Dr. Melinda Davis is the Director of Research for the Oregon Rural Practice-based Research Network (ORPRN). She is also an Associate Professor in the Oregon Health Science University’s (OHSU) Department of Family Medicine and OHSU/Portland State University’s School of Public Health.
Davis collaborates with patient, community, and health system partners to identify and address health disparities in rural and underserved settings. She has been the recipient of research awards that focus on a program designed to address low rates of colorectal cancer screening, follow-up, and referral to care among rural Medicaid adult patients.
Davis discusses her efforts in working with coordinated care organizations (CCOs) to try and get more Oregonians in rural areas screened for cancer in this Q&A.
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State of Reform: You have been working with the ORPRN to improve health outcomes and equity for Oregonians. One way you’ve been doing that is by trying to get more Oregonians in rural areas screened for cancer. How did that become a focus point for your work?
Melinda Davis: “At ORPRN, we work to maintain close, ongoing relationships with health care organizations working in or with rural areas across the state. The idea of cancer screening, and in particular colorectal cancer screening, actually came from community sessions with rural health care providers, community partners, and patients.
In 2013, we received a Patient Centered Outcomes Research Institute award in collaboration with Dr. Kristen Dillon to develop an academic-community collaborative in the Gorge. This collaborative, called the Community Health Advocacy and Research Alliance (CHARA), started looking at regional priorities for research and action. We were discussing the clinical quality measures that were a part of Oregon’s CCOs and colorectal cancer came up because health system partners hadn’t been able to increase screening rates as much as they wanted, and lower screening rates mean worse health outcomes in these areas.
When we started discussing it at a community symposium in The Dalles held in 2015, people were amazed there were other options to screen for colorectal cancer besides colonoscopy. A colonoscopy is a scope that looks for cancer in the colon; it requires going to a medical facility, fasting, and pretty intense preparation. But there’s other options for screening you can do at home – like a fecal immunochemical test (FIT) if you are not in a high-risk category. We heard things like, ‘What? There’s an option besides colonoscopy? I want to [do the FIT]. I can’t believe my doctor never told me about this.’ So there began our collaboration with partners in the Columbia Gorge to find ways to increase colon cancer screening.
At the same time, research collaborators at Kaiser Permanente’s Center for Health Research were working in diverse settings studying different ways to engage patients in screening. They also were collaborating with community health centers and CCOs in multiple states using approaches that mailed FITs to patients’ homes. They had tested a collaborative model where clinics and CCOs partner to encourage people to get screened. We thought that model would work well in rural settings. Together, we are working with health care providers all across the state to put in place cancer screening outreach to rural patients.”
SOR: You have been working with CCOs to distribute colorectal cancer screenings to Oregonians in rural areas. Can you describe how that process works?
MD: “It’s been a really well-received program overall, and we are learning a lot of interesting things about implementing programs with multiple health care partners. We have a collaboration between CCOs and 28 rural clinics throughout Oregon. We’re using this collaborative model to help overcome challenges in rural areas with identifying eligible patients and in helping to centralize the administrative aspects of the program.
The CCOs look at their health care claims to find people who are due for colorectal cancer screening because they have not been screened recently. They send those lists (via our research team) to the clinical practices caring for the people. Then care teams at the clinical practices review and remove any patients who don’t belong on the lists.
The nice thing about this approach is the partnerships. The CCOs mail informational letters and FIT tests to the patients on the lists. Patients can complete the FIT at home and mail it back to a lab or the clinic in an addressed-stamped envelope provided. The care teams are involved in the outreach to their patients and they follow-up with patients after the FIT test. So it’s a nice balance of using the patient care relationship held by the clinical practices and at the same time having the CCOs take on the administrative burden of the mailing itself.”
SOR: How have the updated colorectal cancer screening guidelines affected your work?
MD: “The US Preventive Services Task force issued new guidelines in May 2021 that recommend starting colon cancer screening at age 45 for all average risk patients. Previously screening for average risk people was recommended starting at age 50.
We are learning a lot about user preferences and especially messages that resonate with rural populations and those in younger age groups in our current project. With our current research and future anticipated project, we hope to look at whether different messages resonate or if other outreach strategies are needed to encourage screening in this younger age group.”
SOR: Have you found that some residents have deferred health care due to the COVID-19 pandemic? How has the pandemic affected this work?
MD: “The pandemic has affected this kind of work in multiple ways. For a while, of course, colonoscopy was completely stopped along with various other elective procedures and that created a huge backlog of appointments. But even once those services were open again, many residents have deferred health care and some people are avoiding any unnecessary trips to the doctor.
Clinical practices had to come up with new ways to manage a lot of the routine prevention activities that used to happen when a patient was in the office, including telling patients they are due for colorectal cancer screening. FIT tests were a good option for patients during this time because the tests are easy to do at home and are as clinically effective as a colonoscopy if completed annually.
Additionally, the health care organizations we have worked with, almost without exception, have experienced huge staffing shortages. We heard from clinical administrative staff that providers left or retired, it was hard to hire new staff, and staff and clinical team members were or are burned out. Some practices needed to pare back all activities that weren’t providing direct patient care.
I think we may see the ripple effects of this for years to come. Fortunately, many clinical practices are starting to raise their heads, and many are eager to partner with us to help catch up from the past few years.
In many cases on our project it really helped that the CCOs were able to step in and help the individual clinics by providing the FIT mailing and in some cases phone outreach to people due for screening. One thing our research seems to show is these kinds of partnerships have so much potential to help health care practices, and even more so in times of stress like the pandemic.”
This Q&A was edited for clarity and length.