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>>KOPELOW: I'm Murray Kopelow the chief executive of the Accreditation Council for
Continuing Medical Education.
>>LANE: Hello, I'm Dorothy Lane, I'm Associate Dean for continuing medical education
and Distinguished Service Professor of Preventive Medicine at the School of Medicine,
Stony Brook University
>>KOPELOW: At your medical school you've developed a continuing medical education
activity that integrates a research project with continuing medical education on colorectal
cancer screening as I understand it. So, I'm interested in exploring a number of things
with you. Why this was the subject that you chose? How it relates to your other parts
of your professional life? Why you did it in
a formal research way? And how you went about turning it into a formal research project?
And then we can talk about the continuing medical education activity itself and how
you planned it. And what provisions you had to
build in and what things you had to do special because it was a research project. So, why
don't we start with, with what are your other professional activities or interests at your
medical school; why you picked colorectal screening? And especially, how did you
access the research funds and create the grant application for it? Tell us a little bit about
that.
>>LANE: OK. Your question gives me a lot of thoughts to say, I'll
>>KOPELOW: good, good, good.
>>LANE: start from the beginning. When you talked about my professional involvement at
the school, in addition to being Associate Dean of CME I'm a professor in the
Department of Preventive Medicine. And an area of special interest to me has been
cancer control and cancer screening. And I like to relate what I do in CME to prevention
sort of tie them together. In CME we're always in need of support for educational
activities and commercial support is not the only way to go and so, federal support can
be very helpful. And so, when you know, I stay
on top of what the National Cancer Institute is interested in funding and they have a mechanism,
you know, well, all the federal agencies, called RFA, which is request for
application. And what that is, is rather than waiting for investigator initiated proposals
to come through there are areas where they feel there is like a national need for something
to happen where they fund projects in a specific area. And I saw this announcement
about funding to improve colorectal cancer screening among physician practice groups.
So, that seemed like an ideal marriage to take
advantage of this opportunity to do something in CME.
>>KOPELOW: Do they actually publish and disseminate this RFA or do you have to go find
it? How did you come across it?
>>LANE: Well, there are lots of mechanisms that the federal government uses to get the
word out. In many, in most academic institutions they have a whole research branch that
notifies faculty that have interests in certain areas, every time something comes up either
form the feds, from a foundation, or whatever, that is related to your interest area. And
also, you can get on lists from the NCI, or whatever, by going through a process to get
automatic emails about certain proposals. And I had also had prior funding from the
NCI all these sort of a mechanism that I learned
about this opportunity.
>>KOPELOW: So, there's a lot of ways. So, new people can get
>>LANE: oh definitely
>>KOPELOW: the information about it
>>LANE: Yes.
>>KOPELOW: So, what kind of expectations did the National Cancer Institute haveyou're
your submissions, is this a 500 page production? Is this a 10 page production? What kind
of literature review is involved, what kind of work has to go into that part?
>>LANE: Well, those kinds of things are almost changing as we speak, because the
government is trying to condense to simplify to make things easier. But, I would it's
roughly like, was, a 25 page kind of proposal at that stage. And what's interesting is that
a lot of the things that you do when you're planning CME are things that would be
relevant to developing a grant application in terms of needs assessment, you know,
justifying why, you know, what you're proposing to do, would work, why it's of value,
what the evidence is out there for whatever approach you're using. Because they don't
want you to, unless you're, we were, in fact, testing a proposal, but we had to show a
mechanism of doing this, but we had to show that it was based on some evidence that
made it likely it would work. For example, we were using academic detailing and there
is a literature showing that that is an appropriate
>>KOPELOW: So, your point is that they're duplicative. So that the work that you do
for the submission is useful work for the educational
planning process as well.
>>LANE: Exactly. It's not a complete overlap, but they're certainly related. And so, there's
synergy there.
>>KOPELOW: Right.
>>LANE: If you want to call it that
>>KOPELOW: how long does it take from concept to submission do you think? Is it a six
week, eight week kind of production?
>>LANE: I'd say it's about that. Although, you can spend longer on it. You have to balance
the probability of funding with how much time you want to put in or whatever. But, you
know, you usually have several months after an announcement to come up with the
proposal.
>>KOPELOW: And how long do they take to review them and give you an answer?
>>LANE: That takes longer, you know, they have to form review committees, review
committees meet and then there's
>>KOPELOW: less than a year?
>>LANE: yes. Well, less than a year, but close to a year in terms of the time that it gets
started.
