Interventions to improve follow-up of abnormal findings in cancer screening

Medical Home Implementation and Follow-Up of Cancer-Related Abnormal Test Results in the Veterans Health Administration

Importance

Lack of timely follow-up of cancer-related abnormal test results can lead to delayed or missed diagnoses, adverse cancer outcomes, and substantial cost burden for patients. Care delivery models, such as the Veterans Affairs' (VA) Patient-Aligned Care Team (PACT), which aim to improve patient-centered care coordination, could potentially also improve timely follow-up of abnormal test results. PACT was implemented nationally in the VA between 2010 and 2012.

Objective

To evaluate the long-term association between PACT implementation and timely follow-up of abnormal test results related to the diagnosis of 5 different cancers.

Design, Setting, and Participants

This multiyear retrospective cohort study used 14 years of VA data (2006-2019), which were analyzed using panel data-based random-effects linear regressions. The setting included all VA clinics and facilities. The participants were adult patients who underwent diagnostic testing related to 5 different cancers and had abnormal test results. Data extraction and statistical analyses were performed from September 2021 to December 2023.

Exposure

Calendar years denoting preperiods and postperiods of PACT implementation, and the PACT Implementation Progress Index Score denoting the extent of implementation in each VA clinic and facility.

Main Outcome and Measure

Percentage of potentially missed timely follow-ups of abnormal test results.

Results

This study analyzed 6 data sets representing 5 different types of cancers. During the initial years of PACT implementation (2010 to 2013), percentage of potentially missed timely follow-ups decreased between 3 to 7 percentage points for urinalysis suggestive of bladder cancer, 12 to 14 percentage points for mammograms suggestive of breast cancer, 19 to 22 percentage points for fecal tests suggestive of colorectal cancer, and 6 to 13 percentage points for iron deficiency anemia laboratory tests suggestive of colorectal cancer, with no statistically significant changes for α-fetoprotien tests and lung cancer imaging. However, these beneficial reductions were not sustained over time. Better PACT implementation scores were associated with a decrease in potentially missed timely follow-up percentages for urinalysis (0.3-percentage point reduction [95% CI, -0.6 to -0.1] with 1-point increase in the score), and laboratory tests suggestive of iron deficiency anemia (0.5-percentage point reduction [95% CI,-0.8 to -0.2] with 1-point increase in the score).

Conclusions and Relevance

This cohort study found that implementation of PACT in the VA was associated with a potential short-term improvement in the quality of follow-up for certain test results. Additional multifaceted sustained interventions to reduce missed test results are required to prevent care delays.

The impact of in-house pathology services on downstaging cervical cancer in Tanzania over an 18-year period

PURPOSE

Reducing time between cancer screening, diagnosis, and initiation of treatment is best achieved when services are available in the same hospital. Yet, comprehensive cancer centers are typically unavailable in low- and middle-income countries (LMICs), where resources are limited and services scattered. This study explored the impact of establishing an in-house pathology laboratory at the largest public cancer hospital in Tanzania on the downstaging of cervical cancer.

METHODS

We examined clinical datasets of 8,322 cervical cancer patients treated at the Ocean Road Cancer Institute (ORCI). The first period included patients treated from 2002 to 2016, before establishment of the pathology laboratory at ORCI; the second period (post-pathology establishment) included data from 2017 to 2020. Logistic regression analysis evaluated the impact of the pathology laboratory on stage of cervical cancer diagnosis.

RESULTS

Patients treated during the post-pathology period were more likely to be clinically diagnosed at earlier disease stages compared to patients in the pre-pathology period (pre-pathology population diagnosed at early disease stage: 44.08%; post-pathology population diagnosed at early disease stage: 59.38%, p < 0.001). After adjustment for age, region of residence, and place of biopsy, regression results showed patients diagnosed during the post-pathology period had higher odds of early stage cervical cancer diagnosis than patients in the pre-pathology period (OR 1.35, 95% CI (1.16, 1.57), p < 0.001).

CONCLUSIONS

Integrated and comprehensive cancer centers can overcome challenges in delivering expedited cervical cancer diagnosis and treatment. In-house pathology laboratories play an important role in facilitating timely diagnosis and rapid treatment of cervical and possibly other cancers in LMICs.

A Comprehensive Program to Improve Treatment of Precancerous Cervical Lesions in the Rio Grande Valley of Texas

OBJECTIVE

To assess the impact of a multicomponent intervention in women with cervical dysplasia who were treated with loop electrosurgical excision procedure (LEEP), as well as the time between colposcopy and treatment.

DESIGN

Retrospective cohort study.

INTERVENTION

Clinic participation in a multicomponent cervical cancer prevention program that included community outreach, patient in-reach, and navigation, as well as provider capacity building with in-person training and ongoing telementoring through Project ECHO.

MAIN OUTCOME MEASURES

Medical records were reviewed to evaluate women with cervical dysplasia undergoing treatment with LEEP within 90 days of colposcopy, as well as time between colposcopy and treatment. Baseline data from year 1 were compared with each subsequent year of implementation. Additional variables examined included patient's age, history of abnormal screening results, and percentage of families living below poverty line based on county of residence, parity, and clinic site. We performed logistic regression and multiple linear regression analyses to assess the programmatic impact in the outcomes of interest by year of program implementation.

RESULTS

A total of 290 women were included in the study. The proportion of women undergoing treatment within 90 days of colposcopy increased from 76.2% at baseline to 91.3% in year 3 and 92.9% in year 4 of program implementation. The odds of undergoing treatment within 90 days were 5.11 times higher in year 4 of program implementation than at baseline. The mean time between colposcopy and LEEP decreased from 62 days at baseline to 45 days by year 4 of program implementation.

CONCLUSIONS

Implementation of our multicomponent cervical cancer prevention program increased the proportion of women undergoing LEEP within 90 days of colposcopy and decreased the time between colposcopy and LEEP. This program has the potential to support cervical cancer prevention efforts and could be implemented in other low-resource settings.

A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial

Importance

Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results.

Objective

To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results.

Design, Setting, and Participants

Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021.

Intervention

Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment.

Main Outcomes and Measures

The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk.

Results

Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result.

Conclusions and Relevance

A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT03979495.

Racial and Ethnic Disparities in Cervical Cancer Screening From Three U.S. Healthcare Settings

INTRODUCTION

This study sought to characterize racial and ethnic disparities in cervical cancer screening and follow-up of abnormal findings across 3 U.S. healthcare settings.

METHODS

Data were from 2016 to 2019 and were analyzed in 2022, reflecting sites within the Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings & Populations Research Center, part of the Population-based Research to Optimize the Screening Process consortium, including a safety-net system in the southwestern U.S., a northwestern mixed-model system, and a northeastern integrated healthcare system. Screening uptake was evaluated among average-risk patients (i.e., no previous abnormalities) by race and ethnicity as captured in the electronic health record, using chi-square tests. Among patients with abnormal findings requiring follow-up, the proportion receiving colposcopy or biopsy within 6 months was reported. Multivariable regression was conducted to assess how clinical, socioeconomic, and structural characteristics mediate observed differences.

RESULTS

Among 188,415 eligible patients, 62.8% received cervical cancer screening during the 3-year study period. Screening use was lower among non-Hispanic Black patients (53.2%) and higher among Hispanic (65.4%,) and Asian/Pacific Islander (66.5%) than among non-Hispanic White patients (63.5%, all p<0.001). Most differences were explained by the distribution of patients across sites and differences in insurance. Hispanic patients remained more likely to screen after controlling for a variety of clinical and sociodemographic factors (risk ratio=1.14, CI=1.12, 1.16). Among those receiving any screening test, Black and Hispanic patients were more likely to receive Pap-only testing (versus receiving co-testing). Follow-up from abnormal results was low for all groups (72.5%) but highest among Hispanic participants (78.8%, p<0.001).

CONCLUSIONS

In a large cohort receiving care across 3 diverse healthcare settings, cervical cancer screening and follow-up were below 80% coverage targets. Lower screening for Black patients was attenuated by controlling for insurance and site of care, underscoring the role of systemic inequity. In addition, it is crucial to improve follow-up after abnormalities are identified, which was low for all populations.

