1. Individual Health vs. Public Health If you’re the 1/1000, it’s a 100% for you What absolute level of risk will society/an individual tolerate? Population-based approach should account for safety, cost, availability

2. Medicare 1998 - 2001 Average Risk FOBT Annually Flex Sig q 4 yrs  Screening Colonoscopy q 10 yrs High Risk 1st degree relative w/adenoma or CA FAP, HNPCC Personal hx adenoma or CA or IBD Colonoscopy q 2 yrs Uncertainty in 50-64 age group

3. Prevalence of FOBT/Sigmoidoscopy - 1997 AGE  50 FOBT - 1 YearFS/Procto - 5 Years TotalMFTotalMF 19.818.421.030.635.226.8 Behavioral Risk Factor Surveillance System Ries L, Cancer 2000;88:2398

4. Risk Appropriate Screening Provider Endorsement/Education Public Acceptance Cost/Efficiency Help Physicians

5. Risk Appropriate Screening Provider Endorsement/Education Public Acceptance Cost/Efficiency Help Physicians

6. Sigmoidoscopy Use in 1 o Care Physicians in Allegheny County Surveyed 400 physicians - 70% response rate Median age 44; most full time clinicians Training:44% rigid; 28% flexible Proficiency:32% rigid; 22% flexible Schoen RE, Weissfeld JL, Kuller LH; Preventive Medicine 1995 49% equipment available Regularly refers or schedules pts: 34% Of those: 50%  5 pts/month

7. Sigmoidoscopy Use in 1 o Care Physicians in Allegheny County - Attitudes 83% sigmoidoscopy impt 88% agree with ACS rec’s Factors that influence decision to recommend: Cost - 62% Low prob finding a lesion - 52% Patient discomfort - 48%

8. ACES:Physician Knowledge of Reimbursement for Screening FSG (N=95) - 1999

9. Provider Endorsement Medical services are not baseball stadiums: “Build it and they will come” does NOT Apply

10. Altering Physician Behavior - CRC Screening Media Effect Liability

12. Pittsburgh Post-Gazette May 20, 2000

13. Risk Appropriate Screening Provider Endorsement/Education Public Acceptance Cost/Efficiency Help Physicians

14. Satisfaction with Flexible Sigmoidoscopy (N=1221) General% Strongly Agree Very Satisfied with care97.6 Pain/Discomfort (Didn’t) have a lot of pain96.2 More comfortable than expected68.5 (Didn’t) cause me great discomfort78.1 Enthusiasm Willing to have another93.1 Sigmoidoscopy will benefit my health91.1 Strongly recommend to friends74.9 Schoen. Arch Intl Med 2000;160:1790

15. Risk Appropriate Screening Provider Endorsement/Education Public Acceptance Cost/Efficient Delivery Help Physicians

16. NP’s and Sigmoidoscopy Back to Back FSG, N = 249 Per Polyp Missed Adenomas Missed Adenomas  1 cm Per Patient No polyp FS #1, Polyp FS #2 No adenoma FS #1, Adenoma FS #2 GI 20% (6/30) 2/10 21% (3/14) 0/4.91 NPP Schoenfeld. Gastro 1999;117:312 12% 3% 6% 2%.12.43

17. 10,164 Available T3 Visit 1,360 Did not complete T3 FSG 8,804 (86.4%) Completed T3 FSG Adherence with T3 Flexible Sigmoidoscopy 688 Had T3 Visit 672 No T3 Visit Weissfeld. Cancer 2002 (in press)

18. Sigmoidoscopy & Mammography Need training for proficiency Need Consistent Experience to Maintain Proficiency Need Current Technology Infection Control High Through-Put Standardize Reporting/Terminology Follow outcome

19. Risk Appropriate Screening Provider Endorsement/Education Public Acceptance Cost/Efficiency Help Physicians

20. Systems Approach to Prevention GAPS Put Prevention Into Practice (AHRQ) G oal setting regarding preventive care A ssessment of existing routines P lanning to modify existing routines S tarting and maintaining improved preventive care system Deitrich. Arch Family Med 1994;3:126 PPP

21. Goals Help physicians assess risk Help physicians recommend action Create visible, high quality, high volume, efficient delivery Affordable Accessible