>>KOPELOW: And, and how much money did you get for it?
>>LANE: 250,000
>>KOPELOW: Excellent. All right. So, let's talk abut the, so, now you've got your funds.
You've got your design, you've got your funds. Tell us about the educational activity that
was conceived out of this. What was the, what was the gap you were trying to address?
And, and what techniques or methods did you pick to try and close this gap? What was
the underlying need that you thought that needed to be addressed in order to get a
change?
>>LANE: Well, the need in part probably stimulated the purpose of the whole initiative,
which is the fact that colorectal cancer is one of the biggest killers, if you combine
men and women; it's you know, the second biggest
killer of men and women due to cancer. And if you drill down even further on that
>>KOPELOW: you were using a patient outcome as the problem that you were tying to
address, which was the death from colorectal cancer.
>>LANE: well, it's the
>>KOPELOW: and morbidity and mortality
>>LANE: that's right. That's one level and talking about the gap too that cancer screening
is not utilized well. I mean it was like between
40 and 60% of the population was being screened. Something like mammography had been
many years ago.
>>KOPELOW: So, underlying, underlying the gap that you were addressing you identified
a performance problem, which is failure to screen.
Is that right?
>>LANE: Right.
>>KOPELOW: I'm not putting words in your mouth?
>>LANE: No, it is failure to screen and it could be a two-side thing it could be maybe
the doctors recommending it and the patients aren't
doing it. But, clearly, you know, it was, in part, due to the physicians. Plus, we knew
that physicians, from literature, are real important factor, key factor in motivating
people to get screened.
>>KOPELOW: So, in designing an educational intervention that had as its expected outcome
more screening for colorectal cancer. You must have been faced with a lot of options,
a lot of choices, a lot of things that you could
have done and you had to bring them down to an activity that was an hour long
>>LANE: right
>>KOPELOW: an hour long. So, what did you choose to put as the content in this hour?
>>LANE: OK. What we wanted to give as the content was, first of all, to make them aware
of this, the level of the problem. In the community
>>KOPELOW: so, some knowledge
>>LANE: some knowledge about that
>>KOPELOW: some knowledge, OK.
>>LANE: What the current screening recommendations are and, you know, there are four
different tests that could be utilized to do
>>KOPELOW: so, that's I would have called knowledge in action. That you, that the four
different things are how you take knowledge and operationalize it into four potential
strategies for the docs to use. Is that fair?
>>LANE: Right.
>>KOPELOW: So, what are those four, what are the four?
>>LANE: OK. They are fecal occult blood
>>KOPELOW: I'll count
>>LANE: they are fecal occult blood testing, and there are different types of that that
are available. Then another would be colonoscopy,
sigmoidoscopy, and double contrast barium enema, which is not widely used, really,
but that's an option.
>>KOPELOW: So, the physicians' role in those four is different, the physicians' role in
those four is different, it's some of them are teaching the patient and enabling the
patient. Some of them are explaining and referring
the patient and predisposing them to get it done. So, what did you see from an educational
perspective as the different as the things that you taught about all those four?
>>LANE: OK. Well, in addition to explaining how to properly do the tests, you know, and
how to dispel improper screening practices, for example, something that is occasionally
done but is not considered adequate screening is doing a single test at the time of a ***
exam. So, we highlighted that aspect. We also highlighted barriers to screening in general
among patients and to fully familiarize them with the problem we also went over theories
of health behavior, the most common theories. And to show them how these could be
utilized in motivating patients to follow through with screening.
>>KOPELOW: So, we've talked about this one hour educational intervention, but could you
tell me more about the context in which this happened, about the workplace, about the
involvement of other people in the workplace? What other things did you do that sort of
made the whole picture of this intervention?
>>LANE: OK. Well, we were targeting specifically providers of low income populations, the
county community health centers, because screening rates are lowest among those people
who are the poorest in the community. And we wanted to make it convenient to fit in
with their busy schedule. So, we held these sessions at the time that they had their regular
monthly meetings. So, the group of physicians and nurse practitioner PAs, whoever was
working in each health center this was done like academic detailing going into an
individual office we gathered them all together. And that one hour was an interactive
session with the faculty person using power point slides, but beginning with a question
about, you know, let's say risk factors, who's at risk: asking it as a question and then
showing the answer. But, we realized that to affect change it depended on more than
the physician. The practice environment had to
be involved. And to be innovative in terms of
our grant proposal, too, to come up with something a little new, what we proposed was to
gather the whole health care centers' staff: clinical people, non-clinical people in sort
of a strategic planning session, of SWAT analysis.
