMed, which is actually a fairly qualified health center in and of itself. We have primary care associations and other assorted type organizations that we fund. So like I said, we had to start all over again. Even grantees that continued from the previous cycle to this cycle, we were really pushing them to work with a clinic, get them up and running, get these EBIs implemented, move on to the next set of clinics. That's another conversation. As much as they were able. So we got a lot of new clinics. So we're up to, this is at the end of year two. We're actually moving into year four now, but as of the end of year two, we have 461 clinics reaching about 494,000 people. So the screening rate has just been slower to increase this time around. I think it's for a multitude of reasons, COVID being a huge part of that. The other part of it is what I call low hanging fruit. So I think on the first go around, we reached some of those clinics who were like really eager and interested and wanted to participate and had the resources to do it. Now we're starting to get into clinics where things aren't quite so easy. It takes a lot more legwork to sort of get things going. So I think we all know about COVID, COVID, COVID, COVID is everywhere. So lots of drop off in screening, and this is across the board. This was a paper that talked about how many missed screening tests. And that's just in the space of about a year and a half. So you can see how many probably got missed that we now have to scramble to catch up on. It did see an increase in stool based testing. So I suppose that's a plus, but a drop off in colonoscopy, that's probably not a plus because at some point somebody's going to need a follow up colonoscopy. So if that's not available, that's a real bottleneck. And then as has been mentioned many times, cancer screening is not a test, but a process. So we really try to leverage our program resources to address this entire continuum. It's not easy, as many people have mentioned. But really trying to focus on reaching people before they even get in the clinic, making sure when they do get in the clinic, they get offered a test of some sort, shape or type. That if it's positive or abnormal, they get the appropriate follow up, and then, you know, to diagnosis, to treatment. All right, veins of our existence. So EHRs were a big, huge problem. I can tell you how much time we spent. And this is not our area of expertise, this is not usually our grantees areas of expertise. So we were behind the eight ball a little bit. We had to scramble to sort of help them get resources to figure out, well, how do we even get this information out of these systems that weren't designed to do these sorts of things? They weren't, they're not databases, they're not intended to give us screening rates and follow up screening rates and all this kind of thing. So that was a huge headache and still is really. Follow up colonoscopy was another big, huge problem. Obviously it was a lot easier when we were paying for things, right? Even then it was a problem. It was easier when we were paying for things, but when we were not directly paying for the screening tests and we're asking them to leverage every single partnership they can get their hands on to try to arrange for these follow up tests, it became a lot more challenging, more challenging than I think we were anticipating. I will say when we were paying for screenings, so this is from, you know, when we paid for the whole shebang, we did actually manage to get 83% follow up colonoscopies, which is good, but kind of not good from my perspective because we were kind of expecting it to be a little higher. And you can see the range from 50 to 97%. And when you look at things that contributed to that range, some of it was just the population they were trying to reach. So we had one grantee that had an extremely large seasonal worker population that they were giving FIT and FOBT tests to. So, you know, we had lots of conversations about whether that was really the best approach because you give them their FIT or FOBT, they go off to wherever it is they're working next, you can't get in touch with them to get their follow up colonoscopy and then there you are. So should you just go straight for colonoscopy for those folks, if you know it's going to be hard to follow up with them later. So that was one part of it. And I'll get to the other in a minute. So this is our current program. So because most EHRs aren't set up to actually track completion of colonoscopies, we actually don't have data on that. We're just really starting to push people to help their partner clinics set these systems up. But you can see from here that most clinics didn't have a system to keep track of their fecal tests, the number they gave out and how many they got back. They didn't have a system to figure out how many people got referred to a colonoscopy and if they did, how many finished it. So you can see first we had to get them to create a system and then now that they've done it, you can see only about 55% are returning fecal kits, 48% are, this is all colonoscopy completion first where there's a primary test or follow up, and then for follow up it's only about 44%. So there's really something in the way there. So when looking across all our program experience about all the challenges that we're having, Medicaid times are a big one. So I have programs telling me now, this was back in May and June, that they're all the way out to November for a follow up colonoscopy, reimbursement, it's like if I could make that tick up the whole screen, that would probably be the number one problem. Even when we were paying for the screening test, we're not allowed to go above the Medicare rate as a federal agency and it was actually surprising how many providers would not accept the Medicare rate. They just would not partner with our grantees. Even now we've moved to, with our current program, we've actually moved to giving them some money to help pay for some follow up colonoscopies because it was so problematic and we still can't get colonoscopies. They have money and it's just sitting there because they cannot get GIs to partner with them. I've heard everything from the reimbursements too low, some, how can I say it, nicely preconceived notions about the populations they're working with about them not showing up for their appointments. I've heard grantees, and this is all anecdotal, GIs, even when they have a GI, they're cherry picking. So they'll put the people with higher reimbursement on a schedule first and then everyone else just gets pushed back, back, back, and back. So it's just a big, huge problem across the board, which we have not been able to sort out from our level because to Whitney's point, all solutions are local, right? So they're in Kentucky or California or wherever, it's very hard for us to say, well, do X, and X will magically solve the problem. They have to know their partners. They have to know their community. They have to know who to reach out to and all this sort of thing. I talked about seasonal workers. Unhoused populations are a huge problem. So we have a lot of federally qualified health centers that cater to that population. Well, obviously, it's very hard to do a colonoscopy prep when you don't have a home. So they, you know, I give people credit for being incredibly creative. So they will literally bring people into the clinic and do their entire prep while they're like in the clinic. And then in terms of follow-up colonoscopy, this is what I call the screen and explain later approach. We used to see a lot of people just doing what I call throwing FOBTs and fits up into the air and they would just land on people and they would do them. And then nobody would explain to them up front that you need to have a follow-up colonoscopy afterwards. And then people would be like, no, I'm not doing it. You know, I think we've heard some conversation about why that can be good and like you might hit people who would be like, yeah, sure, I'll do it, you know, and I'll just do the whole thing. But I think we've found with some of the populations in particular that we're working with, it became a real problem just because of trust issues with the health system to just give them a test and not tell them up front, you might need a colonoscopy because then when we come back and say, oh, you need a colonoscopy, well, why didn't you tell me that up front? I would have, you know, said no or, you know, reconsidered my choices. So I find that approach does not work very well with the populations we're trying to reach. So I really have pressed our programs to make sure you have that conversation up front. If they just decline outright, like I will never do a colonoscopy, and then you need to have, you know, you need to keep having that discussion, keep having that discussion, you know, revisit, revisit, revisit until you, you know, sort of get some sort of agreement and not just hope that the test will be negative and that you won't have to deal with it. So I think that pretty much sums up everything for us. I could probably, like, go on forever about all the problems we've had, you know, trying to implement this program just, you know, across the board, but I'm happy to speak with anyone later about all our lessons learned.

CDC

Colorectal Cancer Control Program

follow-up colonoscopy

screening rates

challenges