PRIMARY CARE PRACTICE
AUTONOMY INFLUENCES
COLORECTAL CANCER SCREENING
Patricia H. Parkerton, PhD MPH
Elizabeth M. Yano, PhD MSPH
Lynn M. Soban, MPH BSN
David A. Etzioni, MD MSHS
1
Supported by
• Department of Veterans’ Affairs (VA)
– HSR&D:
Health Services Research and
Development
– QUERI:
Quality Enhancement Research
Initiative, Colorectal Cancer
2
Objectives
• Determine sources of CRC
screening variation
• Determine role of practice and
clinical leader autonomy
3
Colorectal Cancer (CRC)
Screening Modalities
Chart documentation of:
• FOBT in last year,
• Flexible sigmoidoscopy in last 5 years
or
• Colonoscopy in last 10 years
4
CRC Screening Rates:
CDC 2001
• #2 cause of cancer deaths (57,000)
• Early detection reduces mortality
• National average:
53%
• Variation by State:
42--65%
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CRC Screening at the VA
Department of Veterans’ Affairs
• Mean 60%
• Varies by
• Region: 55% to 62%
• Facility: 25% to 88%
• Lowest preventive measure at VA
medical centers
6
Facility Population
•
•
•
•
•
All VA primary-care sites
Serving >4,000 primary care patients
Delivering >20,000 primary care visits
N=235
Response 219 sites (93%)
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Leader Autonomy on
Colorectal Cancer Screening
Environment/
Context
Organizational
Structure
Physician
Characteristics
Practice
Structure
Care
Process
Patient
Outcomes
Patient
Characteristics
C
8
Control Variables
Environmental
Context




Region
Urbanity
HMO penetration
GI availability
Organizational
Structure
• Complexity
• Academic affiliation
• Specialty mix
• Size: physician number
• Type
• Stability
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Study Variables
Practice
Process
Patient
Process
 Autonomy, Leader  • CRCS
 Training program
 Profiling
 QI implementation
 Patient volume
• Other screening
• Integration
• Diabetic management
• Patient satisfaction
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Data Sources

CRC screening rates from the
 External Peer Review Program of
 71,000 charts (2001)
 Organizational structures and processes
from the
 Primary Care Practices Survey (2000)
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Primary Care Leader
Autonomy Scale *
Authority over:
Factor Loading
Clinical procedures
.82
New components
.81
Guideline establishment
.83
Guideline implementation
.70
* Site leader authority over establishing clinical
procedures for guideline-concordant care
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CRC Screening and
Autonomy Correlations
Autonomy
QI implemented
Profiling
Awards PCP quality
QI team decision
support
Screening
Autonomy
.18*
.06
--.04
.10
--.05
-.21**
-.27***
.07
.25**
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Regression Results:
Autonomy on
CRC Screening
B
Autonomy
--.02
2
Sig. R
.02* 0.03
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Regression Results:
Full Model
Autonomy
Site size
Train PCPs
QI Implement ed
Profiling
R
2
B
.027
.000
.017
.007
--.001
Signif.
.00***
.01**
.36
.72
.15
.07
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Conclusions
 Primary care practice leader
autonomy was associated with
higher CRC screening
 No other measure altered this
relationship: academic affiliation,
quality improvement, or size
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Limitations
• Facilities within one health system
• 1999-2000 data in changing times
• Captures perceptions not actual activity
• Leader characteristics are unmeasured
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Implications/Potential Impact:
 Increasing Clinical Leader Autonomy
over practice arrangements may
 enhance receipt of preventive
services
 result in earlier detection of cancer
 lower mortality
 Value of Autonomy relative to needs for
consistency needs further exploration
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