SummaryThe Chinatown Public Health Center, a primary care clinic in San Francisco that serves a patient population that primarily speaks Cantonese, implemented the influenza–fecal occult blood test program in which eligible patients who come in for a primary care visit during influenza season are offered an influenza shot and a home fecal occult blood test that they can complete and return by mail. The nurse-led program targets patients between the ages of 50 and 80 years who have not had recommended colorectal cancer screening. To increase the odds that a patient will complete the test, the patient views a Cantonese-language video that explains the benefits of colorectal cancer screening, and nurses (all of whom speak Cantonese fluently) address any questions or concerns the patient may have. In its first year, the program significantly increased the proportion of clinic patients screened for colorectal cancer, with nine of the patients screened through the program having abnormal results that required followup testing.Moderate: The evidence consists of comparisons of colorectal cancer screening rates among eligible clinic patients who participated in the FLU-FOBT program in its first year to similar patients who did not.
Developing OrganizationsAmerican Cancer Society; Centers for Disease Control and Prevention; Chinatown Public Health Center
Use By Other OrganizationsThe Chinatown Public Health Center intervention served as a pilot test for other San Francisco Department of Public Health Clinics that have since implemented FLU-FOBT Programs. The program is also currently being implemented by community health centers in several states. Kaiser Permanente Northern California has used the program at its mass influenza vaccination clinics to screen thousands of its members every year since 2007. Information about these activities is available at: http://flufit.org.
Date First Implemented2008
Patient PopulationThe clinic primarily serves low-income, Cantonese-speaking Chinese Americans who do not speak English.Race and Ethnicity > Asian; Age > Middle-aged adult (45-64 years); Vulnerable Populations > Non-english speaking/limited english proficiency; Age > Senior adult (65-79 years)
Problem AddressedColorectal cancer is a common, often deadly disease, and many of these deaths could be prevented by appropriate screening and followup. In the United States, screening rates are especially low among foreign-born patients. Annual influenza shot campaigns offer an excellent opportunity to screen patients for colorectal cancer through fecal occult blood tests (FOBT), but few primary care clinics have tried combining these two preventive services into a single program.
- A common, often deadly condition: In 2008, more than 108,000 new cases of colon cancer and more than 40,000 new cases of rectal cancer occurred, making colorectal cancer the third most common form of cancer in the United States. It is also the third leading cause of cancer deaths among U.S. adults, with almost 50,000 individuals dying from the disease in 2008.1
- Many preventable deaths: Many colorectal cancer deaths can be prevented with appropriate screening as recommended by the United States Preventive Services Task Force (USPSTF) guidelines; such screening can identify early-stage, highly treatable cancers, and enables the detection and removal of polyps before they progress to cancer. Despite growing awareness of the need for screening, only 57 percent of eligible U.S. adults are up-to-date with USPSTF recommendations.2 Due to educational, linguistic, social, and cultural factors, screening rates among foreign-born individuals are significantly lower than among those born in the United States.3
- Unrealized potential of combining screening with influenza shots: Annual influenza shot campaigns typically attract many older patients who also need colorectal cancer screening and other preventive health services. Consequently, they provide an excellent opportunity to address multiple needs (including colorectal cancer screening) in a single visit. In addition, nurses or nurse assistants can both administer an influenza shot and distribute an FOBT kit, making it possible to offer both services without disrupting physician workflow. Despite these potential advantages, few primary care clinics have put in place such programs.
Description of the Innovative ActivityThe Chinatown Public Health Center, a primary care clinic in San Francisco that serves a patient population that primarily speaks Cantonese, implemented the influenza–fecal occult blood test (FLU-FOBT) program in which eligible patients who come in for a primary care visit during influenza season are offered an influenza shot and an FOBT kit that they can complete at home and return by mail. The nurse-led program targets patients between the ages of 50 and 80 years who have not had recommended colorectal cancer screening. To increase the odds that a patient will complete the test, the patient views a Cantonese-language video that explains the benefits of colorectal cancer screening, and nurses (all of whom speak Cantonese fluently) address any questions or concerns the patient may have. Key program elements are detailed below:
- Seasonal program targeting eligible patients: Each year when influenza shots are available (typically October through January), the clinic offers eligible patients coming in for a primary care visit an influenza shot and a home FOBT kit if they are due for colorectal cancer screening. Patients are offered the kit if they are between the ages of 50 and 80 years and have not had an FOBT in the past year, flexible sigmoidoscopy in the past 5 years, or a colonoscopy within the past 10 years. A nurse determines eligibility for screening by reviewing the electronic health record (EHR) before seeing the patient.
- Distribution of FOBT kit with influenza shot: The nurse handles the FLU-FOBT portion of the visit, typically before the patient sees the physician, as outlined below:
- Raising issue of cancer screening: During all primary care appointments, the nurse offers eligible patients an influenza shot and provides it to those who want it. At the same time, the nurse asks eligible patients if they would like to learn more about colorectal cancer screening.
