Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers a systematic review of provider reminders

Educational interventions for primary healthcare professionals to promote the early diagnosis of cancer: a systematic review

BACKGROUND

Primary healthcare professionals seem to lack knowledge and skills in the area of diagnosing cancer which may lead to more advanced stage at diagnosis, poorer cancer survival figures and increased morbidity. The aim of this study was to examine the evidence of effectiveness of educational interventions for primary healthcare professionals to promote the early diagnosis of cancer.

METHODS

We searched bibliographic databases, the grey literature and reference lists for randomised controlled trials (RCTs) of educational interventions delivered at an individual clinician and practice level.

RESULTS

We found sufficient evidence that interactive education, computerised reminder systems and audit and feedback delivered to clinicians may significantly increase several cancer detection measures in the short term and some evidence that they promote early diagnosis. Whilst educational outreach and local opinion leaders had some effect, formal education alone seemed ineffectual.

CONCLUSION

Certain educational interventions delivered at a clinician as well as at a practice level may promote the early diagnosis of cancer in primary care. There is currently limited evidence for their long-term sustainability and effectiveness.

Socio-economic differences in healthcare access from a welfare system perspective, Italy: 2007-2010

Inequalities between poorer and wealthier people in accessing healthcare services have been widely studied, but the mechanisms generating them are still to be fully understood. Among these, there is still a lack of evidence of relationships between health prevention/health promotion policies, welfare systems and social differences. We analysed 68 201 females from the PASSI Italian surveillance system for the years 2007-2010. The prevalence of women undergoing Pap testing was used as an example of access to preventive services. An odds ratio gradient was found with regard to different welfare system clusters: the probability of undergoing a screening test is higher for more advanced welfare systems. A strong association was found between having received a letter from the local health unit and having undergone the screening test. Significant differences still exist between high- and low-income women and their access to Italian preventive public services. As we expected, social determinants play an important role in health disparities, as these are also strongly influenced by typologies of welfare systems and by health policies.

Strategies for expanding colorectal cancer screening at community health centers

Community health centers are uniquely positioned to address disparities in colorectal cancer (CRC) screening as they have addressed other disparities. In 2012, the federal Health Resources and Services Administration, which is the funding agency for the health center program, added a requirement that health centers report CRC screening rates as a standard performance measure. These annually reported, publically available data are a major strategic opportunity to improve screening rates for CRC. The Patient Protection and Affordable Care Act enacted provisions to expand the capacity of the federal health center program. The recent report of the Institute of Medicine on integrating public health and primary care included an entire section devoted to CRC screening as a target for joint work. These developments make this the ideal time to integrate lifesaving CRC screening into the preventive care already offered by health centers. This article offers 5 strategies that address the challenges health centers face in increasing CRC screening rates. The first 2 strategies focus on improving the processes of primary care. The third emphasizes working productively with other medical providers and institutions. The fourth strategy is about aligning leadership. The final strategy is focused on using tools that have been derived from models that work.

Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates

OBJECTIVE

To evaluate the effect of the Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) reminder and recall system and pay-for-performance incentives on the delivery rates of cervical and breast cancer screening in primary care practices in Ontario, with or without deployment of nurse practitioners (NPs).

DESIGN

Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP-augmented strategies of the P-PROMPT reminder and recall system.

SETTING

Southwestern Ontario.

PARTICIPANTS

A total of 232 physicians from 24 primary care network or family health network groups across 110 different sites eligible for pay-for-performance incentives.

INTERVENTIONS

The P-PROMPT project combined pay-for-performance incentives with provider and patient reminders and deployment of NPs to enhance the delivery of preventive care services.

MAIN OUTCOME MEASURES

The mean delivery rates at the practice level of time-appropriate mammograms and Papanicolaou tests completed within the previous 30 months.

RESULTS

Before-and-after comparisons of time-appropriate delivery rates (< 30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P < .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services.

