Enhancing Screening Colonoscopy Rates: The Mount Sinai Experience .

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Improving Screening Colonoscopy Rates: The Mount Sinai Experience. Professor of Medicine Associate Director, Division of Gastroenterology Mount Sinai School of Medicine New York, NY (steven.itzkowitz@mountsinai.org). Steven Itzkowitz, MD, FACP, FACG, AGAF .
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Enhancing Screening Colonoscopy Rates: The Mount Sinai Experience Professor of Medicine Associate Director, Division of Gastroenterology Mount Sinai School of Medicine New York, NY (steven.itzkowitz@mountsinai.org) Steven Itzkowitz, MD, FACP, FACG, AGAF

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Screening Colonoscopy Rates are Low: East Harlem, NYC

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Barriers to CRC Screening Physician obstructions: Problems: Failure to suggest (any) CRC screening; trouble orchestrating colonoscopy Solution: Open Access Endoscopy Patient boundaries: Problems: Fear; doubt; capitulation to the inevitable; dialect; inconvenience; proficiency; instruction Solution: Patient Navigation Organizational hindrances Problems: Systems for planning; Insurance Solution: Open Access Endoscopy

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Definition : PCPs allude normal hazard patients straightforwardly to screen without an earlier GI Clinic meeting Advantage: More advantageous for patients Disadvantage: Potentially less understanding by patient of the system signs/prep than with starting GI Clinic visit Ways to Facilitate Colonoscopy: 1. Open Access Endoscopy (OAE)

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Definition : Patient Navigator is somebody who controls the patient through the way toward finishing colonoscopy after PCP referral. Parts of the Navigator : Assist with booking, transportation, understanding instruction re: colonoscopy (method of reasoning, significance, prep) Remind quiet about their arrangement Help mollify fears Ways to Facilitate Colonoscopy: 2. Persistent Navigation (PN)

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Hypothesis : "In the event that we assemble it, they will come." Reduce boundaries for alluding doctors: Nov. 2003: Open Access framework began Help patients finish their colonoscopy: April 2004: Patient Navigator contracted Bilingual Hispanic female wellbeing teacher Remove protection as a deterrent: Medicaid patients (straightforwardly alluded from Internal Medicine Associates and GYN Clinic). Mount Sinai Screening Colonoscopy Demonstration Project

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Open Access Endoscopy Direct Referral Form faxed by Primary Care Provider Reviewed by Gastroenterologist Appropriate cases given to Patient Navigator Patient Navigator then does the accompanying: Step 1: Scheduling Phone Call Step 2: Reminder Postcard Step 3: Two Week Reminder Call Step 4: Three Day Reminder Call Approach

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Patient Navigator: Ms. Anabella Castillo

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Review the accompanying with the patient: Reason for referral Importance of having a colonoscopy Review current drugs Review and mail prep materials Ensure escort Answer all inquiries Address concerns Step 1: Scheduling Phone Call

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D O C T O R\' S O R D E R Step 2: Post Card G E T S C R E N E D

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Confirm receipt of prep and how to perform prep Confirm arrangement time and area Confirm escort Review significance of having a colonoscopy Answer all inquiries Address concerns Steps 3 & 4: Reminder Phone Calls (2 weeks, and 3 days before method)

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RESULTS Total Referrals into OAE System n=1169 Did Not Qualify for Navigation (n=264) Required assessment in GI Clinic (n=208) (18%) Referral preceding onset of PN program (n=56) Qualified for Navigation n=905 Ineligible for SC (n=217) Completed SC without route (n=44) Multiple referrals (n=149) Not yet reached by PN (n=21) Scheduled for future (n=3) Eligible for SC n=688 Non-explored, non-completers n=156 (23%) GI appt fundamental (n-38) Unable to contact (n=92) Language not English or Spanish (n=4) Insurance terminated, left nation, expired (n=22) Navigated n=532 (77%) Completers n=353 (67%) Non-completers n=179 (33%) Chen et al. Clin Gastro Hepatol , in press

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Demographics of Study Population * New York City Department of Health and Mental Hygeine

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Predictors of Completion * p<0.05

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Predictors of Completion Women will probably total than men. Alternately = 1.31 (95% CI 1.11-2.63) Hispanics will probably entire than African Americans. On the other hand = 1.67 (95% CI 1.11-2.50) Multivariate: Hispanic ladies will probably entire than Hispanic men. On the other hand = 1.5 (95% CI 1.23-4.21)