- Educational video and discussion: If the patient agrees to learn more, the nurse provides a brief introduction to appropriate screening, and plays a 4-minute Cantonese-language video that reviews further details about the need for screening and the screening process. After the video, the nurse answers any questions the patient may have.
- Distribution of FOBT kit: The nurse gives all patients who agree to be screened an FOBT kit along with a prepaid return envelope and a one-page instruction sheet in Cantonese that includes information on the importance of screening, instructions for completing the test, and a telephone number to call if questions arise. The sheet includes images of the clinic logo, along with pictures of clinic staff, and a prominent advocate of screening from the local community.
- Nurse documentation: The nurse records the patient's responses about receiving an influenza shot and the FOBT kit on a log sheet, which is later entered in the EHR.
- Followup: Patients complete the kit at home and mail it directly to the laboratory that handles the clinic's tests. Members with negative results receive notification by mail. The clinic proactively contacts those who test positive to schedule a followup diagnostic evaluation, typically a colonoscopy.
Context of the InnovationOne of nine community-based adult primary care clinics operated by the San Francisco Department of Public Health, the Chinatown Public Health Center serves a population consisting mostly of monolingual Cantonese-speaking immigrants who live in San Francisco's Chinatown neighborhood. The clinic has 8 primary care clinicians who each work between 10 and 30 hours a week, collectively handling roughly 14,000 visits each year.
The FLU-FOBT program grew out of discussions in 2004 between Dr. Michael Potter, a family physician and researcher affiliated with the University of California, San Francisco (UCSF) Medical School, and Dr. Larry Dickey, medical director in the Office of Health Information Technology of the California Department of Health Services. The two physicians recognized that influenza season motivates large numbers of people to visit a health care site to get vaccinated, including many who are due for colorectal cancer screening. Consequently, they felt that primary care visits during the influenza season could be an ideal opportunity to not only offer an influenza shot, but also to educate and screen eligible patients for colorectal cancer screening. In addition, they recognized that both services (the influenza shot and distribution of the FOBT kit) could be handled by nurses, making it easy to combine the two offerings without any disruption to clinic or physician workflow.
In 2005, Dr. Potter secured funding from the American Cancer Society to develop a FLU-FOBT Program in collaboration with researchers Dr. Judith Walsh and Dr. Stephen McPhee and the clinical leaders and staff at San Francisco General Hospital. In 2008, the Centers for Disease Control and Prevention granted funding to adapt and test the intervention in primary care clinics. The first primary care clinic to participate in these new activities was Chinatown Public Health Center.
ResultsIn its first year, the program significantly increased the proportion of eligible clinic patients screened for colorectal cancer, with nine of the patients screened through the program having abnormal results that required followup testing.
Moderate: The evidence consists of comparisons of colorectal cancer screening rates among eligible clinic patients who participated in the FLU-FOBT program in its first year to similar patients who did not.
- Much higher screening rates: During the program's first influenza season (2008), the colorectal cancer screening rate among the 970 eligible patients who had primary care visits and received influenza shots increased by 18 percentage points (from 57.3 to 75.3 percent), compared with an increase of only 1.7 percentage points among the 529 eligible patients who had primary care visits during this time frame who did not get an influenza shot.
- Identification of abnormal FOBT tests: In 2008, nine patients who participated in the program had abnormal FOBT results that required followup by clinic physicians.
Planning and Development ProcessKey steps included the following:
- Development of program components: In 2008, Dr. Potter and his research team worked with clinic leaders Dr. Albert Yu and registered nurse Kit Chan to develop key components of the program, including the influenza shot log, information sheets (in both Cantonese and English), and the instructional video.
- Nurse training: Most clinic-based nurses attended a 1-hour group session led by Dr. Potter and the clinic's medical director.
- Program launch: The program launched on September 30, 2008, using home guaiac FOBT kits, which require the patient to collect two stool samples after implementing dietary and medication restrictions. A member of the research team who speaks Cantonese provided on-the-job training during the first few days of the intervention.
- Early changes: After the initial launch, nurses were encouraged to suggest changes to the program and educational materials to improve workflow and program effectiveness. For example, based on their input, program leaders decided to add culturally appropriate pictorial instructions to the information sheets, with the goal of helping low-literacy patients better understand how to complete the test.
- Switch to different type of kit: In 2011, the San Francisco's Department of Public Health switched from the use of guaiac FOBT to the fecal immunochemical test (FIT), a single sample stool test that is more accurate and easier to use than the lower-sensitivity FOBT's previously in use. As a result, the Chinatown Public Health Center began using FIT kits.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as it is largely administered by clinic nurses and nurse assistants as part of their regular jobs, with oversight from clinic physicians and the medical director (also as part of their regular responsibilities). Although the intervention does not require new staff, it does require existing staff to spend time organizing and implementing the program. The amount of time is typically greatest in the first year.
