System

Colorectal cancers are the second most commonly diagnosed cancer in Canada with an estimation of about 26,800 Canadians diagnosed with cancer in 2017 which represented all new cancer cases. This type of cancer has a high mortality rate, ranking second, and researchers are looking for ways of its prevention or its early detection to increase the chances for successful treatment. In the same year, 12 percent of the Canadians with cancer, 9,400 died. Despite the availability of CRC screening, most Canadians notice they have colorectal cancer when it is too late; therefore, most healthcare systems recognize the need to improve colorectal cancer outcomes and consequently, they have created cancer strategies to help with the objective. These strategies have common features such as they all focus on the prevention and rehabilitation of cancer and they are also patient-centric. However, they are different when compared in terms of specificity and ambitions. Healthcare systems are using care pathways to improve not only the outcomes of colorectal cancer patients but also other health conditions such as coronary heart disease and diabetes. Most of these oncology pathways that health systems have implemented today focus on screening as a way of early detection and prevention of cancer. Healthcare systems are following a more holistic pathway approach to help them identify and eliminate the risk factors causing variations in the cancer prevention intervention. For example, the pathway for colorectal cancer involves four stages; primary prevention, diagnosis and staging, treatment and surveillance.

Purpose: Early Detection for Better Health Outcomes for Adult Ages 18-65

The goal of any healthcare system on early cancer detection is to discover cancer during its earliest stage, that is, at its pre-malignant phase. Early detection of cancer is only achievable if there are training and education to the public to promote early diagnosis and screening. A good cancer-screening test is globally accepted by the screening population and is accurate and specific. One must get an early screening test that detects warning signs related to colorectal cancer such as early malignancies, abnormal growths, polyps or precancerous lesions before the appearance of significant symptoms (Gupta, 2013). Most of the people with colorectal cancer begin at age 50 unless the person has other risk factors or symptoms which will require the screening to start at an early age. This method will reduce colorectal cancer incidences and reduce mortality rates because through screening healthcare personnel will recognize possible warning signs of cancer and take necessary action. Most health problems, including cancer, responded better to treatment if diagnosed earlier and treated as soon as possible. Therefore, if a person is at average risk for colorectal cancer, they should start routine screening at an early age. A systematic is conducted with the purpose of getting ways of early detection for better health outcomes for adult ages 18-65 at risk of suffering from colorectal cancer (Ferrira, 2003). The report focuses on the outcomes, processes, and effect of integrated health service delivery systems. Many healthcare systems have adopted a population-based strategy in hospitals and communities with the aim of capturing more of the screening populations. Health systems can only achieve to reduce the mortality rates and the number of incidences of colorectal cancer if they screen as many patients as possible.

Healthcare System Principles

Cancer prevention healthcare systems are working to detect cancer symptoms early enough to improve the health conditions of the patients. The system can take advantage of the health systems established principles and approaches to ensure clinical quality improvement. This article highlights the following principles as the key elements frequently used to provide successful integration of the health system.

Think Systematically: Improving population health requires healthcare systems to propose systems thinking skills that aid policymakers in building policies and programs that are aware of the current CRC condition and show preparedness for unintended impacts. The major premise of the principle is to understand an individual practice within the healthcare system that he/she prescribes to the patient. The system is made up of hospitals, pharmacies, physicians and others. Effective application of the principle improves patient outcomes and safety.

Respect every individual: This principle affirms that healthcare providers and patients should have respect for each other; this behavior will allow them to exercise their moral right of self-determination. A healthcare practitioner should offer guidance to the patient but should not violate their ability to be self-determining. Otherwise, they would be treating the patient as lesser persons which deprives them the essential dignity they require as humans. Every person can make judgments and actions based on their beliefs, preferences, and set of values. The physician must work with the patient undertaking the screening test to respect the fact that he/she is satisfied with the results or not.

Understand and manage variation: This principle is needed to optimize the health system and obtain knowledge on variations. Every health system has its variation, and if it lacks the understanding of variation, there is a likelihood that people will tamper with the processes and the systems and make the outcomes undesirable. Variations in outcomes and care become understandable if the stakeholders reflected differences in the whole process and patient’s satisfaction feelings.