Comorbidities and Risk Factors of Patients Diagnosed with CRC after Positive Fecal Test in Real Life

(1) Background: Fecal occult blood test (FOBT) is the modality of choice in most countries for colorectal cancer (CRC) screening. We aimed to investigate the risk factors for CRC among patients with a positive FOBT in real life. (2) Methods: This was a retrospective study that included patients who tested positive for FOBT. Data regarding the comorbidities and laboratories were collected and compared between CRC and non-CRC groups. (3) Results: Positive FOBT was found among 45,500 (5.36%) subjects and CRC was found in 1502 (3.3%). CRC patients were older, age 62.7 ± 7.15 years compared with 59.33 ± 7.3 years (p < 0.001), and had significantly higher rates of hypertension (48.4% vs. 44.7%, p = 0.002), iron-deficiency anemia (20.6% vs. 16.4, p < 0.001), family history of CRC (7.3% vs. 5.1%, p < 0.001), and previous CRC (6.5% vs. 0.3%, p < 0.001). Lower levels of hemoglobin, iron, and ferritin were found in the CRC group. Age, family history of CRC, and previous CRC were found to be significant risk factors for diagnosis of CRC after positive FOBT with OR of 1.057, 1.4, and 15.9, respectively. (4) Conclusions: Iron-deficiency anemia, family history of CRC, previous colorectal cancer, and low hemoglobin, iron, and ferritin levels should direct physicians to give high priority to colonoscopy scheduling.

Optimization of a Quality Improvement Tool for Cancer Diagnosis in Primary Care: Qualitative Study

Background

The most common route to a diagnosis of cancer is through primary care. Delays in diagnosing cancer occur when an opportunity to make a timely diagnosis is missed and is evidenced by patients visiting the general practitioner (GP) on multiple occasions before referral to a specialist. Tools that minimize prolonged diagnostic intervals and reduce missed opportunities to investigate patients for cancer are therefore a priority.

Objective

This study aims to explore the usefulness and feasibility of a novel quality improvement (QI) tool in which algorithms flag abnormal test results that may be indicative of undiagnosed cancer. This study allows for the optimization of the cancer recommendations before testing the efficacy in a randomized controlled trial.

Methods

GPs, practice nurses, practice managers, and consumers were recruited to participate in individual interviews or focus groups. Participants were purposively sampled as part of a pilot and feasibility study, in which primary care practices were receiving recommendations relating to the follow-up of abnormal test results for prostate-specific antigen, thrombocytosis, and iron-deficiency anemia. The Clinical Performance Feedback Intervention Theory (CP-FIT) was applied to the analysis using a thematic approach.

Results

A total of 17 interviews and 3 focus groups (n=18) were completed. Participant themes were mapped to CP-FIT across the constructs of context, recipient, and feedback variables. The key facilitators to use were alignment with workflow, recognized need, the perceived importance of the clinical topic, and the GPs’ perception that the recommendations were within their control. Barriers to use included competing priorities, usability and complexity of the recommendations, and knowledge of the clinical topic. There was consistency between consumer and practitioner perspectives, reporting language concerns associated with the word cancer, the need for more patient-facing resources, and time constraints of the consultation to address patients’ worries.

Conclusions

There was a recognized need for the QI tool to support the diagnosis of cancer in primary care, but barriers were identified that hindered the usability and actionability of the recommendations in practice. In response, the tool has been refined and is currently being evaluated as part of a randomized controlled trial. Successful and effective implementation of this QI tool could support the detection of patients at risk of undiagnosed cancer in primary care and assist in preventing unnecessary delays.

Delays in Follow-up Care for Abnormal Mammograms in Mobile Mammography Versus Fixed-Clinic Patients

BACKGROUND

Mobile mammographic services (MM) have been shown to increase breast cancer screening in medically underserved women. However, little is known about MM patients' adherence to follow-up of abnormal mammograms and how this compares with patients from traditional, fixed clinics.

OBJECTIVES

To assess delays in follow-up of abnormal mammograms in women screened using MM versus fixed clinics.

DESIGN

Electronic medical record review of abnormal screening mammograms.

SUBJECTS

Women screened on a MM van or at a fixed clinic with an abnormal radiographic result in 2019 (N = 1,337).

MAIN MEASURES

Our outcome was delay in follow-up of an abnormal mammogram of 60 days or greater. Guided by Andersen's Behavioral Model of Health Services Utilization, we assessed the following: predisposing (age, ethnicity, marital status, preferred language), enabling (insurance, provider referral, clinic site), and need (personal breast cancer history, family history of breast/ovarian cancer) factors.

KEY RESULTS

Only 45% of MM patients had obtained recommended follow-up within 60 days of an abnormal screening compared to 72% of fixed-site patients (p < .001). After adjusting for predisposing, enabling, and need factors, MM patients were 2.1 times more likely to experience follow-up delays than fixed-site patients (CI: 1.5-3.1; p < .001). African American (OR: 1.5; CI: 1.0-2.1; p < .05) and self-referred (OR: 1.8; CI: 1.2-2.8; p < .01) women were significantly more likely to experience delays compared to Non-Hispanic White women or women with a provider referral, respectively. Women who were married (OR: 0.63; CI: 0.5-0.9; p < .01), had breast cancer previously (OR: 0.37; CI: 0.2-0.8; p < .05), or had a family history of breast/ovarian cancer (OR: 0.76; CI: 0.6-0.9; p < .05) were less likely to experience delayed care compared to unmarried women, women with no breast cancer history, or women without a family history of breast/ovarian cancer, respectively.

CONCLUSIONS

A substantial proportion of women screened using MM had follow-up delays. Women who are African American, self-referred, or unmarried are particularly at risk of experiencing delays in care for an abnormal mammogram.

A global view of adherence to colonoscopy follow-up in cascade screening of colorectal cancer

OBJECTIVE

To overview the colonoscopy adherence in cascade screening of colorectal cancer (CRC) and evaluate potential influence of the initial tests based on an ecological evaluation.

METHODS

The performance of the initial screening tests and adherence to subsequent colonoscopy were extracted from relevant studies published up to 16 October 2020. The age-standardised incidence (ASRi) of CRC in populations in the year of screening was derived from the Cancer Statistics.

RESULTS

One hundred sixty-six observational studies and 60 experimental studies were identified. Most studies applied cascade screening with faecal occult blood tests (FOBTs) as an initial test. The adherence to colonoscopy varied greatly across populations by continents, gross national income and type of initial tests, with a median (interquartile range) of 79.8% (63.1%-87.8%) in observational studies and 82.1% (66.7%-90.4%) in randomised trials. The adherence was positively correlated with the ASRi of CRC (r = 0.145, p = 0.023) and positive predictive value (PPV) of the initial tests (r = 0.206, p = 0.002) in observational studies and correlated with ASRi of CRC (r = 0.309, p = 0.002) and sensitivity of the initial tests (r = -0.704, p = 0.003) in experimental studies.

CONCLUSIONS

Adherence to colonoscopy varies greatly across populations and is related with performance of the initial tests, indicating the importance to select appropriate initial tests.

Patient Experience of Managing Adherence to Repeat Lung Cancer Screening

Lung cancer screening (LCS) is a process involving multiple low-dose computed tomography (LDCT) scans over multiple years. While adherence to recommended follow-up is critical in reducing lung cancer mortality, little is known about factors influencing adherence following the initial LDCT scan. The purpose of this study was to examine patients’ and providers’ depictions of continued screening and their understandings of patients’ decisions to return for follow-up. Qualitative methodology involves interviews with patients about their understanding of the screening process and perceptions of lung cancer risk, including motivations to adhere to follow-up screening and surveillance. Analysis of interview transcripts followed the general procedures of grounded theory methodology. Patient adherence to LCS was influenced by their understanding of the process of screening, and their expectations for the next steps. Perceptions of lung cancer risk and associated motivation were not static and changed throughout the screening process. Recognizing that patients’ motivations may be dynamic over the course of screening and surveillance will assist providers in helping patients make decisions regarding continued engagement with LCS.