So, similarly for a staff meeting we did a SWAT analysis and the idea was, How can the
health care center improve colorectal cancer screening?
>>KOPELOW: So, this was, when you used the term SWAT analysis it's an unusual
application of it
>>LANE: right
>>KOPELOW: but you were, help clarify for me, you were looking at their strengths in
their systems ability to get people screened, their
weaknesses, what opportunities that they had to increase the rate of screening is that
how you're using those terms?
>>LANE: Right.
>>KOPELOW: OK.
>>LANE: Yeah. And it was very eye opening, I think, for all of us and a great experience
and the way we conducted it, was you know, the same facilitator had the flip chart and
he made the four boxes: strengths, weaknesses,
opportunities, threats. And handed out pieces of paper that had that same grid to
everybody in the room and gave them a few minutes to think about it sort of jot down
what they thought with regard to their health center. You know, how they could improve,
what the issues were
>>KOPELOW: Can you remember some of the things that were in those boxes?
>>LANE: Yeah I definitely can.
>>KOPELOW: Would you share those with me?
>>LANE: Well, for the strengths side a lot of what came out it was that they are there
to serve the people ,that they do that they are
able to do the fecal occult blood screening there. They have policies sand that turned
out to be interesting, because some centers did
have policies some didn't and one
>>KOPELOW: so the presence or absence of policies
>>LANE: about colorectal cancer
>>KOPELOW: could be a strength or a weakness
>>LANE: right. What the
>>KOPELOW: or an opportunity
>>LANE: But, one center that sighted this as a strength they actually had a policy that
recommended the procedure that is not recommended, which is doing a single fecal
>>KOPELOW: so that makes it a limitation or a threat
>>LANE: well, no. But, what it is, is that they thought it was a strength, but that gave
us something that could be corrected. You know,
when we analyzed this
>>LANE: and worked with them on what to do.
>>KOPELOW: What I'm interested in, one of our requirements is, is a that providers use
non-educational strategies
>>LANE: and that's what this is
>>KOPELOW: and this sounds like a strategy to, sort of a planning strategy to identify
system based practices that could be used, augmented, or replaced, or removed in order
to get the outcome. Is that a fair description?
>>LANE: It is. And it also is very useful in terms of building the team that you need.
It strengthens the team delivery of care. And
things that came out of it like some non- clinical staff person said well, I don't even
know what colorectal cancer screening is, what is that? And so, if that staff doesn't
understand, you know, the patients may not understand, too. One of the strong things
that came out of it was that almost as though they didn't have much to discuss in the way
of decision making, because colonoscopy was in a way beyond the reach of their patients
that some of the doctors didn't even talk about it, because they knew that so many of
them were uninsured that they wouldn't be able to get it. And that was very discouraging
to us from academia in realizing that when we had done studies of the private sector
that that was becoming the most recommended way of getting colorectal cancer screening.
So, there's a real disparity there. And so, we
talked about ways, you know, the SWAT analysis we put together all of the thoughts that
came out and went out and over it with the medical director and the other staff in terms
of coming up with an action plan. But, that was
something that couldn't be solved, when we talk about barriers in CME, that was something
that couldn't be solved by the CME, but it was out there, and it was something, it
led to a solution eventually that was not really a
part of the CME, but wouldn't have happened if we didn't go through this exercise.
>>KOPELOW: What was the solution?
>>LANE: The solution, one of the suggestions that came out of it, opportunities, was that,
you know, we should apply for funding to try to get funds for colorectal cancer screening
as there had been funding for breast and cervical cancer. And coincidentally, around the
same time, the Centers for Disease Control put out an announcement about funding
demonstration projects to provide colorectal cancer screening for the uninsured and
underinsured. And because at the SWAT analysis there were points that it was difficult
for their patients to get screened at the University and it was travel and things like
that; we almost felt obliged and in the Department
of Preventive Medicine to apply and we did get funding and so, they were able to get
free colonoscopy.
>>KOPELOW: It strikes me a couple of features of your project were predisposing to this
success. One was the fact that you're a clinician. And, you're a public health clinician
and you're a scientist and that you brought science to continuing education, but also
that you brought continuing education to the workplace
and this session and this meeting that you're talking about where the SWAT analysis
was where you integrated the practice and how care was being delivered. So, now you
had all three: the academic scientific pursuits, you had the educational pursuit, and you had
the clinical place working together. And one led to another where you had potentially had
quite a dramatic change in people's health because they got screened. Continuing education
isn't going to take credit for that, so to speak, but it really is a consequence of this,
this partnership of all three of these things.