The Scope of the System: Scope in and Scope Out

Healthcare systems across the world are creating care pathways to improve the outcomes for patients with chronic diseases such as colorectal cancer, diabetes among others. They focus on the clinical arena of providing prevention or end-of-life services to help in delivering great health outcomes (Levin et al., 2011). The systems help the patients in identifying risk factors that cause cancer and prevent the spreading of the disease. Early detection of the cancer cells is achievable when one gets an early screening test that detects warning signs related to colorectal cancer such as early malignancies, abnormal growths, polyps or precancerous lesions before the appearance of significant symptoms.

Expected Result/Outcomes of the Healthcare System

The procedures of colorectal screening can prevent colorectal cancer. Precancerous polyps can be detected after screening and removal of the polyps done before it becomes cancerous. Removal and detection of the polyps that would cause cancer through colonoscopy seem like an ideal screening tool. Through screening, identification of cancer during the early stages can be made which enhances the treatment to be more effective, and it raises the chances of recovery. Cost of treatment is much less expensive when screening identifies tumor while in its early stages than when detected during late stages of the disease.

Screening examines the entire colon, and this can help to check any abnormalities in the colon. This ensures full bowel cleansing. It can also diagnose other diseases in the colon, and this will lead to immediate treatment to start on the patient. Colonoscopy is required for abnormal results from all other tests. However, this raises the risks of bowel infections and tears as compared to other tests. Also, the test might be uncomfortable to the patient and although healthcare provider might use a sedative; it wears off after few minutes, and the person feels the effects once again (Crouse, Sadrzadeh, de Koning, &Naugler, 2015). The uncomfortable feeling is caused by the air that is pumped into the colon and rectum during the test leaving the patent with gas pains, bloated and cramping. However, after the air passes out, they go back to normal feeling. Overall, the expected results of the CRC screening process as part of the healthcare system is to find cancer early when its small and has not spread which allows for more treatment options. It is beneficial for early cancers that have no signs and symptoms.

Ideal Behaviors of Key Actors within the System

Behavior Role (Physician): physicians have the role of diagnosing and managing the gastrointestinal disorder such as screening for CRC (Blair et al., 2019). He/she plan, oversee, and plan the functions of the healthcare facilities related to the health systems. They also oversee other staff members working in the hospital including doctors and nurses. Physicians play an important role in ensuring that patients taking screen tests receive high-quality care and ethical treatment. Therefore, they help the patient in receiving the best care by performing colonoscopy and recommending occult blood testing.

Behavior Role (NP): Nurse practitioners create a structured training program that involves observations of the full screening test procedure on the patient, the withdrawals that he/she might have through to the full recovery. They also play a significant role in improving discussions with the patient on options and eventually encouraging and improving their uptake of CRC screening. Some patients lack information on the screening and nurses come in handy in explaining the importance of the test and the follow-up.

Behavior Role (Front-line Caregivers): These are the ones with direct contact with the patients. Caregivers have a range of roles from attending to the patient’s physical needs such as the provision of basic needs, for example, food, showers and dressing to logistical tasks such as making sure the patient attends the appointments, ensuring the home is clean, driving the patient to the doctor, etc. They are the strongest and with the most influence on staff behavior. Front-line nurses and caregivers are the significant determinants of healthcare experience of patients and the perception of the healthcare quality they receive.

Tools

Commission on cancer provides the system with various tools to help the cancer centers track and advance the screening tests. For example, the faecal occult blood testing tool is a screening tool which is effective in reducing mortality from colorectal cancer (Jensen et al., 2016). They also offer advocacy education, guidelines, and training materials.

Procedure

When the patient goes to a cancer department, he/she experience processes in the healthcare system. Most health systems are working towards the improvement of cancer outcomes; thus, they have set some cancer strategies to aid in that. Screening the most used method. Colorectal cancer screening tests involve looking for cancer in people who might not be showing any symptoms. The screening process involves two tests; stool-based tests and visual (structural) exams. The latter look at the colon and rectum structures if they might have any abnormality using a scope or special imaging tests while the other test checks the stool for cancer signs. Stool-based tests are more comfortable and less invasive to carry out visual exams; however, they require frequency (Jacob et al. 2013). The patient can carry the test at home and if the stool test is abnormal, meaning positive; he/she will need a colonoscopy to confirm if the cancer is present.