Recent global burden of cervical cancer incidence and mortality, predictors, and temporal trends

BACKGROUNDS

This study investigated the global incidence and mortality of cervical cancer, its predictors, the temporal trend by country and age.

METHODS

Data from Global Cancer Observatory 2020 for 185 countries was used to estimate current cervical cancer incidence and mortality and their associations with predictors by linear regression analysis. Estimated age-standardized rates (ASR) and average annual percentage changes (AAPC) from cancer registries for up to 53 countries through 2018 were used for trend analysis by joinpoint regression.

RESULTS

Wide variations in cervical cancer were observed globally with the highest rates of incidence and mortality in East Africa (ASR, 40.1 and 28.6). The incidence and mortality of cervical cancer were positively associated with human papillomavirus, human immunodeficiency virus infection and negatively associated with cervical cancer screening coverage. In the most recent 5 years, reduction of incidence and mortality was found from 22 (AAPC, -11.2 to -0.5) and 27 countries (-21.5 to -0.3). Increase of incidence and mortality was found from 13 (1.7 to 6.5) and 5 (0.3 to 1.8) countries. Comparing to women aged above 50 years, increasing incidence were additionally found among women under age 50 years from 9 countries (ranging from 0.2 in Denmark to 3.8 in Sweden).

CONCLUSIONS

While most countries with cancer registry have shown reduction in cervical cancer incidence and mortality, the increasing incidence among younger women from some developed countries warrants further implementation of effective cancer screening.

NACP: Partnership for Native American Cancer Prevention

Cancer trends over a two-decade period show a greater reduction in cancer mortality rates for non-Hispanic Whites than for Native Americans. The Partnership for Native American Cancer Prevention (NACP) was established to address cancer health disparities that impact Native Americans. The partners are Northern Arizona University, the University of Arizona Cancer Center, Arizona's tribal communities and the National Cancer Institute. The activities include outreach, research and cancer education. Overall, NACP seeks to expand capacity for culturally-sensitive and community-relevant research on cancer, and to continue developing respectful collaborations that will empower sovereign Native American communities to define, implement, and achieve their goals for cancer health equity.

ACG Clinical Guidelines: Colorectal Cancer Screening 2021

Colorectal cancer (CRC) is the third most common cancer in men and women in the United States. CRC screening efforts are directed toward removal of adenomas and sessile serrated lesions and detection of early-stage CRC. The purpose of this article is to update the 2009 American College of Gastroenterology CRC screening guidelines. The guideline is framed around several key questions. We conducted a comprehensive literature search to include studies through October 2020. The inclusion criteria were studies of any design with men and women age 40 years and older. Detailed recommendations for CRC screening in average-risk individuals and those with a family history of CRC are discussed. We also provide recommendations on the role of aspirin for chemoprevention, quality indicators for colonoscopy, approaches to organized CRC screening and improving adherence to CRC screening. CRC screening must be optimized to allow effective and sustained reduction of CRC incidence and mortality. This can be accomplished by achieving high rates of adherence, quality monitoring and improvement, following evidence-based guidelines, and removing barriers through the spectrum of care from noninvasive screening tests to screening and diagnostic colonoscopy. The development of cost-effective, highly accurate, noninvasive modalities associated with improved overall adherence to the screening process is also a desirable goal.

Barriers to completing colonoscopy after a positive fecal occult blood test

Background

Colorectal cancer leads to significant morbidity and mortality. Early detection and treatment are essential. Screening using fecal occult blood tests has increased significantly, but adherence to colonoscopy follow-up is suboptimal, increasing CRC mortality risk.

The aim of this study was to identify barriers to colonoscopy following a positive FOBT at the level of the patient, physician, organization and policymakers.

Methods

This mixed methods study was conducted at two health care organizations in Israel. The study included retrospective analyses of 45,281 50–74 year-old members with positive fecal immunochemical tests from 2010 to 2014, and a survey of 772 patients with a positive test during 2015, with and without follow-up. The qualitative part of the study included focus groups with primary physicians and gastroenterologists and in-depth interviews with opinion leaders in healthcare.

Results

Patient lack of comprehension regarding the test was the strongest predictor of non-adherence to follow-up. Older age, Arab ethnicity, and lower socio economic status significantly reduced adherence. We found no correlation with gender, marital status, patient activation, waiting time for appointments or distance from gastroenterology clinics. Primary care physicians underestimate non-adherence rates. They feel responsible for patient follow-up, but express lack of time and skills that will allow them to ensure adherence among their patients. Gastroenterologists do not consider fecal occult blood an effective tool for CRC detection, and believe that all patients should undergo colonoscopy. Opinion leaders in the healthcare field do not prioritize the issue of follow-up after a positive screening test for colorectal cancer, although they understand the importance.

Conclusions

We identified important barriers that need to be addressed to improve the effectiveness of the screening program. Targeted interventions for populations at risk for non-adherence, specifically for those with low literacy levels, and better explanation of the need for follow-up as a routine need to be set in place. Lack of agreement between screening recommendations and gastroenterologist opinion, and lack of awareness among healthcare authority figures negatively impact the screening program need to be addressed at the organizational and national level.

Trial registration

This study was approved by the IRB in both participating organizations (Meuhedet Health Care Institutional Review Board #02–2–5-15, Maccabi Healthcare Institutional Review Board BBI-0025-16). Participant consent was waived by both IRB’s.

Determinants of Abnormal Cervical Cancer Screening Follow-Up And Invasive Cervical Cancer Among Uninsured and Underinsured Women in New Jersey

OBJECTIVES

To identify determinants of follow-up care and diagnosis of invasive cervical cancer among uninsured/underinsured women screened for cervical cancer.

METHODS

We examined the associations between health care facility, area-level, and individual-level factors on the outcomes of interest in retrospective cohort of women from the New Jersey Cancer Education and Early Detection Program (2000-2015).

RESULTS

Women screened at department of health clinics (aOR:3.11, 95% CI: 2.30-4.20) and health care system-affiliated clinics (aOR:1.71, 95% CI: 1.11-2.64) had higher odds of lacking follow-up care compared with women in private physician practices. Similarly, women residing in areas with the highest unemployment had higher odds of lacking follow-up (aOR:1.48, 95% CI: 1.07-2.06). Delays in follow-up care were higher for women born in Central/South American countries compared with U.S.-born women (aOR: 1.46, 95% CI: 1.12-1.92).

CONCLUSIONS

Improved outreach efforts and multilevel strategies are needed to address the persistent barriers to appropriate follow-up care for underserved women.

Effect of a complex intervention to improve post-vision screening referral compliance among pre-school children in China: A cluster randomized clinical trial

BACKGROUND

We investigated whether specific appointments for quality-assured care could increase referral uptake, often low in China, in children's vision screening.

METHODS

We randomized children aged 4-7 years in Yudu, Jiangxi, China, by school to Control (free school-based eye screening, parents of children failing screening recommended for further examination [usual practice]) or Intervention (identical examinations, with parents additionally provided with specific appointments for further examinations by quality-assured doctors at a designated local hospital). Both groups could select any hospital for referral exams, which were not free. Six months after screening, parents were interviewed on referral compliance at any hospital (primary outcome) and potential determinants. This trial is registered at the ClinicalTrials.gov, number NCT03251456.

FINDINGS

Among 9936 children at 63 schools randomized to Intervention (32 schools, 5053 [50·9%] children) or Control (31 schools, 4883 [49·1%] children), 1114 children (11·2%) failed screening. Among 513 referred Intervention children (46·1%, 32 schools, mean age 5·36 years, 53·0% boys) and 601 referred Control children (53·9%, 31 schools, mean age 5·30 years, 57·7% boys), 104 (20·3%) and 135 (22·5%) were lost to follow-up respectively. Under Intention to Treat analysis, assuming children lost to follow-up were non-compliant, Intervention children had significantly higher compliance than Controls (308/513 = 60·0% vs. 225/601 = 37·4%, P < 0·001). In regression models, Intervention group membership (Relative risk [RR] 1·53, 95% confidence interval, 1·36-1·72), travel time to hospital (RR: 0·97, 0·95-0·999), baseline glasses wear (RR: 1·37, 1·17-1·60), strabismus (RR: 1·17, 1·01-1·36) and worse uncorrected vision (RR: 1·41, 1·03-1·92) were associated with compliance.