>>LANE: Right.
>>KOPELOW: And what levels did you make your measurements?
>>LANE: OK. Well, one reason that we proposed to the federal government about
approaching this problem within the health centers is that we would have access to
medical records. Because we realized that in the last analysis people want real hard
evidence that there is a change. And so, what we said we would look at, look at is, pre-
this intervention looking back in the medical records for a year of patients in the age
eligible group, an adequate sample, you know, what the screening rates were at that point
in time and then conduct the intervention. And then examine the records of the patients
for the year subsequent to it. In doing things at the level that the federal government often
wants to see in research design we also had to have control centers. So, what we did is
we had, we had we paired, there were eight health
center altogether. And they were put in matched pairs, in terms of, you know, their
size, the ratio of doctors to, you know, patients, etcetera, what their baseline rates
were of screening. And then they were randomized to either the intervention group
or the control group. So, we had that going on too that we could, and what happened with
that group is they got talks on obesity, you know, but we were looking at the same kind
of factors afterwards. And so, although the ultimate desire to outcome is screening, you
know, evidence in the record that the patient was screened, we also thought that it was
fair to include as one of the outcomes whether the doctor either referred the patient for
endoscopy or whether they gave them the kit, you know, to have it or did any of those measures.
So, that counted too. And so those were the things we examined pre- and post
intervention. And we found that there was a
statistically significant, you know, difference between the intervention group and the
control group in terms of improvement and screening.
>>KOPELOW: Did you make any measurements or inferences or of the impact of the
second order intervention, you know, this sort of SWAT analysis approach. Like did you
separate out what the impact was of the one-on-one versus that?
>>LANE: We did not and that's, you know, a weakness, so to speak, but we thought that
it was
>>KOPELOW: or an opportunity
>>LANE: an opportunity right. We felt that it was integral to the success of this that
everybody that the whole team saw that this
>>KOPELOW: of course
>>LANE: was a goal of the program.
>>KOPELOW: How much impact did you have? What was the numbers? What did you,
how did you change things?
>>LANE: It was 16% in the intervention group versus 4% in the control group.
>>KOPELOW: You know, we've been talking for many years about CME as a Bridge to
Quality, CME as a strategic asset to those who are trying to improve patient care. And
it seems that the project that you've described
has had that impact, has taken that place. The, you've modified what the docs know, and
what they can do; you've modified the system in which they operate to predispose
them to being able to deliver care, but, yet, it
sounds like it's all nested inside of a place where there are disparities and barriers to
people getting what it is that they need. You talked about applying for funds to get
more screening is there any other aspects to the
population or community level care that you intervened with?
>>LANE: Yes. Finance is a barrier, but there is other things create barriers and so progress
was made without that. In other words more people were getting screened, more people
who have lesser education, fewer resources were understanding the need for screening
risk and were getting screening. So, a lot had been accomplished just with that alone.
>>KOPELOW: I mean you increased things from 4% to 16%
>>LANE: Yeah.
>>KOPELOW: That's, is that a fourfold increase? That's a lot of increase from 4% to 16%.
Those are a lot of people that were getting screened that weren't getting screened before.
There's still a difference between 100% of the people that are, that need screening and
getting screening. Are you extending this project? Are you doing anything else about
that?
>>LANE: Well, a couple of things that we've done is to put together the materials that
ere used for this, for the purpose of this in
center educational thing to an enduring material and to incorporate into that enduring material
a special focus on the underserved and the experience that we went through with this
project and what the special issues are in working with that population. So, you know,
we've sort of multiplied the project by going that route making it an online activity
that can be looked at on our Web site.
>>KOPELOW: And I would think that for yourself, for other people in the institution and for
other people that are listening to this that this is a model that can be repurposed for
many clinical problems and scenarios in public
health and in screening
>>LANE: definitely
>>KOPELOW: you've developed tools that are available in your publication for teaching
the docs and involving the workplace where the
physician is, identifying other opportunities that you can follow up with, and I think that
this is a wonderful integration of research, of
education, and public health to have a positive impact and like all public health projects,
there's always more to do.
>>LANE: Exactly.
>>KOPELOW: And we need people to think of other things to do. So, I think this is terrific
and I appreciate you taking the time to talk to us about this.
>>LANE: Thank you.
>>KOPELOW: You're welcome.
>>LANE: I enjoyed it.