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INDIAN HEALTH SERVICE. * PHS * 1955 * . Improved Colorectal Cancer Screening in the Indian Health System.

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* PHS * 1955 *

Improved Colorectal Cancer Screening in the Indian Health System

Ty Reidhead, MD1; Cindy Hupke, RN, MBA2; Bruce Finke, MD1; Patricia Lundgren, RN, EdD1; Lisa Dolan-Branton, RN1; Lindsay Hunt; Kedar Mate, MD2; Tracy Jacobs, RN2; Nathaniel Cobb, MD, MPH1; Don Goldmann, MD2; Gerald Langley2

1 Indian Health Service, Rockville, MD, 2Institute for Healthcare Improvement, Cambridge, MA





  • At the outset only 14.3% of microsystems (n =2) had rates of CRC screening above 50%.
  • By August 2008, 42.8% of sites (n=6) had screening rates above 50%.
  • Colorectal cancer (CRC) kills an estimated 50,000 Americans annually.1
  • The US Preventive Services Task Force (USPSTF) has estimated that attainment of population-level goals for CRC screening could save 18,800 lives annually.2
  • Despite widespread availability of these screening techniques, CRC screening remains woefully inadequate with only 52% of Americans screened annually.3
  • In the Indian Health System (federal, tribal, and urban Indian health programs) the screening rate for CRC is 29%.4

Innovations in Planned Care (IPC) Collaborative

  • Indian Health Service (IHS) partnered with the Institute for Healthcare Improvement (IHI).
  • Fourteen pilot Indian Health facilities responded to a request for participation and were enrolled in a Breakthrough Series Collaborative from March 2007 to August 2008.5
  • Within each facility, a group of providers and their patients were identified as a clinical “microsystem.”
  • The microsystem teams used rapid cycle improvement methods (plan-do-study-act cycles) as well as process mapping to identify, test and implement a variety of strategies to improve CRC screening.
  • Best practices were communicated to improvement teams in other facilities in the Collaborative to facilitate adoption and replication.
  • Individual microsystem screening rates as well as aggregate collaborative-wide screening rates were tracked using web-based monthly reporting tools (extranet).
  • CRC screening rates increased over the 18 month-period from a weighted average of: 32.4% (min 8.5%, max 74.3%) to 57.8% (min 29.7%, max 89.8%)

Specific changes that led to these improvements in CRC screening rates:

  • Empanelment of patients
  • Development of care teams
  • Optimization of the roles of and communication among members of the care team
  • Standardization of protocols
  • Testing, referral, and follow-up orders
  • Utilization of the electronic clinical information system for planning, screening reminders, and feedback
  • Identification of opportunities for improvement
  • Partnerships with Community Health Representatives and other non traditional care team members


  • Participating sites self selected to participate and were motivated to improve.
  • There was no control group to compare findings.


    • Breakthrough Series Collaborative methods, process mapping and rapid cycle improvement improved CRC screening rates among participating microsystems within Indian Health sites.
  • Further follow-up will be needed to ascertain the durability and spread potential of these improvements.

1Ries LA. SEER Cancer Statistics Review, 1975-2005. Bethesda, MD: National Cancer Institute; 2007.

2USPSTF Screening for Colorectal Cancer Recommendation Statement. 10/08. Also: Maciosek MV, Solberg LI, Coffield AB, Edwards NM, Goodman MJ. Colorectal cancer screening: health impact and cost effectiveness. Am J Prev Med 2006;31:80-9

3Agency for Healthcare Research and Quality (AHRQ). National Healthcare Quality Report and National Healthcare Disparities Report. 2006

4Indian Health Service Quality of Care Website: Colorectal Cancer Screening. Accessed 1/14/09

5The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003. (Available on