INTERPRETATION

Providing specific appointments for quality-assured eye care improved referral compliance in this setting.

Repeated Automated Mobile Text Messaging Reminders for Follow-Up of Positive Fecal Occult Blood Tests: Randomized Controlled Trial

Background

Fecal occult blood tests (FOBTs) are recommended by the US Preventive Services Task Force as a screening method for colorectal cancer (CRC), but they are only effective if positive results are followed by colonoscopy. Surprisingly, a large proportion of patients with a positive result do not follow this recommendation.

Objective

The objective of this study was to examine the effectiveness of text messaging (short message service, SMS) in increasing adherence to colonoscopy follow-up after a positive FOBT result.

Methods

This randomized controlled trial was conducted with patients who had positive CRC screening results. Randomization was stratified by residential district and socioeconomic status (SES). Subjects in the control group (n=238) received routine care that included an alert to the physician regarding the positive FOBT result. The intervention group (n=232) received routine care and 3 text messaging SMS reminders to visit their primary care physician. Adherence to colonoscopy was measured 120 days from the positive result. All patient information, including test results and colonoscopy completion, were obtained from their electronic medical records. Physicians of study patients completed an attitude survey regarding FOBT as a screening test for CRC. Intervention and control group variables (dependent and independent) were compared using chi-square test. Logistic regression was used to calculate odds ratios (ORs) and 95% CIs for performing colonoscopy within 120 days for the intervention group compared with the control group while adjusting for potential confounders including age, gender, SES, district, ethnicity, and physicians’ attitude.

Results

Overall, 163 of the 232 patients in the intervention group and 112 of the 238 patients in the control group underwent colonoscopy within 120 days of the positive FOBT results (70.3% vs 47.1%; OR 2.17, 95% CI 1.49-3.17; P<.001); this association remained significant after adjusting for potential confounders (P=.001).

Conclusions

A text message (SMS) reminder is an effective, simple, and inexpensive method for improving adherence among patients with positive colorectal screening results. This type of intervention could also be evaluated for other types of screening tests.

Trial Registration

ClinicalTrials.gov NCT03642652; https://clinicaltrials.gov/ct2/show/NCT03642652 (Archived by WebCite at http://www.webcitation.org/74TlICijl)

Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests: A Systematic Review

BACKGROUND

Fecal immunochemical testing is the most commonly used method for colorectal cancer screening worldwide. However, its effectiveness is frequently undermined by failure to obtain follow-up colonoscopy after positive test results.

PURPOSE

To evaluate interventions to improve rates of follow-up colonoscopy for adults after a positive result on a fecal test (guaiac or immunochemical).

DATA SOURCES

English-language studies from the Cochrane Central Register of Controlled Trials, PubMed, and Embase from database inception through June 2017.

STUDY SELECTION

Randomized and nonrandomized studies reporting an intervention for colonoscopy follow-up of asymptomatic adults with positive fecal test results.

DATA EXTRACTION

Two reviewers independently extracted data and ranked study quality; 2 rated overall strength of evidence for each category of study type.

DATA SYNTHESIS

Twenty-three studies were eligible for analysis, including 7 randomized and 16 nonrandomized studies. Three were at low risk of bias. Eleven studies described patient-level interventions (changes to invitation, provision of results or follow-up appointments, and patient navigators), 5 provider-level interventions (reminders or performance data), and 7 system-level interventions (automated referral, precolonoscopy telephone calls, patient registries, and quality improvement efforts). Moderate evidence supported patient navigators and provider reminders or performance data. Evidence for system-level interventions was low. Seventeen studies reported the proportion of test-positive patients who completed colonoscopy compared with a control population, with absolute differences of -7.4 percentage points (95% CI, -19 to 4.3 percentage points) to 25 percentage points (CI, 14 to 35 percentage points).

LIMITATION

More than half of studies were at high or very high risk of bias; heterogeneous study designs and characteristics precluded meta-analysis.

CONCLUSION

Patient navigators and giving providers reminders or performance data may help improve colonoscopy rates of asymptomatic adults with positive fecal blood test results. Current evidence about useful system-level interventions is scant and insufficient.

PRIMARY FUNDING SOURCE

National Cancer Institute. (PROSPERO: CRD42016048286).

Impact of GP reminders on follow-up of abnormal cervical cytology: a before-after study in Danish general practice

BACKGROUND

Dysplasia may progress because of a loss to follow-up after an abnormal cervical cytology. Approximately 18% of Danish women postpone the recommended follow-up, which depends on the cytology results.

AIM

To investigate if a reminder to the GP about missed follow-up could reduce the proportion of women who fail to act on a recommended follow-up, and to analyse the effect on sociodemographic and general practice variations.

DESIGN AND SETTING

A national electronic GP reminder system was launched in Denmark in 2012 to target missed follow-up after screening, opportunistic testing, or surveillance indication. The authors compared follow-up proportions in a national observational before-after study.

METHOD

From national registries, 1.5 million cervical cytologies (from 2009 to 2013) were eligible for inclusion. Approximately 10% had a recommendation for follow-up. The proportion of cervical cytologies without follow-up was calculated at different time points. Results were stratified by follow-up recommendations and sociodemographic characteristics, and changes in practice variation for follow-up were analysed.

RESULTS

Fewer women with a recommendation for follow-up missed follow-up 6 months after a GP reminder. Follow-up improved in all investigated sociodemographic groups (age, ethnicity, education, and cohabitation status). Interaction was found for age and cohabitation status. Variation between practices in loss to follow-up was significantly reduced.

CONCLUSION

An electronic GP reminder system showed potential to improve the quality of cervical cancer screening through reduced loss to follow-up.

Reasons for Lack of Diagnostic Colonoscopy After Positive Result on Fecal Immunochemical Test in a Safety-Net Health System

BACKGROUND

Effective colorectal cancer screening depends on timely diagnostic evaluation in patients with abnormal results on fecal immunochemical tests (FITs). Although prior studies suggest low rates of follow-up colonoscopy, there is little information among patients in safety-net health systems and few data characterizing reasons for low follow-up rates. This study aimed to characterize factors contributing to lack of follow-up colonoscopy in a racially diverse and socioeconomically disadvantaged cohort of patients with abnormal results on FIT ("abnormal FIT" for brevity) receiving care in an integrated safety-net health system.

METHODS

We performed a retrospective electronic medical record review of patients aged 50-64 years with abnormal FIT at a population-based safety-net health system between January 2010 and July 2013. Review of electronic medical records focused on patients without follow-up colonoscopy to characterize patient-, provider-, and system-level reasons for lack of diagnostic evaluation. We used logistic regression analysis to identify predictors of follow-up colonoscopy within 12 months of abnormal FIT.

RESULTS

Of 1267 patients with abnormal FIT, 536 (42.3%) failed to undergo follow-up colonoscopy within 1 year. Failure was attributable to patient-level factors in 307 (57%) cases, provider factors in 97 (18%) cases, and system factors in 118 (22%) cases. In multivariate analysis, follow-up colonoscopy was less likely among those aged 61-64 years (odds ratio 0.63, 95% confidence interval 0.46-0.87) compared with 50-55 year olds.

CONCLUSIONS

Nearly half (42%) of patients with abnormal FIT failed to undergo follow-up colonoscopy within 1 year. Lack of diagnostic evaluation is related to a combination of patient-, provider-, and system-level factors, highlighting the need for multilevel interventions to improve follow-up colonoscopy completion rates.

Organization of surveillance in GI practice

BACKGROUND

Several reports documented an inefficient utilisation of available resources, as well as a suboptimal compliance with surveillance recommendations. Although, evidence suggests that organisational issues can influence the quality of care delivered, surveillance protocols are usually based on non-organized approaches.

