This project, led by Dr. Jennifer Weiss, aimed to characterize factors at the system, clinic, provider and patient levels that influence colorectal cancer (CRC) screening rates at rural and urban clinics. CRC is the second leading cause of cancer-related deaths for adults in Wisconsin, and it the most preventable yet least prevented cancer due to low uptake of screening. Recognizing that many rural, low-income, and racial/ethnically diverse communities have disproportionately low screening rates, the National Colorectal Cancer Roundtable announced a campaign to achieve screening rates of 80 percent and higher in every community. Wisconsin has a screening rate of 73.4 percent; however, there is wide geographic variation among rural and urban clinics.
The research team successfully developed a novel rural-urban geodisparity model that revealed significant disparities in CRC screening rates between rural and urban clinics. High-performing clinics, particularly those serving subpopulations with historically low screening rates, utilized stool-based screening tests more frequently, likely due to fewer resources and less access to colonoscopy facilities in rural areas. Additionally, the research team conducted interviews with clinic staff who highlighted the critical roles of medical assistants and primary care providers, shared decision-making and the need for stratified screening rate information to inform interventions aimed at reducing disparities and improving CRC screening practices.
The Challenge
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths for adults in Wisconsin and nationally. It is the most preventable, yet least prevented cancer due to low uptake of CRC screening. At the state level, Wisconsin’s overall CRC screening rate is 73.4 percent, compared to 67.3 percent nationally, however there is wide geographic variation among rural and urban clinics. The National Colorectal Cancer Roundtable recently announced their new campaign to achieve screening rates of 80 percent and higher in every community, recognizing that many rural, low-income and racial/ethnically diverse communities have disproportionately lower screening rates. As a result, there was a need to learn directly from high-performing clinics in rural and urban settings, as well as clinics that are high-performers for specific subpopulations with historically low screening rates to share best practices to improve overall screening and reduce disparities.
Project Goals
The goal of this project was to reduce CRC incidence and mortality across Wisconsin by characterizing factors across multiple levels, including system, clinic, provider and patient, that distinguish high- from low-performing rural and urban clinics. It sought to identify successful CRC screening strategies, particularly for underserved populations like Medicaid recipients and racial/ethnic minorities. Researchers planned to partner with the Wisconsin Collaborative for Healthcare Quality (WCHQ) and utilize extensive electronic health record data from 14 health care systems encompassing 230 clinics statewide to achieve the following specific aims:
Identify multi-level predictors of CRC screening among patients in rural and urban clinics.
Examine specific rural and urban clinics that are high-performing for subpopulations with historically low screening, including Medicaid recipients and racial and ethnic minorities.
Contrast strategies used to support CRC screening in high-performing clinics with lower-performing clinics across rural and urban settings, overall and for subpopulations with historically low screening.
Results
The research team achieved each of its aims. First, the team developed a novel rural-urban geodisparity model that considers regional health care capacity and needs across Wisconsin. This model was applied to data from the WCHQ and revealed significant disparities in CRC screening rates between rural and urban clinics. Rural clinics had lower screening rates even after adjusting for multiple factors, including patient demographics, socioeconomic status, insurance type, comorbidities, provider workload and clinic resources. The disparities were more pronounced in underserved areas, highlighting the complexity of issues related to health care access.
Next, the study identified high-performing clinics, especially for subpopulations with historically low screening rates such as Medicaid recipients, un- and underinsured patients, and racial/ethnic minorities. Analysis showed that higher-performing clinics utilized stool-based screening tests more frequently, while lower-performing clinics relied more heavily on structural exams like colonoscopies. Rural clinics were significantly more likely to use stool-based tests, possible due to fewer resources and less access to colonoscopy facilities and specialists. The research team presented these findings at Digestive Disease Week 2024.
Finally, the team conducted interviews with staff from high-performing clinics to identify effective CRC screening strategies. Key themes included the critical roles of medical assistants and primary care providers in managing the screening process, the importance of shared decision-making and the influence of clinic managers on screening rates. Preliminary results suggested a significant interest among providers in receiving stratified screening rate information by race/ethnicity and insurance coverage. These insights have the potential to help develop interventions to enhance CRC screening practices, reduce disparity and improve patient outcomes across diverse populations in Wisconsin.
Looking to the Future
The research team has applied and received funding from the American Cancer Society to expand their work to focus on rural primary care clinics and include clinics that do not participate in WCHQ, as well as clinics across multiple states in the upper Midwest, including Minnesota, Iowa and Illinois.
