Colorectal screening program falls flat

An analysis of a multipractice quality improvement (QI) program in New Jersey found that full-scale, emergent practice transformation efforts don’t necessarily lead to quantifiable gains in targeted measures, even when the program is implemented successfully, according to a study published in the May/June issue of Annals of Family Medicine.

The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study had aimed to improve colorectal cancer (CRC) screening rates through a mix of externally orchestrated, single-target interventions and practice-directed improvement efforts, but this method had a minimal effect on screening rates, explained Eric K. Shaw, PhD, of the Cancer Institute of New Jersey in New Brunswick, and colleagues.

“If improving performance measures for a preselected target, such as CRC screening rates, is the focus, perhaps a more traditional targeted continuous QI approach would be more appropriate,” they wrote.

SCOPE featured 23 participating practices in New Jersey that underwent observation and facilitation from study personnel. After this initial phase, practices were directed to form reflective adaptive process (RAP) teams, which would then drive the practice’s individual CRC screening improvement efforts. “A central assumption was that getting multiple stakeholder buy-in through this approach would enhance motivation and commitment to the change process,” wrote the authors.

Baseline data on CRC screening rates were collected, and then a 12-month follow-up assessed change in rates as well as gathered qualitative data through surveys and interviews focused on the program implementation itself.

Results showed that in the intervention practices there was only a small increase in appropriate CRC screening rates, from 49 percent to 53 percent, while a group of control practices saw screening rates drop from 43 percent to 38 percent, but Shaw and colleagues noted these differences were not statistically significant.

The qualitative analysis revealed that not all practices were successful in fostering a climate of change throughout the entire practice because of communication breakdowns or because team members didn’t feel “psychologically safe to take risks during the change process,” reported the authors. However, successful implementation of the program did not always result in improved screening rates.

Despite not leading to improved screening rates, Shaw and colleagues said the SCOPE trial offered some important lessons, including the observation that letting practice RAP teams choose their own objectives meant that some would focus efforts on other concerns not directly related to screening rates. “RAP teams that focused on poor communication or chaos in the practice viewed these issues to be of sufficient priority that they needed to be addressed before the teams could delve into concrete clinical improvements.”

RAP teams often featured a limited number of clinicians and communication of CRC screening goals tended to be poor. Also, the study facilitators were generalists with expertise in change processes, but the authors speculated that facilitators with expertise in the target condition could have more directly impacted screening rates.

“Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal,” concluded Shaw and colleagues. “Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.”