METHODS

We conducted a literature search (publication date: 01/2000-06/2016) on PubMed and Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and Cochrane Central Register of Controlled Trials for guidelines, or consensus statements, for surveys of practice, reporting information about patients, or providers attitudes and behaviours, for intervention studies to enhance compliance with guidelines. Related articles were also scrutinised. Based on the clinical relevance and burden on endoscopy services this review was focused on surveillance for Barrett's oesophagus, IBD and post-polypectomy surveillance of colonic adenomas.

RESULTS

Existing guidelines are generally recognising structure and process requirements influencing delivery of surveillance interventions, while less attention had been devoted to transitions and interfaces in the care process. Available evidence from practice surveys is suggesting the need to design organizational strategies aimed to enable patients to attend and providers to deliver timely and appropriate care. Well designed studies assessing the effectiveness of specific interventions in this setting are however lacking. Indirect evidence from screening settings would suggest that the implementation of automated standardized recall systems, utilisation of clinical registries, removing financial barriers, could improve appropriateness of use and compliance with recommendations.

CONCLUSIONS

Lack of sound evidence regarding utility and methodology of surveillance can contribute to explain the observed variability in providers and patients attitudes and in compliance with the recommended surveillance.

Optimising colorectal cancer screening acceptance: a review

The study aims to review available evidence concerning effective interventions to increase colorectal cancer (CRC) screening acceptance. We performed a literature search of randomised trials designed to increase individuals' use of CRC screening on PubMed, Embase, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects. Small (≤ 100 subjects per arm) studies and those reporting results of interventions implemented before publication of the large faecal occult blood test trials were excluded. Interventions were categorised following the Continuum of Cancer Care and the PRECEDE-PROCEED models and studies were grouped by screening model (opportunistic vs organised). Multifactor interventions targeting multiple levels of care and considering factors outside the individual clinician control, represent the most effective strategy to enhance CRC screening acceptance. Removing financial barriers, implementing methods allowing a systematic contact of the whole target population, using personal invitation letters, preferably signed by the reference care provider, and reminders mailed to all non-attendees are highly effective in enhancing CRC screening acceptance. Physician reminders may support the diffusion of screening, but they can be effective only for individuals who have access to and make use of healthcare services. Educational interventions for patients and providers are effective, but the implementation of organisational measures may be necessary to favour their impact. Available evidence indicates that organised programmes allow to achieve an extensive coverage and to enhance equity of access, while maximising the health impact of screening. They provide at the same time an infrastructure allowing to achieve a more favourable cost-effectiveness profile of potentially effective strategies, which would not be sustainable in opportunistic settings.

Follow-up to abnormal cancer screening tests: considering the multilevel context of care

The call for multilevel interventions to improve the quality of follow-up to abnormal cancer screening has been out for a decade, but published work emphasizes individual approaches, and conceptualizations differ regarding the definition of levels. To investigate the scope and methods being undertaken in this focused area of follow-up to abnormal tests (breast, colon, cervical), we reviewed recent literature and grants (2007-2012) funded by the National Cancer Institute. A structured search yielded 16 grants with varying definitions of "follow-up" (e.g., completion of recommended tests, time to diagnosis); most included minority racial/ethnic group participants. Ten grants concentrated on measurement/intervention development and 13 piloted or tested interventions (categories not mutually exclusive). All studies considered patient-level factors and effects. Although some directed interventions at provider levels, few measured group characteristics and effects of interventions on the providers or levels other than the patient. Multilevel interventions are being proposed, but clarity about endpoints, definition of levels, and measures is needed. The differences in the conceptualization of levels and factors that affect practice need empirical exploration, and we need to measure their salient characteristics to advance our understanding of how context affects cancer care delivery in a changing practice and policy environment.

A comparison of different strategies used to invite subjects with a positive faecal occult blood test to a colonoscopy assessment. A randomised controlled trial in population-based screening programmes

OBJECTIVE

The purpose of this parallel randomised controlled trial was to compare compliance with different modalities used to invite patients with a positive immunochemical faecal occult blood test (FIT+) for a total colonoscopy (TC).

METHOD

FIT+ patients from nine Italian colorectal cancer screening programmes were randomised to be invited for a TC initially by mail or by phone and, for non-compliers, to be recalled by mail, for counselling with a general practitioner, or to meet with a specialist screening practitioner (nurse or healthcare assistant).

RESULTS

In all, 3777 patients were randomised to different invitation strategies. Compliance with an initial invitation by mail and by phone was similar (86.0% vs. 84.0%, relative risk - RR: 1.02; 95%CI 0.97-1.08). Among non-responders to the initial invitation, compliance with a recall by appointment with a specialist practitioner was 50.4%, significantly higher than with a mail recall (38.1%; RR:1.33; 95%CI 1.01-1.76) or with a face-to-face counselling with the GP (30.8%; RR:1.45;95%CI 1.14-1.87).

CONCLUSION

Compliance with an initial invitation for a TC by mail and by phone was similar. A personal meeting with a specialist screening practitioner was associated with the highest compliance among non-compliers with initial invitations, while the involvement of GPs in this particular activity seemed less effective.

How can diagnostic assessment programs be implemented to enhance inter-professional collaborative care for cancer?

BACKGROUND

Inter-professional collaborative care (ICC) for cancer leads to multiple system, organizational, professional, and patient benefits, but is limited by numerous challenges. Empirical research on interventions that promote or enable ICC is sparse so guidance on how to achieve ICC is lacking. Research shows that ICC for diagnosis could be improved. Diagnostic assessment programs (DAPs) appear to be a promising model for enabling ICC. The purpose of this study was to explore how DAP structure and function enable ICC, and whether that may be associated with organizational and clinical outcomes.

METHODS

A case study approach will be used to explore ICC among eight DAPs that vary by type of cancer (lung, breast), academic status, and geographic region. To describe DAP function and outcomes, and gather information that will enable costing, recommendations expressed in DAP standards and clinical guidelines will be assessed through retrospective observational study. Data will be acquired from databases maintained by participating DAPs and the provincial cancer agency, and confirmed by and supplemented with review of medical records. We will conduct a pilot study to explore the feasibility of estimating the incremental cost-effectiveness ratio using person-level data from medical records and other sources. Interviews will be conducted with health professionals, staff, and referring physicians from each DAP to learn about barriers and facilitators of ICC. Qualitative methods based on a grounded approach will be used to guide sampling, data collection and analysis.

DISCUSSION

Findings may reveal opportunities for unique structures, interventions or tools that enable ICC that could be developed, implemented, and evaluated through future research. This information will serve as a formative needs assessment to identify the nature of ongoing or required improvements, which can be directly used by our decision maker collaborators, and as a framework by policy makers, cancer system managers, and DAP managers elsewhere to strategically plan for and implement diagnostic cancer services.

Electronic health record-based triggers to detect potential delays in cancer diagnosis

BACKGROUND

Delayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate 'trigger' algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis.

METHODS

We mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV).

RESULTS

The PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers.

CONCLUSIONS

EHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer.

Impact of patient navigation on cancer diagnostic resolution among Northwest Tribal communities

The patient navigator model has not been widely implemented in American Indian/Alaska Native (AI/AN) communities, but may be effective in improving cancer outcomes for this population. Subjects were enrolled from eight clinics at Tribes throughout the Northwest (n = 1,187). Four clinics received navigation. Time between abnormal finding and definitive diagnosis was recorded. We examined whether odds of obtaining definitive diagnosis by 60, 90, and 365 days differed between the two groups. The odds of definitive diagnosis within 365 days for navigated subjects was 3.6 times (95 % CI, 1.47, 8.88; p = 0.01) the odds for control subjects. The outcome at 60 and 90 days did not significantly differ between the two groups. Our findings indicate that patient navigation did not significantly impact chance of diagnosis by 60 or 90 days from abnormal finding. However, it did improve the chance of avoiding extreme delays in obtaining a definitive diagnosis.

Postreferral colonoscopy delays in diagnosis of colorectal cancer: a mixed-methods analysis

BACKGROUND

Delays in diagnosis of colorectal cancer (CRC) are one of the most common reasons for malpractice claims and lead to poor outcomes. However, they are not well studied.

