Colorectal Cancer a Leading Cause of Cancer Death in NYC This graph represents the latest counts of leading cancer deaths in NYC. Lung cancer continues to be the number one cancer killer. However, our focus in this presentation is the number 2 cancer killer in NYC, colorectal cancer. Colorectal cancer (CRC) can potentially be prevented via CRC screenings. This presentation focuses specifically on colonoscopies for CRC screening. Source: NYC Office of Vital Statistics, 2015.

Colon Cancer Prevention: NYC Screening Colonoscopy Adherence Trending Upward From 2003 to 2016, colonoscopy screening in New York City went from 42% to 69%. This translates to a 64% increase, or an additional 902,000 people who were screened in 2016 compared to 2003. Although New York City has made great progress in increasing the colonoscopy screenings, there is still room for improvement. Data Source: NYC DOHMH Community Health Survey, 2003-2016. Trend is significant at p < .001.

Gaps in NYC Screening Colonoscopy Adherence by Race/Ethnicity Narrowing From 2010- 2015, the Community Health Survey detected no statistically significant racial disparities in colonoscopy screening rates between White and Black, Asian or Latino New Yorkers. The elimination of disparities by race/ethnicity for screening colonoscopy rates was a huge accomplishment for NYC. This was in large part due to the incredible work of NYC Health + Hospitals. The inequities by race/ethnicity in colon cancer prevention evident in 2003 were eliminated by 2010. In 2016, the New York City Community Health Survey shows that Asians/Pacific Islanders had significantly lower rates of timely screening colonoscopy as compared either to Blacks or Hispanics, for New Yorkers ages 50 and older. No significant differences were found in rates of timely screening colonoscopy between Whites and other races/ethnicities. Data Source: NYC DOHMH Community Health Survey, 2003-2016. Trend for each race/ethnicity is significant at p < .001.

Colonoscopy Adherence Lower for Uninsured New Yorkers The largest disparity that persists is the one between the insured and the uninsured. In 2016, screening colonoscopy for New Yorkers with health insurance was 69%, while it was just 44% for the uninsured. The uninsured percent estimate should be interpreted with caution, because the sample size is small. This disparity brings us to the story of the inception of the NYC Community Cares Project (CCP). Data Source: NYC DOHMH Community Health Survey, 2016. *Estimate should be interpreted with caution. Sample size is small, making the estimate potentially unreliable.

NYC Community Cares Project (CCP) Model Links Uninsured Patients to Care Leverages NYS Certificate of Need requirement for charity care from Ambulatory Surgery Centers Creates linkages between primary care and endoscopy PCPs directly refer uninsured patients for colonoscopy Endoscopy Center provides free colonoscopy screenings CCP aims to reduce inequity between the insured and the uninsured. CCP leverages a NYS Certificate of Need requirement. This states that free standing ambulatory surgery centers must reach targeted levels of service for the uninsured to obtain their facility license. CCP acts as a liaison between these ambulatory surgery centers (Endoscopy Centers, ECs) and community health centers (CHCs) to create linkages between primary care and endoscopy. In this model, primary care physicians directly refer their eligible uninsured patients to partnered ECs for colonoscopy. The ECs provide free colonoscopy screenings, as well as free anesthesia and pathology. The NYC Community Cares Project is a collaboration supported by the C5 Coalition, the NYS Department of Health and the NYC Department of Health and Mental Hygiene.

NYC CCP Referring Sites NYC Health + Hospitals Gouverneur NYC Health + Hospitals Morrisania NYC Health + Hospitals Sydenham (Renaissance) NYC Health + Hospitals Cumberland NYC Health + Hospitals East New York NYC Health + Hospitals Kings County NYC Health + Hospitals Queens Primary Care Centers Boriken Neighborhood Health Center Charles B. Wang Community Health Center Community Healthcare Network Institute for Family Health The William F. Ryan Community Health Network Family Healthy Centers at NYU Langone Urban Health Plan Jamaica Hospital Medical Center Mount Sinai - EHHOP Grameen VidaSana Health + Hospital Primary Care Sites CCP is partnered with 56 clinical sites in New York City. Of these, 8 are NYC Health + Hospitals. CCP is partnered with 5 out of the 7 Gotham Health sites. Active participating sites as of October 2017.