CONCLUSION

The use of provider and patient reminders and pay-for-performance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.

Using concept mapping in the knowledge-to-action process to compare stakeholder opinions on barriers to use of cancer screening among South Asians

BACKGROUND

Using the knowledge-to-action (KTA) process, this study examined barriers to use of evidence-based interventions to improve early detection of cancer among South Asians from the perspective of multiple stakeholders.

METHODS

In 2011, we used concept mapping with South Asian residents, and representatives from health service and community service organizations in the region of Peel Ontario. As part of concept mapping procedures, brainstorming sessions were conducted with stakeholders (n = 53) to identify barriers to cancer screening among South Asians. Participants (n = 46) sorted barriers into groups, and rated barriers from lowest (1) to highest (6) in terms of importance for use of mammograms, Pap tests and fecal occult blood tests, and how feasible it would be to address them. Multi-dimensional scaling, cluster analysis, and descriptive statistics were used to analyze the data.

RESULTS

A total of 45 unique barriers to use of mammograms, Pap tests, and fecal occult blood tests among South Asians were classified into seven clusters using concept mapping procedures: patient's beliefs, fears, lack of social support; health system; limited knowledge among residents; limited knowledge among physicians; health education programs; ethno-cultural discordance with the health system; and cost. Overall, the top three ranked clusters of barriers were 'limited knowledge among residents,' 'ethno-cultural discordance,' and 'health education programs' across surveys. Only residents ranked 'cost' second in importance for fecal occult blood testing, and stakeholders from health service organizations ranked 'limited knowledge among physicians' third for the feasibility survey. Stakeholders from health services organizations ranked 'limited knowledge among physicians' fourth for all other surveys, but this cluster consistently ranked lowest among residents.

CONCLUSION

The limited reach of cancer control programs to racial and ethnic minority groups is a critical implementation issue that requires attention. Opinions of community service and health service organizations on why this deficit in implementation occurs are fundamental to understanding the solutions because these are the settings in which evidence-based interventions are implemented. Using concept mapping within a KTA process can facilitate the engagement of multiple stakeholders in the utilization of study results and in identifying next steps for action.

The association between chronic disease and physical disability among female Medicaid beneficiaries 18-64 years of age

BACKGROUND

Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population.

OBJECTIVE

This study described the prevalence of chronic disease among adult (18-64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005.

METHODS

Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability.

RESULTS

Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts.

DISCUSSION

Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the long-run.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Collaborative development of a randomized study to adapt a diabetes quality improvement initiative for federally qualified health centers

This case study describes how we are translating a diabetes care quality improvement initiative from an insured (HMO) setting into federally qualified health centers (FQHCs). We outline the innovative collaborative processes whereby researchers and FQHC providers adapted this initiative, which includes health information technology tools, to meet the FQHCs' needs.

A personalized automated messaging system to improve adherence to prostate cancer screening: research protocol

Background

Public adherence to cancer screening guidelines is poor. Patient confusion over multiple recommendations and modalities for cancer screening has been found to be a major barrier to screening adherence. Such problems will only increase as screening guidelines and timetables become individualized.

Objective

We propose to increase compliance with cancer screening through two-way rich media mobile messaging based on personalized risk assessment.

Methods

We propose to develop and test a product that will store algorithms required to personalize cancer screening in a central database managed by a rule-based workflow engine, and implemented via messaging to the patient’s mobile phone. We will conduct a randomized controlled trial focusing on prostate cancer screening to study the hypothesis that mobile reminders improve adherence to screening guidelines. We will also explore a secondary hypothesis that patients who reply to the messaging reminders are more engaged and at lower risk of non-adherence. We will conduct a randomized controlled trial in a sample of males between 40 and 75 years (eligible for prostate cancer screening) who are willing to receive text messages, email, or automated voice messages. Participants will be recruited from a primary care clinic and asked to schedule prostate cancer screening at the clinic within the next 3 weeks. The intervention group will receive reminders and confirmation communications for making an appointment, keeping the appointment, and reporting the test results back to the investigators. Three outcomes will be evaluated: (1) the proportion of participants who make an appointment with a physician following a mobile message reminder, (2) the proportion of participants who keep the appointment, and (3) the proportion of participants who report the results of the screening (via text or Web).

