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Research ArticleOriginal Research

A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics

Emily M. Mader, Chester H. Fox, John W. Epling, Gary J. Noronha, Carlos M. Swanger, Angela M. Wisniewski, Karen Vitale, Amanda L. Norton and Christopher P. Morley
The Journal of the American Board of Family Medicine September 2016, 29 (5) 533-542; DOI: https://doi.org/10.3122/jabfm.2016.05.160109
Emily M. Mader
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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Chester H. Fox
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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John W. Epling
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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Gary J. Noronha
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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Carlos M. Swanger
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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Angela M. Wisniewski
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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Karen Vitale
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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Amanda L. Norton
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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Christopher P. Morley
the Department of Family Medicine, State University of New York Upstate Medical University, Syracuse (EMM, JWE, ALN, CPM); the Department of Family Medicine, State University of New York at Buffalo (CHF, AMW); the Department of Public Health & Preventive Medicine, State University of New York Upstate Medical University, Syracuse (JWE, CPM); the Center for Primary Care, University of Rochester School of Medicine and Dentistry, Rochester, NY (GJN, CMS); the Center for Community Health, University of Rochester School of Medicine and Dentistry, Rochester (KV); and the Department of Psychiatry & Behavioral Sciences, State University of New York Upstate Medical University, Syracuse (CPM).
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  • Article
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Article Figures & Data

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    Table 1.

    Characteristics of 23 Primary Care Practices Enrolled in the Practice Facilitation and Academic Detailing Project, 2014–2015

    Practice StructurePhysicians (n)NPs and/or PAs (n)ADS Attendees (n)
    FQHC6–15≥27
    FQHC2–5≥29
    FQHC6–15≥210
    FQHC6–15≥212
    Medical group/health system2–5≥29
    Medical group/health system1≥25
    Medical group/health system105
    Medical group/health system2–506
    Medical group/health system112
    Medical group/health system2–5117
    Medical group/health system6–15120
    Medical group/health system2–518
    Medical group/health system2–5112
    Medical group/health system2–519
    Non-profit clinic2–5≥26
    Physician-owned2–5≥24
    Physician-owned2–5≥25
    Physician-owned2–5≥212
    Physician-owned6–15≥28
    University hospital/clinic2–5≥223
    University hospital/clinic≥1619
    University hospital/clinic6–1506
    University hospital/clinic2–5≥26
    • ADS, academic detailing session; FQHC, federally qualified health center; NP, nurse practitioner; PA, physician assistant.

    • View popup
    Table 2.

    One-Way Repeated Measures Analysis of Variance Comparison of Intervention Cancer Screening Rates Before and After the Intervention at 23 Primary Care Practices Enrolled in the Practice Facilitation and Academic Detailing Project, 2014–2015

    Cancer TargetScreening Rate Before the Project, Mean (SD)Screening Rate After the Project, Mean (SD)F Statistic (P Value)
    Breast cancer36.96% (17.44%)49.96% (20.62%)14.17 (0.001)
    Cervical cancer35.65% (18.68%)38.85% (20.34%)0.998 (NS)
    Colorectal cancer32.74% (16.18%)38.30% (20.80%)15.740 (0.001)
    • NS, not significant at α = .05; SD, standard deviation.

    • View popup
    Table 3.

    Comparison of Average Pre- and Post-Intervention TRANSLATE Model Element Scores at 23 Primary Care Practices Enrolled in Practice Facilitation and Academic Detailing Project, 2014–2015

    TRANSLATE Element*Score, Mean (SD)†P Value
    Before the InterventionAfter the Intervention
    Target2.70 (0.95)3.00 (1.02).031
        PF13.00 (1.00)3.00 (1.00)
        PF23.33 (0.68)3.33 (0.68)
        PF32.80 (0.84)4.00 (0.00)
        PF41.86 (0.69)2.00 (0.82).001
    Registry and reminder systems3.22 (0.72)3.39 (0.48)NS
    Administrative buy-in3.15 (0.75)3.43 (0.59).029
    Network information systems3.22 (0.86)3.48 (0.70).007
    Site coordination3.09 (0.60)3.22 (0.60)NS
    Local physician champion2.74 (1.09)2.80 (1.02)NS
    Audit and feedback2.63 (0.96)2.85 (0.85).022
    Team approach2.85 (0.98)3.11 (1.03)NS
    Education2.70 (0.67)2.91 (0.63).057
        PF12.60 (0.22)2.60 (0.22)
        PF22.17 (0.41)3.00 (0.00)
        PF33.60 (0.55)3.60 (0.55).014
        PF42.57 (0.54)2.57 (0.79)
    Cumulative score26.28 (3.68)28.20 (3.56)≤.001
    • ↵* Practice facilitator (PF) scores are displayed only for those measures with significant differences between groups (Bonferonni post-hoc analysis).