NYC CCP Participating Ambulatory Surgery Sites Carnegie Hill Endoscopy Center East Side Endoscopy Center Advanced Endoscopy Center Flushing Endoscopy Center Manhattan Endoscopy Center New York GI Center Queens Endoscopy Center West Side GI Center South Brooklyn Endoscopy Center Queens Boulevard Endoscopy Center The Endoscopy Center of NY Gramercy Park Digestive Disease Center Liberty Endoscopy Center NYC CCP has partnered with 56 clinical sites and has established over 50 clinical partnerships! CCP is partnered with 13 ECs and has established over 50 clinical partnerships between CHCs and ECs. Active participating sites as of October 2017.

CCP Participating Sites Across the City and Colonoscopy Screening Rates Our primary care sites and ECs are scattered through 4 out of the 5 boroughs (all except Staten Island). The largest concentration of sites is in Manhattan, which has the most free standing ECs as noted by the red stars. Many of the areas of NYC with the lowest colonoscopy screening rates also do not have many options for ECs, and so people may have to travel for the screening. Colonoscopy Screening Rates Data Source: NYC DOHMH Community Health Survey, 2016.

NYC CCP Data Collection From all participating sites DOHMH collects: Number of colonoscopy referrals received from primary care centers Number of patients scheduled for colonoscopy Number of patients screened by colonoscopy, no-shows, cancellations Number of patients with adenomas detected during colonoscopy Number of patients with a colon cancer diagnosis Each month CCP collects de-identified data from our partnered CHCs and ECs to assess the program and provide feedback to participating sites. From CHCs: How many referrals were made How many patients were screened by colonoscopy How many patients were scheduled How many colonoscopy reports were received From ECs: How many patients were referred How many patients were medically cleared How many patients were “no shows” How many patients cancelled How many reports were sent to the CHC confirming that a screening colonoscopy was completed How many patients had adenomas removed How many cancer diagnoses were made and if any, what stage These data points are essential to aggregating information on the program’s progress.

NYC CCP New Colonoscopy Screenings Increase Year Over Year This graph shows the number of referrals (left) and the number of colonoscopy screenings (right) from 2013-2017. The numbers for both referrals and screenings have been steadily increasing. At the end of 2017, almost 6,000 patients were referred for colonoscopy and more than 3,000 had screenings completed free of cost. As you may notice, there is a completion gap between the number referred and those actually screened. This number hovers around 50% and is a sign that although much progress has been made, barriers remain. These include transportation, bowel prep, language, etc. that need to be addressed to close the completion gap.

Uninsured Lives Potentially Saved from Cancer: CCP Site Adenoma Detection Increasing This graph represents the number of screenings vs. adenomas from 2014 to 2017. Adenomas removed during a colonoscopy represent a potential averted cancer, as an adenoma may progress to colon cancer.

NYC CCP Provides Feedback Reporting to Participating Sites CHC 2 2 CHC 1 CHC 3 Endo Center A The data collected monthly from the CHCs and ECs are important because on a quarterly basis data are aggregated into Feedback Reports and distributed to respective sites. These reports are useful in showing sites their progress as well as highlighting barriers and areas for improvement. We hope this will lead to continuous improvement. The reports show total screenings/referrals by the specific site compared to the unidentified top performer and referrals and screenings by CHC/ partnered EC.

NYC CCP Feedback Tracks Colonoscopy Completions and Cancer Diagnoses Lastly, the reports show scheduling outcomes (what happens after the point of referral) and screening outcomes. Much of the data is reported by the ECs as they provide the scheduling and screening outcome data. This type of reporting is an evidence-based approach that encourages continuous improvement because it allows sites to visually note their gaps and successes.

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