AIMS

We used a mixed quantitative-qualitative approach to analyze postreferral colonoscopy delays in CRC patients and explored referring physician's perception of processes surrounding these delays.

METHODS

Two physician-raters conducted independent electronic health record reviews of new CRC cases in a large integrated safety-net system to determine postreferral colonoscopy delays, which we defined as failures to perform colonoscopy within 60 days of referral for an established indication(s). To explore perceptions of colonoscopy processes, we conducted semistructured interviews with a sample of primary care physicians (PCPs) and used a content analysis approach.

RESULTS

Of 104 CRC cases that met inclusion criteria, reviewers agreed on the presence of postreferral colonoscopy delays in 35 (33.7%) cases; κ = 0.99 (95% CI, 0.83-0.99). The median time between first referral and completion of colonoscopy was 123.0 days (range 62.0-938.0; interquartile range = 90.0 days). In about two-thirds of instances (64.8%), the reason for delay was a delayed future appointment with the gastroenterology service. On interviews, PCPs attributed long delays in scheduling to reduced endoscopic capacity and inefficient processes related to colonoscopy referral and scheduling, including considerable ambiguity regarding referral guidelines. Many suggested that navigation models be applied to streamline CRC diagnosis.

CONCLUSION

Postreferral delays in CRC diagnosis are potentially preventable. A comprehensive mixed-methods methodology might be useful for others to identify the steps in the diagnostic process that are in most need for improvement.

Theoretically informed correlates of hepatitis B knowledge among four Asian groups: the health behavior framework

BACKGROUND

Few studies have examined theoretically informed constructs related to hepatitis B (HBV) testing, and comparisons across studies are challenging due to lack of uniformity in constructs assessed. The present analysis examined relationships among Health Behavior Framework factors across four Asian American groups to advance the development of theory-based interventions for HBV testing in at-risk populations.

METHODS

Data were collected from 2007-2010 as part of baseline surveys during four intervention trials promoting HBV testing among Vietnamese-, Hmong-, Korean- and Cambodian-Americans (n = 1,735). Health Behavior Framework constructs assessed included: awareness of HBV, knowledge of transmission routes, perceived susceptibility, perceived severity, doctor recommendation, stigma of HBV infection, and perceived efficacy of testing. Within each group we assessed associations between our intermediate outcome of knowledge of HBV transmission and other constructs, to assess the concurrent validity of our model and instruments.

RESULTS

While the absolute levels for Health Behavior Framework factors varied across groups, relationships between knowledge and other factors were generally consistent. This suggests similarities rather than differences with respect to posited drivers of HBV-related behavior.

DISCUSSION

Our findings indicate that Health Behavior Framework constructs are applicable to diverse ethnic groups and provide preliminary evidence for the construct validity of the Health Behavior Framework.

A multilevel research perspective on cancer care delivery: the example of follow-up to an abnormal mammogram

In 1999, researchers and policy makers recognized the challenge of creating an integrated patient-centered cancer care process across the many types of care from risk assessment through end of life. More than a decade later, there has been limited progress toward that goal even though the standard reductionist approach to health services and medical research has resulted in major advances in tests, procedures, and individualized patient approaches to care. In this commentary, we propose that considering an entire care process within its multilevel context may increase progress toward an integrated experience and improvements in the quality of care. As an illustrative case, we describe the multilevel context of care delivery for the process of follow-up to an abnormal screening mammogram. By taking a multilevel perspective on this process, we identify a rich set of options for intervening and improving follow-up to abnormalities and, therefore, outcomes of screening. We propose that taking this multilevel perspective when designing interventions may improve the quality of cancer care in an effective and sustainable way.

Design of a prostate cancer patient navigation intervention for a Veterans Affairs hospital

BACKGROUND

Patient navigation programs have been launched nationwide in an attempt to reduce racial/ethnic and socio-demographic disparities in cancer care, but few have evaluated outcomes in the prostate cancer setting. The National Cancer Institute-funded Chicago Patient Navigation Research Program (C-PNRP) aims to implement and evaluate the efficacy of a patient navigation intervention for predominantly low-income minority patients with an abnormal prostate cancer screening test at a Veterans Affairs (VA) hospital in Chicago.

METHODS/DESIGN

From 2006 through 2010, C-PNRP implemented a quasi-experimental intervention whereby trained social worker and lay health navigators worked with veterans with an abnormal prostate screen to proactively identify and resolve personal and systems barriers to care. Men were enrolled at a VA urology clinic and were selected to receive navigated versus usual care based on clinic day. Patient navigators performed activities to facilitate timely follow-up such as appointment reminders, transportation coordination, cancer education, scheduling assistance, and social support as needed. Primary outcome measures included time (days) from abnormal screening to diagnosis and time from diagnosis to treatment initiation. Secondary outcomes included psychosocial and demographic predictors of non-compliance and patient satisfaction. Dates of screening, follow-up visits, and treatment were obtained through chart audit, and questionnaires were administered at baseline, after diagnosis, and after treatment initiation. At the VA, 546 patients were enrolled in the study (245 in the navigated arm, 245 in the records-based control arm, and 56 in a subsample of surveyed control subjects).

DISCUSSION

Given increasing concerns about balancing better health outcomes with lower costs, careful examination of interventions aimed at reducing healthcare disparities attain critical importance. While analysis of the C-PNRP data is underway, the design of this patient navigation intervention will inform other patient navigation programs addressing strategies to improve prostate cancer outcomes among vulnerable populations.

Timeliness of cervical cancer diagnosis and initiation of treatment in the National Breast and Cervical Cancer Early Detection Program

OBJECTIVES

To examine time intervals from cervical cancer screening to diagnosis and treatment initiation among low-income and uninsured women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) during two consecutive time periods.

METHODS

We analyzed NBCCEDP data for women with abnormal Pap tests (n=100,167), from which 1,417 invasive cervical cancers were diagnosed. We examined two time intervals for this study: diagnostic interval (time from abnormal Pap test to the date of definitive diagnosis) and treatment initiation interval (time from definitive diagnosis to treatment initiation) for two time periods: 1996-2002 and 2003-2009. We compared median time intervals for diagnostic and treatment initiation using the Kruskal-Wallis test. Adjusted proportions (predicted marginals) were calculated using logistic regression to examine diagnosis and treatment within program benchmarks (≤60 days).

RESULTS

Median diagnostic intervals decreased overall by 6 days (54 vs. 48 days, p<0.001). This decrease in the median diagnostic interval was noted for all variables examined. The median treatment initiation intervals remained stable over the two time periods.

CONCLUSIONS

Women screened by the NBCCEDP receive diagnostic follow-up and initiate treatment within preestablished program guidelines.

Depression and anxiety diagnoses are not associated with delayed resolution of abnormal mammograms and pap tests among vulnerable women

BACKGROUND

Delays in care after abnormal cancer screening contribute to disparities in cancer outcomes. Women with psychiatric disorders are less likely to receive cancer screening and may also have delays in diagnostic resolution after an abnormal screening test.

OBJECTIVE

To determine if depression and anxiety are associated with delays in resolution after abnormal mammograms and Pap tests in a vulnerable population of urban women.

DESIGN

We conducted retrospective chart reviews of electronic medical records to identify women who had a diagnosis of depression or anxiety in the year prior to the abnormal mammogram or Pap test. We used time-to-event analysis to analyze the outcome of time to resolution after abnormal cancer screening, and Cox proportional hazards regression modeling to control for confounding.

PARTICIPANTS

Women receiving care in six Boston-area community health centers 2004-2005: 523 with abnormal mammograms, 474 with abnormal Pap tests.

RESULTS

Of the women with abnormal mammogram and pap tests, 19% and 16%, respectively, had co-morbid depression. There was no difference in time to diagnostic resolution between depressed and not-depressed women for those with abnormal mammograms (aHR = 0.9, 95 CI 0.7,1.1) or Pap tests (aHR = 0.9, 95 CI 0.7,1.3).