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Pathology Detected Pts w/adenomas 58/353 (16.4%) Pts w/progressed adenoma 7/353 (2.0%) 2 growths (Stage I) 1 HGD 1 villous adenoma

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Patient Satisfaction (among completers) 64% of patients would not have finished colonoscopy without the help of the Patient Navigator Felt the technique had been clarified: by PCP: 84.2% by PN: 92.1% Understood gut prep: by PCP: 34.9% by PN: 58.5% Satisfied with inside prep clarification: by PCP: 83.0% by PN: 99.1%

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What\'s in it for the Hospital? The accompanying slides give a rough gauge of budgetary advantages managed by contracting a Patient Navigator. The information demonstrate that: Without changing any Endoscopy Unit operations, a Patient Navigator averts "lost" income to the healing facility. By expanding proficiency and including more cases every week, extra income is caught.

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Patient Navigation Improves Efficiency Prep Quality: Inadequate or Poor Pre-Navigation: 12% Post-Navigation: 5% "No-Show" Rates Pre-Navigation: 40% Post-Navigation: 9.8%

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Financial Impact of: Better Prep Rates Assuming 2,500 colos every year: 12% poor prep without PN 300 5% poor prep with PN 125 More finished colos 175* *4 more cases every week Revenue: @ $500 per case $ 87,500 @ $1000 per case $175,000

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Financial Impact of: Improved No-Show Rate Assuming 2,500 colos every year: 40% no-show without PN 1,000 15% no-show with PN - 375 More finished colos 625* * 14 more cases for every week Revenue: @ $500 per case $312,000 @ $1000 per case $625,000

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Financial Impact of: "Lost" Colonoscopies Poor preps: 4 cases/week No-shows: 14 cases/week Total: Lost colos: 18 cases/week Without route, lost income (for similar overhead): @ $500 per case $405,000 @ $1000 per case $810,000

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Financial Impact of: Enhanced Efficiency Avoiding Lost Colonoscopies (for similar overhead): @ $500 per case $405,000 @ $1000 per case $810,000 Increasing effectiveness of existing operations: 15 new cases included every week @$500 per case $338,000 @$1,000 per case $675,000

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Financial Impact of: PN + Enhanced Efficiency 33 more cases for each week 18 because of PN 15 new cases because of better productivity 1,485 more colos every year Revenue: @ $500 per case $ 742,500/yr @ $1000 per case $1,485,000/yr Pathology recognized: Adenomas (16% incidence) 238 new cases Cancers (@0.6% incidence) 8-9 new cases

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Financial Implications: Hospital Expenses To take care of business, the Hospital may need to consider the accompanying money related ventures: Patient pilot: $ 50,000 Physician(s): $200,000 TOTAL: $250,000 But: These costs are counteracted upgraded proficiency and through-put… ..

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Conclusions The Mount Sinai Screening Colonoscopy Demonstration Project uncovers the accompanying: Minority patients in East Harlem can be effectively explored into screening colonoscopy. Quiet Navigation enhances the current productivity of Endoscopy Unit operations by notably bringing down the "no-show" and "poor prep" rates. The Hospital benefits fiscally from this program.

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Areas for Future Improvement Even with frameworks set up to advance the simplicity of getting colonoscopy (medical coverage, open get to referral, understanding route), 33% of urban minority subjects still did not finish colonoscopy. Ladies will probably total than men, and Hispanics will probably total than African-Americans How would we enhance the 33% non-culmination rate? What behavioral or potentially social issues characterize patients who finish route versus the individuals who don\'t? Is there a part for associate route? Socially focused on mediations? How would we get doctors at intentional clinics to scope underinsured/uninsured patients?

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Acknowledgments Gastroenterologists Maria Abreu, MD Peter Chang, MD Sita Chokhavatia, MD Eric Goldstein, MD Peter Legnani, MD Michelle Kim, MD Lloyd Mayer, MD Thomas Ullman, MD Xianyang Yio, MD, PhD Navigation Program Steven Itzkowitz, MD Jennifer Christie, MD Lina Jandorf Anabella Castillo Yira Duplessi Lea Ann Chen, MD (restorative assistant) Stephanie Santos, MD (GI individual) Grant Support NYC DOHMH & American Cancer Society Mount Sinai Dept of Medicine Advisory Board

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D O C T O R\' S O R D E R Step 2: Post Card G E T S C R E N E D

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