Results

This is an ongoing project, supported by by a small business commercialization grant from the National Center for Advancing Translational Sciences of the National Institutes of Health.

Conclusions

We believe that the use of centralized databases and text messaging could improve adherence with screening guidelines. Furthermore, we anticipate this method of increasing patient engagement could be applied to a broad range of health issues, both inside and outside of the context of cancer. This project will be an important first step in determining the feasibility of personalized text messaging to improve long-term adherence to screening recommendations.

FOXM1 coming of age: time for translation into clinical benefits?

A decade since the first evidence implicating the cell cycle transcription factor Forkhead Box M1 (FOXM1) in human tumorigenesis, a slew of subsequent studies revealed an oncogenic role of FOXM1 in the majority of human cancers including oral, nasopharynx, oropharynx, esophagus, breast, ovary, prostate, lung, liver, pancreas, kidney, colon, brain, cervix, thyroid, bladder, uterus, testis, stomach, skin, and blood. Its aberrant upregulation in almost all different cancer types suggests a fundamental role for FOXM1 in tumorigenesis. Its dose-dependent expression pattern correlated well with tumor progression starting from cancer predisposition and initiation, early premalignancy and progression, to metastatic invasion. In addition, emerging studies have demonstrated a causal link between FOXM1 and chemotherapeutic drug resistance. Despite the well-established multifaceted roles for FOXM1 in all stages of oncogenesis, its translation into clinical benefit is yet to materialize. In this contribution, I reviewed and discussed how our current knowledge on the oncogenic mechanisms of FOXM1 could be exploited for clinical use as biomarker for risk prediction, early cancer screening, molecular diagnostics/prognostics, and/or companion diagnostics for personalized cancer therapy.

Local breast cancer spatial patterning: a tool for community health resource allocation to address local disparities in breast cancer mortality

Despite available demographic data on the factors that contribute to breast cancer mortality in large population datasets, local patterns are often overlooked. Such local information could provide a valuable metric by which regional community health resources can be allocated to reduce breast cancer mortality. We used national and statewide datasets to assess geographical distribution of breast cancer mortality rates and known risk factors influencing breast cancer mortality in middle Tennessee. Each county in middle Tennessee, and each ZIP code within metropolitan Davidson County, was scored for risk factor prevalence and assigned quartile scores that were used as a metric to identify geographic areas of need. While breast cancer mortality often correlated with age and incidence, geographic areas were identified in which breast cancer mortality rates did not correlate with age and incidence, but correlated with additional risk factors, such as mammography screening and socioeconomic status. Geographical variability in specific risk factors was evident, demonstrating the utility of this approach to identify local areas of risk. This method revealed local patterns in breast cancer mortality that might otherwise be overlooked in a more broadly based analysis. Our data suggest that understanding the geographic distribution of breast cancer mortality, and the distribution of risk factors that contribute to breast cancer mortality, will not only identify communities with the greatest need of support, but will identify the types of resources that would provide the most benefit to reduce breast cancer mortality in the community.

Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services

CONTEXT

Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions.

EVIDENCE ACQUISITION

Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews.

EVIDENCE SYNTHESIS

Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories.

CONCLUSIONS

Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.

Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening

The Community Preventive Services Task Force (Task Force) recommends increasing screening for breast cancer through use of group education, one-on-one education, client reminders, reducing client out-of-pocket costs, and provider assessment and feedback; increasing screening for cervical cancer through use of one-on-one education, client reminders, and provider assessment and feedback; and increasing screening for colorectal cancer through use of one-on-one education, client reminders, reducing structural barriers to screening, and provider assessment and feedback. The Task Force found insufficient evidence to determine the effectiveness of increasing screening for breast cancer through use of client incentives, mass media, or provider incentives; for cervical cancer screening through use of group education, client incentives, mass media, reducing client out-of-pocket costs, reducing structural barriers, or provider incentives; and for colorectal cancer screening through use of group education, client incentives, mass media, reducing client out-of-pocket costs, or provider incentives. Details of these findings, and some considerations for use, are provided in this article.

Health reform and Healthy People initiative

The passage of the Affordable Care Act builds on and strengthens the foundation for prevention and wellness that Healthy People--the nation's health promotion and disease prevention aspirations for a healthier nation--established. The Affordable Care Act reaffirms the themes of Healthy People by promoting population-based prevention and sets the stage for Healthy People 2020. The heart of Healthy People 2010 lies in its leading health indicators, reflecting high-priority health issues for the nation. National progress requires broad application of the ecological health model. We reviewed the status of each Healthy People 2010 indicator and noted how the Affordable Care Act drives future positive health outcomes using the ecological model of health as a prism for viewing health improvement.

Was the drop in mammography rates in 2005 associated with the drop in hormone therapy use?

BACKGROUND

In 2005, mammography rates in the United States dropped nationally for the first time among age-eligible women. An increased risk of breast cancer related to hormone therapy (HT) use reported in 2002 led to a dramatic drop in its use by 2005. Because current users of HT also tend to have higher mammography rates, the authors examined whether concurrent drops in HT and mammography use were associated.

METHODS

Multivariate logistic regression was used to test for an interaction between HT use and survey year, controlling for a range of measurable factors in data from the 2000 and 2005 National Health Interview Surveys (NHIS).

RESULTS

Women ages 50 to 64 years were more likely to report a recent mammogram if they also reported more education, a usual source of care, private health insurance, any race except non-Hispanic Asian, talking with an obstetrician/gynecologist or other physician in the past 12 months, or were currently taking HT. Women aged ≥ 65 years were more likely to report a recent mammogram if they also reported younger age (ages 65-74 years), more education, a usual source of care, having Medicare Part B or other supplemental Medicare insurance, excellent health, any race except non-Hispanic Asian, talking with an obstetrician/gynecologist or other physician in the past 12 months, or were currently taking HT.

CONCLUSIONS

The change in HT use was associated with the drop in mammography use for women ages 50 to 64 years but not for women aged ≥ 65 years. NHIS data explained 70% to 80% of the change in mammography use.

Systems strategies to support cancer screening in U.S. primary care practice

BACKGROUND

Although systems strategies are effective in improving health care delivery, little is known about their use for cancer screening in U.S. primary care practice.

METHODS

We assessed primary care physicians' (N = 2,475) use of systems strategies for breast, cervical, and colorectal cancer (CRC) screening in a national survey conducted in 2007. Systems strategies included patient and physician screening reminders, performance reports of screening rates, electronic medical records, implementation of in-practice guidelines, and use of nurse practitioners/physician assistants. We evaluated use of both patient and physician screening reminders with other strategies in separate models by screening type, adjusted for the effects of physician and practice characteristics with multivariate logistic regression.

RESULTS

Fewer than 10% of physicians used a comprehensive set of systems strategies to support cancer screening; use was greater for mammography and Pap testing than for CRC screening. In adjusted analyses, performance reports of cancer screening rates, medical record type, and in-practice guidelines were associated with use of both patient and physician screening reminders for mammography, Pap testing, and CRC screening (P < 0.05).

CONCLUSION

Despite evidence supporting use of systems strategies in primary care, few physicians report using a comprehensive set of strategies to support cancer screening.

IMPACT

Current health policy initiatives underscore the importance of increased implementation of systems strategies in primary care to improve the use and quality of cancer screening in the United States.