    • ↵† Scores are based on evaluations by PFs on a scale of 1 (no accomplishment) to 4 (high accomplishment).

    • NS, not significant at α = .05; SD, standard deviation.

    • View popup
    Table 4.

    Spearman Correlation of Screening Rates and Post-Intervention TRANSLATE Element Scores After the Intervention at 23 Primary Care Practices Enrolled in the Practice Facilitation and Academic Detailing Project, 2014–2015

    Correlation Coefficient (P Value)
    Breast Cancer ScreeningCervical Cancer ScreeningColorectal Cancer Screening
    Target−0.01 (NS)0.01 (NS)0.16 (NS)
    Registry and reminder systems−0.11 (NS)−0.07 (NS)0.09 (NS)
    Administrative buy-in0.07 (NS)0.20 (NS)0.47 (0.024)
    Network information systems0.11 (NS)0.11 (NS)0.23 (NS)
    Site coordination0.47 (0.023)0.72 (0.001)0.37 (0.086)
    Local physician champion−0.06 (NS)−0.04 (NS)−0.19 (NS)
    Audit and feedback0.28 (NS)0.31 (NS)0.48 (0.022)
    Team approach0.20 (NS)0.50 (0.025)0.05 (NS)
    Education0.42 (0.048)0.54 (0.014)0.48 (0.021)
    Cumulative score0.28 (NS)0.49 (0.030)0.34 (NS)
    • NS, not significant at α = .05.

    • View popup
    Table 5.

    Common Barriers and Supports for Increasing Cancer Screening Expressed During Focus Groups and Key Informant Interviews at 23 Primary Care Practices Enrolled in the Practice Facilitation and Academic Detailing Project, 2014–2015

    Barriers to Increased ScreeningSupports of Increased Screening
    Patient level∙ Transportation∙ Education and outreach
    ∙ Insurance/financial constraints∙ Case management and follow up
    ∙ Language/communication issues at the point of care∙ Lifestyle-amenable screening methods
    ∙ Comprehension∙ Reduction of structural barriers
    ∙ Refusal/noncompliance
    Staff level∙ Lack of time∙ Shared responsibility to discuss and document screening with patients
    ∙ EHR data errors∙ Standardized data entry and/or EHR technical assistance
    ∙ Lack of investment in quality improvement interventions∙ Performance assessment and feedback
    ∙ Point-of-care reminders
    Practice level∙ Lack of personnel∙ Quality improvement coaching
    ∙ Workflow inefficiencies∙ Workflow assessment and adjustment
    ∙ EHR data errors and reporting limitations∙ EHR “workarounds”
    ∙ Two-way communication with specialists∙ PCMH certification requirements
    ∙ EHR technical assistance
    • EHR, electronic health record; PCMH, patient-centered medical home.

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The Journal of the American Board of Family     Medicine: 29 (5)
The Journal of the American Board of Family Medicine
Vol. 29, Issue 5
September-October 2016
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A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics
Emily M. Mader, Chester H. Fox, John W. Epling, Gary J. Noronha, Carlos M. Swanger, Angela M. Wisniewski, Karen Vitale, Amanda L. Norton, Christopher P. Morley
The Journal of the American Board of Family Medicine Sep 2016, 29 (5) 533-542; DOI: 10.3122/jabfm.2016.05.160109

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A Practice Facilitation and Academic Detailing Intervention Can Improve Cancer Screening Rates in Primary Care Safety Net Clinics
Emily M. Mader, Chester H. Fox, John W. Epling, Gary J. Noronha, Carlos M. Swanger, Angela M. Wisniewski, Karen Vitale, Amanda L. Norton, Christopher P. Morley
The Journal of the American Board of Family Medicine Sep 2016, 29 (5) 533-542; DOI: 10.3122/jabfm.2016.05.160109
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  • Analysis of Variance
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