Vallejo, CA, in Solano County, is one of the most racially/ethnically diverse cities in the state
7 and has undergone significant financial hardships over the years.
8 The city, which is home to 2 of La Clinica de la Raza's Bay Area clinics, has a population of 22.1% African American, 22.6% Hispanic, 24.9% Asian, and 32.8% white people.
9 In 2014, La Clinica de la Raza received a 1-year grant from the American Cancer Society's 80% by 2018 initiative to increase the rates of CRC screening among their client population in Solano County. In fall 2014, 2 Touro University California osteopathic medical students (T.J.F. and M.G.B.), under the auspices of the 2015-2016 Bay Area Albert Schweitzer Fellowship, worked in collaboration with La Clinica de la Raza's panel managers to develop a protocol for patient outreach. Previous studies have shown that CRC disproportionately affects minorities, particularly Hispanics and blacks,
10 as well as groups of low socioeconomic status. This setting, therefore, afforded an opportunity to engage a community that has a high number of people at increased risk of CRC.
Owing to the user-friendly nature of at-home fecal occult blood stool sample collection tests,
11 La Clinica de la Raza activities to reach the grant benchmarks included generating a list of patients due for a CRC screening according to an electronic medical record (EMR) search and subsequently mailing a FIT to 2133 patients from November 2014 through October 2015. Lists of patients potentially eligible for the CRC screening interventions were generated by panel managers using I2I and NextGen software. Initially, 2 inclusion criteria were used to identify patients who needed annual CRC screening: (1) age between 50 and 75 years and (2) not having completed a FIT or fecal occult blood test (FOBT) within the past year. Patients were identified as eligible for screening in November 2014. After a few months, it was discovered that using the initial 2 inclusion criteria was not sufficiently approximating the true target population; many patients were misclassified as needing screening when they did not. Before launching this CRC screening intervention, additional exclusion criteria were identified: history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease; a family history of colorectal cancer; a normal colonoscopy result in the past 10 years; a normal flexible sigmoidoscopy result in the past 5 years; or a normal FIT result in the past year. (These patients were being monitored under other screening protocols completely separate from this intervention.)
Phone conversations and messages took place between August 2015 and February 2016. There was a 2-month period of transition between the mass mailing and telephone conversation protocol because the clinic personnel had to be retrained on the new exclusion criteria and telephone call intervention. In-person clinic appointments spanned the entire study period from November 2014 through February 2016 (
Figure 1). The protocol was designed based on the hypothesis that having a one-on-one conversation with patients about the need for CRC screening, the screening process, as well as answering patient questions by certified medical assistants, can increase the rate of FIT completion among the populations at greatest risk for the disease over the mass-mailing strategy that was being used. Osteopathic principles were applied to promote preventive screening; our approach was to integrate patients as partners in their own care through personal conversations, education, and motivation that included eliciting commitment to complete the screen, thereby increasing the engagement between the clinic and its patients. Mailings, conversations, and outreach attempts were all recorded in patients’ EMRs.
The 2 medical students conducted a medical record review using patient EMRs to assess which La Clinica de la Raza patients received a FIT between November 1, 2014, and February 29, 2016. The data collected included how they were informed by La Clinica de la Raza of the need to complete a FIT (in person, by telephone, by mail, or some combination), whether they had another contact with the clinic via the aforementioned methods, and whether they returned the FIT to the laboratory for processing, thereby completing the screening protocol. The medical students were trained in La Clinica's standard EMR and Health Insurance Portability and Accountability Act regulations before accessing any patient data, and the study was approved by the Touro University California Institutional Review Board.