CONCLUSIONS

An active diagnosis of depression and/or anxiety in the year prior to an abnormal mammogram or Pap test was not associated with a prolonged time to diagnostic resolution. Our findings imply that documented mood disorders do not identify an additional barrier to resolution after abnormal cancer screening in a vulnerable population of women.

Concordance with ASCO guidelines for surveillance after colorectal cancer treatment: a population-based analysis

PURPOSE

Intensive surveillance after curative treatment of colorectal cancer (CRC) is associated with improved overall survival. This study examined concordance with the 2005 ASCO surveillance guidelines at the population level.

METHODS

A cohort of 250 patients diagnosed with stage II or III CRC in 2004 and alive 42 months after diagnosis was identified from health administrative data in Manitoba, Canada. Colonoscopy, liver imaging, and carcinoembryonic antigen (CEA) testing were assessed over 3 years. Guidelines were met if patients had at least one colonoscopy in 3 years and at least one liver imaging test and three CEA tests annually. Multivariate logistic regression assessed the effect of patient and physician characteristics and disease and treatment factors on guideline concordance.

RESULTS

Guidelines for colonoscopy, liver imaging, and CEA were met by 80.4%, 47.2%, and 22% of patients, respectively. Guideline concordance for colonoscopy was predicted by annual contact with a surgeon, higher income, and the diagnosis of colon (rather than rectal) cancer. Adherence was lower in those older than 70 years and with higher comorbidity. For liver imaging, significant predictors were annual contact with an oncologist, receipt of chemotherapy, and diagnosis of colon cancer. Concordance with CEA guidelines was higher with annual contact with an oncologist and high levels of family physician contact, and lower in urban residents, in those older than 70, and in those with stage II disease.

CONCLUSION

Completion of recommended liver imaging and CEA testing fall well below guidelines in Manitoba, whereas colonoscopy is better provided. Addressing this gap should improve outcomes for CRC survivors.

Sociodemographic factors associated with cervical cancer screening and follow-up of abnormal results

OBJECTIVE

To determine the sociodemographic factors associated with cervical cancer screening and follow-up of abnormal results.

DESIGN

Population cohort study.

SETTING

Ontario.

PARTICIPANTS

Women between the ages of 18 and 70 years who were eligible for Papanicolaou testing.

MAIN OUTCOME MEASURES

Rates of cervical cancer screening and follow-up of abnormal and inadequate Pap test results, and associated sociodemographic factors such as age, neighbourhood income level, and health region. Multivariate logistic regression was used to identify independent factors associated with screening and follow-up.

RESULTS

Of the 3.7 million women eligible for screening, 69% had had Pap tests in the past 3 years. These rates varied by age, income, and region (P < .001). Women residing in the lowest-income neighbourhoods were half as likely to be screened (odds ratio 0.56, 95% CI 0.55 to 0.56). Only 44% of those whose Pap test results revealed atypical squamous cells of uncertain significance or low-grade squamous intraepithelial lesions had repeat Pap tests or colposcopy within 6 months, and this varied by age, income, and region (P < .001). Among women with unsatisfactory Pap test results, only 35% were retested within 4 months, and this varied by age (P < .001).

CONCLUSION

Despite universal health coverage, cervical cancer screening rates are suboptimal among low-income women at greatest risk. Follow-up among women with inadequate or abnormal test results is often poor. Novel models of cervical cancer screening are needed to address these inadequacies.

Comparative performance of human papillomavirus DNA testing using novel sample collection methods

To explore alternative cervical cancer screening approaches in an underserved population, we compared the performance of human papillomavirus (HPV) DNA assays in combination with different sample collection methods for primary cervical screening in the Mississippi Delta region. Three specimens were collected from women aged 26 to 65 years who were either routinely undergoing screening (n = 252) or not (n = 191): clinician-collected cervical specimens, clinician-collected cervicovaginal specimens, and self-collected cervicovaginal specimens taken at home. A novel collection device and medium were used for cervicovaginal sampling. Specimens were tested by three HPV DNA assays: hybrid capture 2 (HC2; Qiagen Corp., Gaithersburg, MD), Linear Array (LA; Roche Molecular Systems, Pleasanton, CA), and Amplicor (Roche Molecular Systems, Pleasanton, CA). Liquid-based cytology was performed on cervical specimens. We compared the overall positivity (a proxy for clinical specificity) for any carcinogenic HPV genotype and calculated the agreement across assay and specimen type using McNemar's test for differences in test positivity. Across all three assays there were no significant differences between clinician-collected and self-collected cervicovaginal specimens (P > 0.01 for all comparisons). For both cervicovaginal specimens (clinician collected and self-collected), fewer women tested positive by HC2 than by LA or Amplicor (P < 0.01 for all comparisons). HC2 had the best agreement between specimens for all assays. HC2 is likely more clinically specific, although possibly less sensitive, than either PCR test. Thus, use of HC2 on cervicovaginal specimens for screening could result in fewer referrals compared to LA and Amplicor.

An investigation into the social context of low-income, urban Black and Latina women: implications for adherence to recommended health behaviors

Understanding factors that promote or prevent adherence to recommended health behaviors is essential for developing effective health programs, particularly among lower income populations who carry a disproportionate burden of disease. We conducted in-depth qualitative interviews (n = 64) with low-income Black and Latina women who shared the experience of requiring diagnostic follow-up after having a screening mammography with abnormal findings. We found that in addition to holding negative and fatalistic cancer-related beliefs, the social context of these women was largely defined by multiple challenges and major life stressors, factors that may interfere with their ability to attain health. Factors commonly mentioned included competing health issues, economic hardship, demanding caretaking responsibilities and relationships, insurance-related challenges, distrust of health care providers, and inflexible work policies. Black women also reported discrimination and medical mistrust, whereas Latinas experienced difficulties associated with immigration and social isolation. These results suggest that effective health interventions not only address change among individuals but must also change health care systems and social policies in order to reduce health disparities.

How can we improve cancer care? A review of interprofessional collaboration models and their use in clinical management

BACKGROUND

Multimodal cancer care requires collaboration among different professionals in various settings. Practice guidelines provide little direction on how this can best be achieved. Research shows that collaborative cancer management is limited, and challenged by numerous issues. The purpose of this research was to describe conceptual models of collaboration, and analyze how they have been applied in the clinical management of cancer patients.

METHODS

A review of the literature was performed using a two-phase meta-narrative approach. The first phase involved searching for conceptual models of collaboration. Their components and limitations were summarized. The second phase involved targeted searching for empirical research on evaluation of these concepts in the clinical management of cancer patients. Data on study objective, design, and findings were tabulated, and then summarized according to collaborative model and phase of clinical care to identify topics warranting further research.

RESULTS

Conceptual models for teamwork, interprofessional collaboration, integrated care delivery, interorganizational collaboration, continuity of care, and case management were described. All concepts involve two or more health care professionals that share patient care goals and interact on a continuum from consultative to integrative, varying according to extent and nature of interaction, degree to which decision making is shared, and the scope of patient management (medical versus holistic). Determinants of positive objective and subjective patient, team and organizational outcomes common across models included system or organizational support, team structure and traits, and team processes. Twenty-two studies conducted in ten countries examining these concepts for cancer care were identified. Two were based on an explicit model of collaboration. Many health professionals function through parallel or consultative models of care and are not well integrated. Few interventions or strategies have been applied to promote models that support collaboration.

CONCLUSIONS

Ongoing development, implementation and evaluation of collaborative cancer management, in the context of both practice and research, would benefit from systematic planning and operationalization. Such an approach is likely to improve patient, professional and organizational outcomes, and contribute to a collective understanding of collaborative cancer care.

Performance of a fail-safe system to follow up abnormal mammograms in primary care

OBJECTIVES

Missed and delayed breast cancer diagnoses are major sources of potential harm to patients and medical malpractice liability in the United States. Follow-up of abnormal mammogram results is an essential but challenging component of safe breast care. To explore the value of an inexpensive method to follow up abnormal test results, we examined a paper-based fail-safe system.

