Lay health educators within primary care practices to improve cancer screening uptake for South Asian patients: challenges in quality improvement

Figures & data

Table 1 Characteristics and screening rates for four participating physicians

	Physician #1	Physician #2	Physician #3	Physician #4
Gender	Male	Male	Female	Female
Family practice model	Traditional, primarily fee-for-service	Team-based, primarily capitation (same practice as Physician #3)	Team-based, primarily capitation (same practice as Physician #2)	Traditional, primarily fee-for-service
Screening uptake prior to quality improvement initiatives at practice level:
Breast	68%	43%	58%	57%
Cervical	65%	59%	61%	53%
Colorectal	66%	50%	66%	41%

Table 2 Quality improvement initiatives for Physician #1

	Initiative 1 (October–November 2015)	Initiative 2 (November 2015–January 2016)	Initiative 3 (January–April 2016)
Initiatives	One-on-one education with patients – HAs approached patients in the waiting room to talk about cancer screening and to hand out pamphlets Posters were put up in waiting room in Urdu, Punjabi, and English	One-on-one education with patients – physician identified patients due for screening from the appointment list and chart review, and HAs had conversations while they waited in the room to see the physician	Phone calls by HAs to patients who were overdue for screening – patients were identified based on lists of overdue patients provided by the provincial cancer agency. Telephone scripts were agreed upon between the physician and HAs HAs maintained a list of patients who were called to assess screening uptake
Findings/challenges	Patients were approached during an evening clinic so as not to disrupt other physicians in the practice; however, the number of eligible patients who were approached was quite low. HAs only talked to 4 patients. Conversations were not well received by patients during the evening clinic due to the more acute nature of most visits	This initiative was better received by patients, but the number of patients reached (26) was still relatively low as the approach was opportunistic	A total of 404 phone calls were made, 141 of which were to patients of South Asian ethnicity. HAs were able to speak directly to patients for 47.8% of calls overall and for 55.3% of calls made to South Asian patients (78 patients). Of these 78 patients, 48 stated they would get the test done, 4 stated they would discuss it further with their physician, 7 reported they were no longer overdue for screening, and 1 refused. The remainder had no explicit response. Nearly 61.5% of South Asian patients spoken to directly were willing to be screened Overall, by July 2016, 55/188 (29.2%) of telephoned patients overdue for colorectal screening came in for screening, 45/101 (44.6%) of telephoned patients overdue for breast cancer screening had mammograms, 68/187 (36.3%) of telephoned patients overdue for cervical screening had Pap tests

Note: HAs worked three hours per week in this practice.

Abbreviation: HA, health ambassador.

Table 3 Quality improvement initiatives for Physicians #2 and #3

	Initiative 1 (September–October 2015)	Initiative 2 (October–December 2015)	Initiative 3 (November 2015–April 2016)
Initiatives	Educational videos shown in the waiting room One-on-one education with patients – HAs approached patients in the waiting room to talk about cancer screening	One-on-one education with patients – HAs identified patients due for screening from the appointment list and chart review and had conversations while they waited in the room to see the physician	Phone calls by HAs to patients overdue for screening and to book for Pap test clinic. Patients were identified based on lists of overdue patients provided by the provincial cancer agency. Telephone scripts were agreed upon between the physician and HAs
Findings/challenges	Anecdotal increase in conversation about cancer screening with videos but was not reaching patients who do not come into the office HAs had conversation with 37 patients in the waiting room. Physicians and office staff preferred these conversations to happen in a more private setting	HAs had conversation with 56 patients. Patients were generally receptive to the information. However, many patients coming into the office were not necessarily South Asian and/or overdue for screening. Sometimes, the HAs would have very few in-person conversations in a given clinic	A total of 222 phone calls were made, 116 of which were to patients of South Asian ethnicity. HAs were able to speak directly to patients for 31% of calls overall and for 44% of calls made to South Asian patients (51 patients). Of these 51 patients, 10 booked an appointment on the spot, 22 did not book but reported willingness to be screened, and 2 reported they were no longer overdue for screening. A total of 62.7% of South Asian patients spoken to directly were willing to be screened, with 19.6% booking an appointment on the spot

Note: HAs worked five hours per week in this practice.

Abbreviation: HA, health ambassador.

Table 4 Quality improvement initiatives for Physician #4

	Initiative 1 (September 2015–February 2016)
Initiatives	One-on-one education with patients – HAs approached patients in the waiting room to talk about cancer screening and to hand out pamphlets. HAs spent three hours per week at the office Posters were put up in waiting room in Urdu, Punjabi, and English
Findings/challenges	HAs had conversation with 107 people in total. Of those 107 patients, only 23 reported they were overdue for at least one type of cancer screening. Of these 23, 15 reported willingness to be screened after the conversations, 5 wanted to think about it, and 2 were not interested. A total of 65.2% of South Asian patients spoken to directly were willing to be screened

Note: HAs worked three hours per week in this practice.

Abbreviation: HA, health ambassador.