Promoting cancer screening within the patient centered medical home

While consensus has grown that primary care is the essential access point in a high-performing health care system, the current model of primary care underperforms in both chronic disease management and prevention. The Patient Centered Medical Home model (PCMH) is at the center of efforts to reinvent primary care practice, and is regarded as the most promising approach to addressing the burden of chronic disease, improving health outcomes, and reducing health spending. However, the potential for the medical home to improve the delivery of cancer screening (and preventive services in general) has received limited attention in both conceptualization and practice. Medical home demonstrations to date have included few evidence-based preventive services in their outcome measures, and few have evaluated the effect of different payment models. Decreasing use of hospitals and emergency rooms and an emphasis on improving chronic care represent improvements in effective delivery of healthcare, but leave opportunities for reducing the burden of cancer untouched. Data confirm that what does or does not happen in the primary care setting has a substantial impact on cancer outcomes. Insofar as cancer is the leading cause of death before age 80, the PCMH model must prioritize adherence to cancer screening according to recommended guidelines, and systems, financial incentives, and reimbursements must be aligned to achieve that goal. This article explores capacities that are needed in the medical home model to facilitate the integration of cancer screening and other preventive services. These capacities include improved patient access and communication, health risk assessments, periodic preventive health exams, use of registries that store cancer risk information and screening history, ability to track and follow up on tests and referrals, feedback on performance, and payment models that reward cancer screening.

Women's knowledge about cervical cancer risk factors, screening, and reasons for non-participation in cervical cancer screening programme in Estonia

Background

The attendance rate in Estonian cervical cancer screening programme is too low therefore the programme is hardly effective. A cross-sectional population based survey was performed to identify awareness of cervical cancer risk factors, reasons why women do not want to participate in cervical screening programme and wishes for better organisation of the programme.

Method

An anonymous questionnaire with a covering letter and a prepaid envelope was sent together with the screening invitation to 2942 randomly selected women. Results are based on the analysis of 1054 (36%) returned questionnaires.

Results

Main reasons for non-participation in the national screening programme were a recent visit to a gynaecologist (42.3%), fear to give a Pap-smear (14.3%), long appointment queues (12.9%) and unsuitable reception hours (11.8%). Fear to give a Pap-smear was higher among women aged 30 and 35 than 50 and 55 (RR 1.46; 95% CI: 0.82-2.59) and women with one or no deliveries (RR 1.56, 95% CI: 0.94-2.58). In general, awareness of cervical cancer risk factors is poor and it does not depend on socio-demographic factors. Awareness of screening was higher among Estonians than Russians (RR 1.64, 95% CI: 1.46-1.86). Most women prefer to receive information about screening from personally mailed invitation letters (74.8%).

Conclusions

Women need more information about cervical cancer risk factors and the screening programme. They prefer personally addressed information sharing. Minority groups should be addressed in their own language. A better collaboration with service providers and discouraging smears outside the programme are also required.

Academic detailing to increase colorectal cancer screening by primary care practices in Appalachian Pennsylvania

BACKGROUND

In the United States, colorectal cancer (CRC) is the third most frequently diagnosed cancer and second leading cause of cancer death. Screening is a primary method to prevent CRC, yet screening remains low in the U.S. and particularly in Appalachian Pennsylvania, a largely rural area with high rates of poverty, limited health care access, and increased CRC incidence and mortality rates. Receiving a physician recommendation for CRC screening is a primary predictor for patient adherence with screening guidelines. One strategy to disseminate practice-oriented interventions is academic detailing (AD), a method that transfers knowledge or methods to physicians, nurses or office staff through the visit(s) of a trained educator. The objective of this study was to determine acceptability and feasibility of AD among primary care practices in rural Appalachian Pennsylvania to increase CRC screening.

METHODS

A multi-site, practice-based, intervention study with pre- and 6-month post-intervention review of randomly selected medical records, pre- and post-intervention surveys, as well as a post-intervention key informant interview was conducted. The primary outcome was the proportion of patients current with CRC screening recommendations and having received a CRC screening within the past year. Four practices received three separate AD visits to review four different learning modules.

