Creating and Implementing a National Public Health Campaign: The American Cancer Society's and National Colorectal Cancer Roundtable's 80% by 2018 Initiative

In 2014, the National Colorectal Cancer Roundtable (NCCRT), an organization cofounded and co‐supported by the American Cancer Society (ACS) and the Centers for Disease Control and Prevention (CDC) launched 80% by 2018, a national effort to regularly screen 80% of recommended adults for colorectal cancer (CRC) by 2018. The goal was adopted after then Assistant Secretary for Health, Dr. Howard Koh, challenged organizations, including ACS, CDC and other federal agencies, the American College of Gastroenterology, the National Association of Community Health Centers (NACHC), and the many member organizations of the NCCRT to launch a bold and audacious goal to accelerate CRC screening progress. Out of that challenge, the 80% by 2018 goal was born. Motivation to achieve the goal spread rapidly, inspired by three common understandings: 1) CRC screening works. Indeed, evidence had shown that CRC incidence and mortality dropped by over 30% in the U.S. among adults 50 and older over a fifteen‐year period with a substantial fraction of these declines due to screening; [1] 2) Screening was still underutilized with over 23 million adults who were not being screening according to guidelines despite recent improved access to CRC screening thanks to the passage of the Affordable Care Act [2], and 3) By 2030, over 203,000 lives could be saved by achieving the 80% by 2018 goal [3]. The purpose of this paper is to give a brief overview of the components, operations, progress, and future directions of the 80% by 2018 effort.

Strategic planning to achieve the 80% by 2018 goal began in the summer of 2014, during which over a hundred individuals representing over 50 organizations met to map out the path to an 80% CRC screening goal. The strategy grew out of consideration of a well‐established body of work on the barriers to CRC screening, coupled with knowledge about evidence‐based interventions (EBIs) shown to increase CRC screening in practice [4]. The 80% by 2018 strategic plan outlined the following four key objectives to achieve the goal: (1) move consumers to action; (2) activate providers, health systems, payers, and employers to support screening; (3) increase access and remove barriers to screening and follow‐up; and (4) evaluate the efforts and maintain momentum [5].

The campaign recruited partner organizations by inviting them to sign the 80% by 2018 pledge (http://nccrt.org/80‐2018‐pledge/), which essentially was a pledge to dedicate organizational time and resources to improving CRC screening rates for all and acknowledging that ensuring equal access to care is everyone's responsibility [5]. The NCCRT set an initial goal of having 50 organizations sign the pledge, but the effort quickly grew, as state and local entities rapidly joined the effort and focused on implementation in partnership with a broad range of local stakeholders.

State‐based activities were boosted significantly by the engagement of the community‐based ACS health systems staff, a 500‐person strong workforce specially trained in quality improvement and practice implementation of EBIs. These staff embraced the goal, recruiting organizations to sign the pledge and partnering with state health departments, state comprehensive cancer coalitions, locally based roundtables, state primary care associations, physician and academic leaders, CDC grantees, hospitals, employers, and many others to stimulate local efforts and goal adoption. These efforts were strengthened by ACS and NCCRT national leaders who visited hundreds of communities to spur interest, present the vision for the effort, outline the strategic plan, offer national support, and help foster the campaign's momentum. Finally, expert members from the NCCRT shared their professional knowledge by helping to develop a series of evidence‐based resources that provide in depth guidance on how different entities, such as primary care, hospitals and health systems, communities, women's health providers, health plans, gastroenterologists, radiologists, elected officials, and communities, could contribute to the shared goal [5].

While “momentum” is hard to establish or measure, 80% by 2018 is widely recognized to have strengthened local capacity to address screening by energizing a passionate network of coalitions and roundtables whose members became invested in creating change. Over 1700 organizations across all 50 states signed the pledge [5], not only committing to the goal, but also catalyzing action to achieve that goal. The NCCRT measured partnership engagement through an annual 80% by 2018 partnership survey of NCCRT members and pledge signers. Survey results demonstrated both an increase in partner activity around CRC screening and increases in screening rates for responding organizations, most notably among community health centers (CHCs), cancer centers, and hospitals/medical centers/health systems. Aggregated partner survey results indicate that more than two‐thirds of respondents engaging in CRC screening activities launched, expanded or intensified at least one of their activities after getting involved in the campaign, and more than half have plans for more [5].

The NCCRT documented hundreds of examples of individual systems, health plans, medical groups, and individual practices that have achieved or surpassed the 80% goal, as well as numerous others that did not achieve an 80% screening rate, but still achieved substantial screening rate increases [5]. Notably, the systems hitting the 80% goal had largely done so by implementing many of the recommended EBIs, such as patient and provider reminders, tracking and sharing provider screening rates, navigation, and team‐based approaches to care [5]. These examples serve as numerous individual instances of proof of concept, that implementing EBIs works, even in settings that serve some of the most underserved populations.