- Costs: Data on program-related costs are not available. However, such costs tend to be small, consisting primarily of the upfront time spent on training (several hours), the time and money required to develop and produce program materials (e.g., video, information sheets), and the costs of purchasing additional FOBT kits to meet the increase in demand for testing.
Funding SourcesAmerican Cancer Society; Centers for Disease Control and Prevention; Alexander and Margaret Stewart Trust; HMO Cancer Research Network
The American Cancer Society, the Centers for Disease Control and Prevention, the HMO Cancer Research Network, and the Alexander and Margaret Stewart Trust have provided funding to support the development, implementation, and evaluation of the FLU-FOBT program.
Tools and Other ResourcesMore information about FLU-FOBT programs, including training materials, log sheets, and patient information sheets that can be adapted to other sites, is available at: http://flufit.org/index.html. The site also includes video interviews with patients and staff who have participated in the program.
Getting Started with This Innovation
- Consider use outside primary care: The FLU-FOBT program can work in any site where patients receive influenza shots. In addition to the primary care clinic described in this profile, it has been used successfully in a public hospital, at influenza shot clinics organized by a large health maintenance organization, and at commercial pharmacies.
- Start planning early: To ensure the program runs smoothly, start planning well in advance of influenza season. Once details have been determined (e.g., program scope, participating staff), schedule a training session approximately 1 week before program launch.
- Consider initial small-scale test: Before fully implementing the program, consider running a small-scale test to evaluate its impact on day-to-day operations. For example, a small subset of nurses can begin offering FOBT kits to patients they administer influenza shots, or the clinic can initially offer the program only 2 days a week.
- Make sure followup care is available: A FLU-FOBT program will likely increase the number of FOBT kits requiring laboratory analyses and the number of patients requiring followup colonoscopies. Before launching the program, implementing sites need to make sure the laboratory can handle the increase in testing, and that gastrointestinal specialists will be available to perform colonoscopies in a timely fashion. Long delays in getting test results or waiting for followup tests will likely reduce the program's effectiveness.
Sustaining This Innovation
- Focus on return rate: Adopting sites should carefully monitor the proportion of patients who complete and return the test. If that percentage falls or remains lower than desired, consideration should be given to enhancing followup efforts. For example, those not returning the test within a set time frame could be contacted by mail, telephone, e-mail, or text message.
- Consider adding more elements: Once the program is running smoothly, the clinic may want to consider "bundling" additional elements, such as having the nurse also offer eligible patients the opportunity to get other needed vaccines (e.g., shingles, pneumonia), enroll in a smoking cessation program, or make an appointment for a mammography.
Additional ConsiderationsThe FLU-FOBT Program was recognized with the 2013 "Laurel Award for Innovative Programs," awarded jointly by the Prevent Cancer Foundation, the National Colorectal Cancer Roundtable, and the American College of Obstetricians and Gynecologists. The award recognizes and celebrates innovators and leaders in the fight against colorectal cancer.
Contact the InnovatorMichael B. Potter, MD
UCSF Department of Family and Community Medicine
500 Parnassus Avenue
MU3E-329, Box 0900
San Francisco, CA 94143-0900
Innovator DisclosuresDr. Potter reported his institution received research grants from the Centers for Disease Control and Prevention, the American Cancer Society, and the National Cancer Institute related to the work described in this profile; in addition, information on funders is available in the Funding Sources section.
References/Related ArticlesPotter MB, Yu TM, Gildengorin G, et al. Adaptation of the FLU-FOBT Program for a primary care clinic serving a low-income Chinese American community: new evidence of effectiveness. J Health Care Poor Underserved. 2011;22(1):284-95. [PubMed]
Potter MB, Phengrasamy L, Hudes ES, et al. Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates. Ann Fam Med. 2009;7(1):17-23. [PubMed]
Potter MB, Somkin CP, Ackerson LM, et al. The FLU-FIT program: an effective colorectal cancer screening program for high volume flu shot clinics. Am J Manag Care. 2011;17(8):577-83. [PubMed]
Potter MB, Walsh JM, Yu TM, et al. The effectiveness of the FLU-FOBT program in primary care a randomized trial. Am J Prev Med. 2011;41(1):9-16. [PubMed]
Walsh JM, Gildengorin G, Green LW, et al. The FLU-FOBT Program in community clinics: durable benefits of a randomized controlled trial. Health Educ Res. 2012;27(5):886-94. [PubMed]
2 Centers for Disease
Control and Prevention. Increased use of colorectal cancer tests—United
States, 2002 and 2004. MMWR Morb Mortal Wkly Rep. 2006;55(11):308-11. [PubMed] 3
Goel MS, Wee CC, McCarthy EP, et al. Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care. J Gen Intern Med. 2003;18(12):1028-35. [PubMed]
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Original publication: September 11, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: September 11, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.