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The St Mark’s Bowel Cancer Screening Centre – Improvements to Uptake

Andrew Prentice on behalf of The St Mark’s Bowel Cancer Screening Centre

Authors and Institution

Sarah Marshall – Clinical Programme Manager
Andrew Prentice – Health Improvement Principal
Sameer Choglay – Health Promotion Officer

Summary of the service story

Bowel scope screening for colorectal cancer has been demonstrated to be an effective intervention which reduces incidence and mortality and the UK has been in the process of establishing a comprehensive programme since 2013. However, uptake has been below the levels seen in clinical trials, which reduces the overall effectiveness of the programme.

Challenges

St Mark’s Hospital Bowel Cancer Screening Service’s (BCSC) uptake for bowel scope stood at 40%. The BCSC sought to increase its uptake rate by engaging with participants who had previously not responded to the invite for bowel scope screening upon their first invitation.

How we managed the challenges

Our previous RCT reported the beneficial impact of reminders, which offer non- responders (DNR) and non-attenders (DNA) to arrange a new bowel scope appointment at 12 months after the first invitation. We were successful in a CQUIN application to send a 12-month reminder letter to DNAs and DNRs during 2017/18. 5078 participants were sent reminder letters with the option of indicating preferred days and times and the preference of gender of clinician, to reschedule their BSS appointment. Participants wishing to book an appointment could either fill out a return slip and post it back in a prepaid envelope or call the screening centre directly to book their appointment.

Evaluation and Outcomes

Between April 2017 and March 2018, 5,078 men (n=2649, 52.2%) and women (n=2429, 47.8%) were sent a self-referral reminder on the anniversary of their invitation. The overall uptake was 8.7% (n=441). The only significant predictor was past behaviour, with previous non-attenders (individuals who previously indicated that they would attend BSS, but failed to show) being significantly more likely to book and attend an appointment than previous non-responders (individuals who had not previously indicated that they would attend BSS); uptake was 16.5% and 7.6%, respectively (adjusted Odds Ratio [aOR]: 2.45, 95% Confidence Intervals [CI]: 1.95, 3.15; P: <0.001). Among those who attended screening, 191 (43.3%) had no abnormalities detected, 64 (14.5%) had polyps with no other pathology (such as haemorrhoids or diverticulitis), 34 (7.7%) had polyps and other pathology, and 150 (34%) had other pathology without polyps. Among those who had polyps detected (n = 98), 61 had at least one adenoma, of which 45 had adenomas classed as ‘low risk’, 6 had adenomas classed as ‘intermediate-risk’ and 10 had adenomas classed as ‘high risk’ (the overall adenoma detection rate among the screened population was 13.8%; the mean number of adenomas detected per person screened was 1.7). Twenty-three individuals were referred for colonoscopy; the majority (60.9%; n = 14) were subsequently referred for surveillance. One person was diagnosed with cancer.

Learning Points

The implementation of a 12-month self-referral reminder at St Mark’s Hospital led to a substantial number of additional men and women being screened, as well as the detection of a significant number of adenomas requiring clinical intervention. Evidence also suggests that the interventions could reduce existing inequalities in bowel scope screening uptake between men and women. St Mark’s BCSC continues to send previous non-responders reminder letters at 12 months, with over 8,500 letters being sent this year. The change to the standard patient pathway to include this intervention has led to an increase in the bowel scope screening uptake rate, is evidence-based and contributed to the reduction of bowel cancer morbidity and mortality in the local population.

Supporting information

See table one below

Tools: [implementation methods; processes required; IT support etc.

Participants

Participants were men and women, living in Brent, Harrow and Hillingdon, who did not attend a BSS appointment within 12 months of receiving an invitation from the screening programme.

Intervention

  • Participants were sent a self-referral reminder on the anniversary of their invitation.
  • The self-referral reminder highlighted the process for self-referral and gave individuals the option to book an appointment either by calling the screening centre on a Freephone telephone number or by returning an appointment- request slip via a Freepost return
  • Both options gave individuals the chance to express a preference for the day and time of the appointment and the gender of the practitioner performing the test.
  • All appointments took place at St. Mark’s Hospital in Harrow.

 

Associated documents

See CQUIN Indicator below – [ Bowel Scope]

CQUIN Indicator – [ Bowel Scope]
Indicator number N/A
Indicator name Increasing Uptake of Bowel Scope Screening through reminder letters for Non-responder (NR) and Non-attenders (DNA)
Indicator weighting
(% of CQUIN scheme available)
2.5%
Description of indicator ·       Twelve months after receiving an initial invitation for participation, all eligible adults will receive a reminder letter with the option of indicating preferred days and times to reschedule their BSS appointment.

·       An average of 450 letters a month adjusted to capacity and flexed from a minimum of 225 and a maximum of 600 per month with a minimum of 2,700 a year.

·       We will expect an uptake of >5% across this group of eligible adults.

Numerator 1.     Number of NRs, DNAs sent reminder letter
Denominator 1.     Number of NRs, DNAs attending Bowel Scope Screening
Rationale for inclusion Evidence shows that for men and women aged 55 – 64 who attend a one-off bowel scope screening test, mortality from bowel cancer in this age group can be reduced by 43% (31% on an invited population basis) and incidence can be reduced by 33% (23% on a population basis). However, uptake/ attendance for Bowel Scope is lower than for gFOBt. In London uptake for bowel scope in Q1 2016/17 was 38.11% compared to 45.6% for gFOBt across the same time period. Reminder letters for NRs, DNAs will increase uptake of Bowel Scope Screening across North West London.

 

A recent RCT reported the beneficial impact of additional reminders, which offer former non- responders and non-attenders to arrange a new bowel scope appointment at 12 months after the first invitation.

Data source BCSS to identify participants

 

Frequency of data collection Quarterly
Organisation responsible for data collection Screening Service
Frequency of reporting to commissioner Quarterly
Baseline period/date 2016/17

 

Baseline value
Final indicator period/date (on which payment is based) April 2017- March 2018
Final indicator value (payment threshold)
Final indicator reporting date 1st Quarter 2018/19
Are there rules for any agreed in-year milestones that result in payment? Yes

End of Q1, Q2, Q3 and Q4 a minimum of 225 letters to have been sent for each month in each quarter. Failure to meet target in any month will result in withholding of payment.

Are there any rules for partial achievement of the indicator at the final indicator period/date? Yes

References

Prof Brian Saunders

Director of Screening

St Mark’s Hospital Bowel Cancer Screening Centre

[email protected]

Dr Siwan Thomas-Gibson

Ass. Director of Screening

St Mark’s Hospital Bowel Cancer Screening Centre

[email protected]

Maggie Vance

Nurse Consultant

St Mark’s Hospital Bowel Cancer Screening Centre

[email protected]

 

Contact details for members interested in getting more information

Health Promotion Team

St Mark’s Bowel Cancer Screening Centre

St Mark’s Hospital, Watford Road, Harrow, Middlesex

[email protected]