Triggers

The potential trigger is the failure of patients to keep an appointment probably because the process becomes pricey after the test. When the tests are done, and there are abnormalities, the patient may get discouraged on getting more diagnostic testing because the costs may go high. Some patients argue that the follow-up colonoscopy should be offered without cost-sharing and private insurers should also cover the costs. The follow-up tests are equally important as health providers consider it part of the diagnostic process. The best way to achieve a full CRC screening test and follow-up is by taking a health insurance policy and letting the insurers cover the extra costs (Crouse, 2015). Other triggers may include ignorance from the population, unavailability of tests and unawareness of physician.

Renewal Mechanisms (Including Funding, Accreditation, and Evaluation Reviews)

Healthcare providers including community centers, primary care providers and hospitals benefit from joining an accreditation program. Providers who follow through accreditation prove their dedication to health improvement and gold standards. Health system’s investments are higher compared to the outcomes it is achieving. Health systems should include five essential components in its construction; focusing on individuals and their families, cost control platform, redesigning of primary care services and structures, and integration and execution of the system (Crouse, 2015). Accreditation of the health system gives access to resources for interested organizations and bodies and recognizes professionals as top providers.

Health systems can save money by improving patient outcomes, minimizing emergency room visits, and reducing health disparities. It should focus on patient-centered care; thus; for example, reduce the cost of the screening test and provide ways which patients can get screened by minimizing barriers such as cultural and travels.

Measurements (KPIs and KBIs)

Key performance indicators or performance measures are used to measure the quality of health service delivered as they help health professionals assess services and identify improvement areas for good practice. Markedly, good information is essential when delivering excellent health services. KPIs and KBIs help health service providers to give the best service to the cancer patients through tracking their care pathway, identifying whether it is strong or where it needs extra attention. In this health system, the KPIs are the percentage of patients receiving screening in a particular timeframe and way. The healthcare providers use this percentage to set targets of cancer screening that should be done in a month, week or appropriate timeframe (Gupta et al., 2016). Tracking the KPIs helps healthcare providers visualize areas where cancer services need to be optimized; then highlight common problems or risk factors associated with colorectal cancer that should be resolved.

Patient safety is another KPI. Delayed diagnosis of colorectal cancer due to lack of follow-up leads or missed screening may lead to preventable mortality and morbidity. Some of the critical factors of ensuring successful and safe screening programs are patient engagement, keeping track of results, leadership support, and health information technology tools. The effort that the patient puts in showing up for screening services helps in achieving a timely diagnosis of cancer and thus preventing it from spreading. Patient safety in cancer health systems focuses on several issues such as the preexisting conditions before the screening, issues that may crop up from the screening; that is issues that may result from the cancer screening directly or indirectly affecting the patient. Healthcare practitioners use treatment reports, procedure-related data and patient logs to measure patient safety.

Cost of the screening process: the Canadian Task Force on Preventive Health Care recommends that an adult at risk of contracting colorectal cancer should be screened. An average of diagnostic colonoscopy cost approximately $352 and 467 Canadian dollars for a therapeutic colonoscopy after addition of overhead costs. OHIP however, continues funding patients for CRC screening when it is medically necessary, and the patient has a risk of developing colon cancer (Devaux, 2015). Inability to pay for expenses related to cancer treatment is a significant barrier when accessing quality healthcare for cancer patients. For example, FIT is a bit expensive as compared to guaiac-based screening tests. Moreover, they are more convenient and show better performance characteristics. Patients unable to afford the procedure are often not provided with the services, and if they are at risk of contracting colorectal cancer by age 50, they are diagnosed with the disease. The health system should include every person and lower the cost of the screening procedure. Alternatively, each person should take his/her choice of screen tests based on their affordability. Currently, screening rates are higher among people with a source of medical care or insurance or have higher levels of income or education (Devaux, 2015).

