Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians

Yonas Martin; Leo Alexander Braun; Marc-Andrea Janggen; Kali Tal; Nikola Biller-Andorno; Cyril Ducros; Kevin Selby; Reto Auer; Adrian Rohrbasser

doi:10.1136/bmjoq-2019-000670

Offering patients a choice for colorectal cancer screening: a quality improvement pilot study in a quality circle of primary care physicians

BMJ Open Qual. 2019 Oct 3;8(4):e000670. doi: 10.1136/bmjoq-2019-000670. eCollection 2019.

Authors

Yonas Martin^{1

2}, Leo Alexander Braun¹, Marc-Andrea Janggen¹, Kali Tal¹, Nikola Biller-Andorno³, Cyril Ducros⁴, Kevin Selby⁵, Reto Auer^{1

5}, Adrian Rohrbasser⁶

Affiliations

¹ Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland.
² Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
³ Institute for Biomedical Ethics and History of Medicine (IBME), University of Zurich, Zurich, Switzerland.
⁴ Foundation for Cancer Screening of the Canton of Vaud (FVDC), Lausanne, Switzerland.
⁵ Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.
⁶ Medbase, Wil, Switzerland.

Abstract

Background: Guidelines recommend primary care physicians (PCPs) offer patients a choice between colonoscopy and faecal immunochemical test (FIT) for colorectal cancer (CRC) screening. Patients choose almost evenly between both tests but in Switzerland, most are tested with colonoscopy while screening rates are low. A quality circle (QC) of PCPs is an ideal site to train physicians in shared decision-making (SDM) that will help more patients decide if they want to be tested and choose the test they prefer.

Objective: Systematically assess CRC screening status of eligible 50-75 y.o. patients and through SDM increase the proportion of patients who have the opportunity to choose CRC screening and the test (FIT or colonoscopy).

Methods: Working through four Plan-Do-Study-Act (PDSA) cycles in their QC, PCPs adapted tools for SDM and surmounted organisational barriers by involving practice assistants. Each PCP included 20, then 40 consecutive 50-75 y.o. patients, repeatedly reported CRC status as well as the proportion of eligible patients with whom CRC screening could be discussed and patients' decisions.

Results: 9 PCPs initially included 176, then 320 patients. CRC screening status was routinely noted in the electronic medical record and CRC screening was implemented in daily routine, increasing eligible patients' chance to be offered screening. Over a year, screening rates trended upwards, from 37% to 40% (p=0.46) and FIT use increased (2%-7%, p=0.008). Initially, 7/9 PCPs had no patient ever tested with FIT; after the intervention, only 2/8 recorded no FIT tests.

Conclusions: Through data-driven PDSA cycles and significant organisational changes, PCPs of a QC systematically collected data on CRC screening status and implemented SDM tools in their daily routine. This increased patients' chance to discuss CRC screening. The more balanced use of FIT and colonoscopy suggests that patients' values and preferences were better respected.

Keywords: PDSA; patient-centred care; primary care; quality improvement; shared decision making.