Perhaps most important, the progression of the 80% by 2018 campaign coincided with upward trends in CRC screening rates measured across the major data sets, which is particularly significant given that the two major CRC national tracking measures (the CDC's Behavioral Risk Factor Surveillance Survey (BRFSS) and the National Health Interview Survey) showed that rates had begun to plateau at the time of the campaign's launch [2]. The BRFSS, NHIS, the Uniform Data Set (UDS) (the measure for Federally Qualified Health Centers), and the National Committee for Quality Assurance's Healthcare Effectiveness Data and Information Set (HEDIS) (a measure used by >90% of America's health plans) all reveal rising CRC screening rates since the early years of the campaign [2,6,7,8]. While final screening rates for 2018 won't be available for measures until 2019 and 2020, the consistent trend of increases justifies optimism, as these rate increases represent significant overall numbers of additional people screened. For instance, the recent UDS rate increase to 42.2% compared to the 2012 rate of 30% means that 467,541 more people were screened in the last two years in FQHCs; [7] the BRFSS rate increase means that an additional 3.3 million people were screened between 2014 and 2016 [2], and the NHIS rate increase means an additional 3,785,600 adults age 50 or older were screened in 2015 alone. In fact, if the NHIS screening rate holds at this level, an additional 37,200 lives will be saved through 2030 [9]. Further, an 80% screening rate is within reach for the Medicare population since 2016 BRFSS data shows 78.4% of those 65 to 75 report recent screening [2].

As 2018 draws to a close, the NCCRT, ACS, CDC and its many partners remain committed to ensuring that the 80% goal is something that is achieved in every community. The NCCRT and the ACS will be launching a new umbrella campaign to maintain momentum and continue to harness the tremendous increased capacity and expertize in increasing CRC screening. In this new initiative, an analysis of screening patterns highlights the need for an intensified focus on communities that have not seen equal progress, such as the commercially insured pre‐Medicare populations, rural communities, certain racial and ethnic groups, and those aged 50‐54 for whom CRC screening rates are below 50%. The NCCRT and ACS will explore new partnerships such as with employers and media, to further expand the reach of the effort, while remaining invested in the work with CHCs and hospitals and health systems.

The NCCRT and ACS 80% by 2018 campaign demonstrates the value of a single, intensive, bold, and ambitious public health goal. The time stamp of 2018 created urgency. The pledge allowed the ACS to leverage its stature as a respected convener to attract partners, who could then publicly celebrate their commitment to the effort. The bold goal allowed states to achieve progress not thought possible. Indeed in 2016, 13 states had achieved or surpassed the Healthy People 2020 goal of a 70.5% CRC screening rate, four years early [10]. The framework can serve as a model for future public health campaigns. Notably, the ACS has already launched a similar 80% goal for HPV vaccination, building on many of the 80% by 2018 tenants and responsive to the lessons learned. As 2018 winds down, the many partners who have dedicated the last four years to increasing CRC screening rates have earned the chance to celebrate their hard work and most importantly, the many lives they have saved.

ACKNOWLEDGEMENTS

We would like to acknowledge these individuals for their tremendous efforts in supporting the 80% by 2018 Campaign: Lisa Richardson, Thomas Weber, Dennis Ahnen, April Barry, Emily Bell, Heather Brandt, Lynn Butterly, Franklin Berger, Mari Carlesimo, Dionne Christopher, Gloria Coronado, Heather Dacus, Anjee Davis, Andrea Dwyer, Jasmine Greenamyer, Dave Greenwald, Heather Hampel, Nikki Hayes, Steve Itzkowitz, Djenaba Joseph, Karen Kim, Caleb Levell, Xavier Llor, Beth McFarland, Karen Peterson, Marcus Plescia, Mark Pochapin, Joseph Ravenell, Holly Wolf, Faye Wong, Ann Zauber, and Howard Koh. Additional thanks to Cam Escoffery and Sean Halpin for the work on the manuscript.

CONFLICT OF INTEREST

Guarantor of the article: Mary Doroshenk, MA.

Specific author contributions: Mary Doroshenk, Richard C. Wender, Durado Brooks, and Robert A. Smith: study concept, design, data collection and interpretation of the data, drafting of the manuscript. Mary Doroshenk, Richard C. Wender, Durado Brooks, and Robert A. Smith, Durado Brooks and James Hotz: review and proofing of manuscript.

Financial support: 80% by 2018 activities were supported by the American Cancer Society and by the Cooperative Agreement Number, DP004969, funded by the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Potential Competing Interests: None.