Patient satisfaction: if patients are satisfied, it shows that the quality of services provided is effective. Currently, tests used for screening are either visualizing the colon or the stool-based test. Healthcare providers should track how patients under cancer screening procedure perceive the different treatment aspects such as quality of care, wait time, and the amount is taken for the test thus creating a better aggregate view. They use this indicator to help in determining the budget allocation for the screening and incentives for staff under the procedure. The simplest and effective way of tracking this KPI is through the use of survey data either on a dashboard or CSV file (Potter et al., 2011). Some customers complain that they take long hours to get the screening and other tests done. These complaints on delay affect other areas and cause deployment of diagnosis and other bottlenecks for different patients. The hospital, therefore, has to tailor responses related to the complains and make headway that aims at improving patient satisfaction.  The endoscopic and stool-based tests receive the most compliments from the patients. They improve disease prognosis as they even detect advanced adenomas that are likely to progress to cancer as well as the early-stage treatable cancers. Patients rate the characteristics and effectiveness of the various tests available for CRC screening to gauge their satisfaction. High satisfaction means that the individual patient is satisfied with the tests and is willing to undergo more with the goal of better health outcome. Septin-9 and Digital rectal examination are also CRC screening tests but are not effective (Charters, Strumpf&Sewitch, 2013). Most patients who undergo this test refuse further screening because they are not satisfied with the test.

Another major concern for not achieving quality health care for these patients is their fears and distress. Oncology social workers have to assist the patient in overcoming the barriers to getting help and help them achieve optimum quality of life (Telford, 2011). The patient should be aware of the benefits of screening. They should understand that earlier removal of premalignant adenomas prevents colorectal cancer which in the long-term prevents CRC-related death.

References

Blair, A., Gauvin, L., Schnitzer, M. E., & Datta, G. D. (2019). The role of access to a regular primary care physician in mediating immigration-based disparities in colorectal screening: Application of multiple mediation methods. Cancer Epidemiology and Prevention Biomarkers, cebp-0825.

Charters, T. J., Strumpf, E. C., &Sewitch, M. J. (2013). The effectiveness of an organized colorectal cancer screening program on increasing adherence in asymptomatic average-risk Canadians. BMC health services research, 13(1), 449.

Crouse, A. (2015). Community Fecal Immunotesting for Colorectal Cancer Screening (Doctoral dissertation, University of Calgary).

Crouse, A., Sadrzadeh, S. H., de Koning, L., &Naugler, C. (2015). Sociodemographic correlates of fecal immunotesting for colorectal cancer screening. Clinical biochemistry, 48(3), 105-109.

Devaux, M. (2015). Income-related inequalities and inequities in health care services utilization in 18 selected OECD countries. The European Journal of Health Economics, 16(1), 21-33.

Ferrira, M. R., Lee, J., Dolan, N. C., Fitzgibbon, M. L., Davis, T. C., & Bennett, C. L. (2003). Sociodemographic barriers to colorectal cancer screening. Gastroenterology, 124(4), A81-A82.

Gupta, S., Halm, E. A., Rockey, D. C., Hammons, M., Koch, M., Carter, E., … & Argenbright, K. (2013). Comparative effectiveness of fecal immunochemical test outreach, colonoscopy outreach, and usual care for boosting colorectal cancer screening among the underserved: a randomized clinical trial. JAMA internal medicine, 173(18), 1725-1732.

Gupta, S., Sussman, D. A., Doubeni, C. A., Anderson, D. S., Day, L., Deshpande, A. R., … & Allison, J. (2014). Challenges and possible solutions to colorectal cancer screening for the underserved. JNCI: Journal of the National Cancer Institute, 106(4).

Jacob, B. J., Sutradhar, R., Moineddin, R., Baxter, N. N., &Urbach, D. R. (2013). Methodological approaches to population-based research of screening procedures in the presence of selection bias and exposure measurement error: colonoscopy and colorectal cancer outcomes in Ontario. BMC medical research methodology, 13(1), 59.

Jensen, C. D., Corley, D. A., Quinn, V. P., Doubeni, C. A., Zauber, A. G., Lee, J. K., … & Lee, A. T. (2016). Fecal immunochemical test program performance over four rounds of annual screening: a retrospective cohort study. Annals of internal medicine, 164(7), 456-463.

Levin, T. R., Jamieson, L., Burley, D. A., Reyes, J., Oehrli, M., & Caldwell, C. (2011). Organized colorectal cancer screening in integrated health care systems. Epidemiologic reviews, 33(1), 101-110.

Potter, M. B., Walsh, J. M., Tina, M. Y., Gildengorin, G., Green, L. W., & McPhee, S. J. (2011). The effectiveness of the FLU–FOBT program in primary care: a randomized trial. American journal of preventive medicine, 41(1), 9-16.

Telford, J. J. (2011). Canadian guidelines for colorectal cancer screening. Canadian Journal of Gastroenterology and Hepatology, 25(9), 479-481.