METHODS

We examined a fail-safe system used to follow up abnormal mammograms at a primary care practice at an urban teaching hospital. We analyzed all abnormal mammogram reports and clinicians' responses to follow-up reminders. We characterized potential lapses identified in this system and used regression models to identify patient, provider, and test result characteristics associated with such lapses.

RESULTS

Clinicians responded to fail-safe reminders for 92% of 948 abnormal mammograms. Clinicians reported that they were unaware of the abnormal result in 8% of cases and that there was no follow-up plan in place for 3% of cases. Clinicians with more years of experience were more likely to be aware of the abnormal result (odds of being unaware per incremental year in practice, 0.92; 95% confidence interval, 0.88-0.97) and were more likely to have a follow-up plan.

CONCLUSIONS

A paper-based fail-safe system for abnormal mammograms is feasible in a primary care practice. However, special care is warranted to ensure full clinician adherence and address staff transitions and trainee-related issues.

Perspectives on Pap test follow-up care among rural Appalachian women

Approximately one- to three-quarters of women notified of abnormal Pap test results do not receive appropriate follow-up care, dramatically elevating their risk for invasive cervical cancer. We explored barriers to and facilitators of follow-up care for women in two counties in Appalachian Kentucky, where invasive cervical cancer incidence and mortality are significantly higher than the national average. In-depth interviews were conducted among 27 Appalachian women and seven local health department personnel. Those who had been told of an atypical Pap test result tended to have one of three reactions: (1) not alarmed and generally did not obtain follow-up care; (2) alarmed and obtained follow-up care; or (3) alarmed, but did not obtain care. Each of these typologies appeared to be shaped by a differing set of three categories of influences: personal factors; procedure/provider/system factors; and ecological/community factors. Recommendations to increase appropriate follow-up care included pursuing research on explanations for these typologies and developing tailored interventions specific to women in each of the response types.

Impact of the 2002 American society for Colposcopy and Cervical Pathology guidelines on cervical cancer diagnosis in a geographically diverse population of commercially insured women, 1999-2004

OBJECTIVE

To report the impact of the release of the 2002 American Society for Colposcopy and Cervical Pathology guidelines on the management of abnormal cytological findings on time to diagnosis of cervical cancer in an insured population.

METHODS

This retrospective study identified women with cervical cancer (invasive and carcinoma in situ) through commercially insured administrative claims data. The cervical cancer case definition required a claim for cervical cancer and a claim with a diagnostic procedure (colposcopy, conization, biopsy, or hysterectomy). Time to diagnosis was defined as days between the initial Pap screening and the diagnostic procedure.

RESULTS

Between 1999 and 2004, there were 3,325 women aged 18 to 64 years who met the case definition for cervical cancer. Median time to diagnosis decreased from 42 days (interquartile range = 23-93 d) to 36.5 days (interquartile range = 20.5-80 d) for women with invasive cancer after the guideline change. The number of follow-up Pap screenings before biopsy also decreased (p = .0067). Among women with carcinoma in situ whose initial Pap screening was completed by a family practice clinician, time to diagnosis was projected to be more than 9 days longer compared with those whose screening was performed by a gynecologist.

CONCLUSIONS

The 2002 American Society for Colposcopy and Cervical Pathology guidelines for the management of abnormal cytological findings seem to have had a positive impact on the time to diagnosis and Pap screening use before biopsy for women diagnosed with cervical cancer.

Lack of follow-up after fecal occult blood testing in older adults: inappropriate screening or failure to follow up?

BACKGROUND

It is unclear whether lack of follow-up after screening fecal occult blood testing (FOBT) in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up vs failure to complete follow-up in healthy patients.

METHODS

A prospective cohort study of 2410 patients 70 years or older screened with FOBT was conducted at 4 Veteran Affairs (VA) medical centers from January 1 to December 31, 2001. The main outcome measure was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving a complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema), and medical records were reviewed to determine reasons for lack of follow-up.

RESULTS

A total of 212 patients (9%) had positive FOBT results; 42% received a complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of a complete follow-up, which was similar among patients 70 to 74 years old with a Charlson score of 0 compared with patients 80 years or older with a Charlson score of 1 or higher (48% vs 41%; P=.28). The VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive a complete follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received a complete follow-up.

CONCLUSIONS

While follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision making, including decisions to screen and decisions to follow up.

Functional health literacy in Spanish-speaking Latinas seeking breast cancer screening through the National Breast and Cervical Cancer Screening Program

Background:

This analysis examines the association between functional health literacy and follow-up after mammography among women receiving breast cancer screening at a National Breast and Cervical Cancer Early Detection Program site in New York City that provides universal bilingual case management.

Methods:

A total of 707 Latinas who spoke Spanish as their primary language completed a survey of health and demographic characteristics and the Test of Functional Health Literacy in Spanish (TOFHLA-S). Survey results were matched with clinical outcome data.

Results:

Among the survey participants, 98% were foreign-born and 99% had no health insurance. While the study found significant differences in access to health information and past screening behavior, women without adequate health literacy in Spanish were no less likely to receive clinical resolution of abnormal mammograms within 60 days (81.8% overall; n = 110) or to return for a repeat mammogram within 18 months (57.2% overall; n = 697). In fact, among those referred for a Pap test (n = 310), women without adequate health literacy were more likely to receive a Pap test within 60 days of their mammogram than those with adequate health literacy (82% compared to 71%, OR: 1.83, 95% CI: 1.04–3.22).

Discussion:

The lack of significantly lower follow-up outcomes among women with inadequate and marginal functional health literacy in this population of primary Spanish-speaking Latinas suggests that, once women have accessed screening services, programmatic approaches may exist to mitigate barriers to follow-up and to ensure optimal cancer screening outcomes for women of all literacy levels.

How to enhance physician and public acceptance and utilisation of colon cancer screening recommendations

Colorectal Cancer (CRC) screening delivery is a multidisciplinary undertaking, aiming at reducing mortality from and incidence of CRC without adversely affecting the health status of participants. The adoption of a public health perspective involves commitment to ensure equity of access and sustainability of the program over time. We reviewed available evidence concerning predictors of CRC screening uptake and the impact of interventions to improve adoption of screening using conceptual frameworks defining the role of determinants of preventive behaviours and the reach and target of interventions. The results of this review indicate that policy measures aimed at supporting screening delivery, as well as organisational changes, influencing the operational features of preventive services, need to be implemented, in order to allow individual's motivation to be eventually realised. To ensure coverage and equity of access and to maximise the impact of the intervention, policies aimed at implementing organised programs should be adopted, ensuring that participation in screening and any follow-up assessment should not be limited by financial barriers. Participants and providers beliefs may determine the response to different screening modalities. To achieve the desired health impact, an active follow-up of people with screening abnormalities should be implemented, supported by the introduction of infrastructural changes and multidisciplinary team work, which can ensure sustainability over time of effective interventions. Continuous monitoring as well as the adoption of plans to evaluate for program effectiveness represent crucial steps in the implementation of a successful program.

Peer navigation improves diagnostic follow-up after breast cancer screening among Korean American women: results of a randomized trial

Objective

To test an intervention to increase adherence to diagnostic follow-up tests among Asian American women.

Methods

Korean American women who were referred for a diagnostic follow-up test (mainly diagnostic mammograms) and who had missed their follow-up appointment were eligible to participate in the study. Women from two clinics (n = 176) were randomly allocated to a usual care control arm or a peer navigator intervention arm. A 20-min telephone survey was administered to women in both study arms six months after they were identified to assess demographic and socio-economic characteristics and the primary outcome, self-reported completion of the recommended follow-up exam.

Results

Among women who completed the survey at six-month follow-up, self-reported completion of follow-up procedures was 97% in the intervention arm and 67% in the control arm (p < 0.001). Based on an intent-to-treat analysis of all women who were randomized and an assumption of no completion of follow-up exam for women with missing outcome data, self-reported completion of follow-up was 61% in the intervention arm and 46% in the usual care control arm (p < 0.069).

Conclusions

Our results suggest that a peer navigator intervention to assist Korean American women to obtain follow-up diagnostic tests after an abnormal breast cancer screening test is efficacious.