RESULTS

We reviewed 323 records pre-intervention and 301 post-intervention. The prevalence of being current with screening recommendation was 56% in the pre-intervention, and 60% in the post-intervention (p=0.29), while the prevalence of having been screened in the past year increased from 17% to 35% (p<0.001). Colonoscopies were the most frequently performed screening test. Provider knowledge was improved and AD was reported to be an acceptable intervention for CRC performance improvement by the practices.

CONCLUSIONS

AD appears to be acceptable and feasible for primary care providers in rural Appalachia. A ceiling effect for CRC screening may have been a factor in no change in overall screening rates. While the study was not designed to test the efficacy of AD on CRC screening rates, our evidence suggests that AD is acceptable and may be efficacious in increasing recent CRC screening rates in Appalachian practices which could be tested through a randomized controlled study.

Cancer Screening Behaviors of African American Women Enrolled in a Community-Based Cancer Prevention Trial

Background: African American women have increased mortality rates for cervical, breast, and colorectal cancers, yet not all receive the recommended screening tests for these cancers. We characterized the cancer screening behaviors of African American women enrolled in a community-based cancer prevention trial. Methods: We examined cross-sectional data from 1123 African American customers aged ≥18 years from 37 beauty salons in North Carolina who completed the North Carolina BEAUTY and Health Project baseline survey. Mixed logistic regression models were used to identify correlates of receiving cervical, breast, and colorectal cancer screening tests within recommended screening guidelines. Results: Overall, 94% (1026 of 1089) of women aged ≥18 years reported receiving a Pap smear test within the last 3 years, 70% (298 of 425) of women aged ≥40 years reported receiving a mammography within the last year, and 64% (116 of 180) of women aged ≥50 years were considered to be within recommended screening guidelines for colorectal cancer. Age was correlated with recent Pap smear testing and mammography. Women who reported receiving a recent Pap smear test were more likely to report a mammogram in the last year, and women with a recent mammogram were more likely to be within recommended screening guidelines for colorectal cancer. Many women reported multiple barriers to getting recommended cancer screening tests. Conclusions: Almost all women reported receiving a Pap smear test within the last 3 years. Future interventions should focus on increasing breast and colorectal cancer screening among African American women.

Common abnormal results of pap and human papillomavirus cotesting: what physicians are recommending for management

OBJECTIVE

To evaluate the association between physician and practice characteristics and adherence to management guidelines to better understand the factors associated with different screening recommendations by primary care physicians.

METHODS

We used a cross-sectional nationally representative survey of 950 primary care physicians familiar with human papillomavirus (HPV) testing to assess adherence to management guidelines by analyzing responses to two clinical vignettes of a 35-year-old woman who had Pap and HPV tests results: 1) discordant (normal Pap and positive HPV) or 2) mildly abnormal (atypical squamous cells of undetermined significance Pap and negative HPV). Analyses included multivariable logistic regression.

RESULTS

For the discordant test results, 54.3% (95% confidence interval [CI] 51-57.6%) of physicians recommended both Pap and HPV testing in 6-12 months, adhering to management guidelines. For the mildly abnormal results, only 12.2% (95% CI 10-14.7%) had a guideline-adherent recommendation of Pap testing in 12 months with no HPV test. In multivariable analyses, no significant difference among physicians' specialties was observed for the discordant results. For the mildly abnormal results, physician specialty was associated with guideline adherence in which obstetrician-gynecologists had the highest percent of adherence (19.8%) compared with family and general practitioners (9.3%) and internists (11%) (P<.001).

CONCLUSION

Even for the most common abnormal results, many physicians reported recommendations that did not adhere to current management guidelines. Evidence-based interventions are needed to improve adherence to management guidelines for the newer HPV DNA test.