Results of a randomized controlled trial to increase colorectal cancer screening in a managed care health plan

Identifying behaviour change techniques in 287 randomized controlled trials of audit and feedback interventions targeting practice change among healthcare professionals

BACKGROUND

Audit and feedback (A&F) is among the most widely used implementation strategies, providing healthcare professionals with summaries of their practice performance to prompt behaviour change and optimize care. Wide variability in effectiveness of A&F has spurred efforts to explore why some A&F interventions are more effective than others. Unpacking the variability of the content of A&F interventions in terms of their component behaviours change techniques (BCTs) may help advance our understanding of how A&F works best. This study aimed to systematically specify BCTs in A&F interventions targeting healthcare professional practice change.

METHODS

We conducted a directed content analysis of intervention descriptions in 287 randomized trials included in an ongoing Cochrane systematic review update of A&F interventions (searched up to June 2020). Three trained researchers identified and categorized BCTs in all trial arms (treatment & control/comparator) using the 93-item BCT Taxonomy version 1. The original BCT definitions and examples in the taxonomy were adapted to include A&F-specific decision rules and examples. Two additional BCTs ('Education (unspecified)' and 'Feedback (unspecified)') were added, such that 95 BCTs were considered for coding.

RESULTS

In total, 47/95 BCTs (49%) were identified across 360 treatment arms at least once (median = 5.0, IQR = 2.3, range = 129 per arm). The most common BCTs were 'Feedback on behaviour' (present 89% of the time; e.g. feedback on drug prescribing), 'Instruction on how to perform the behaviour' (71%; e.g. issuing a clinical guideline), 'Social comparison' (52%; e.g. feedback on performance of peers), 'Credible source' (41%; e.g. endorsements from respected professional body), and 'Education (unspecified)' (31%; e.g. giving a lecture to staff). A total of 130/287 (45%) control/comparator arms contained at least one BCT (median = 2.0, IQR = 3.0, range = 0-15 per arm), of which the most common were identical to those identified in treatment arms.

CONCLUSIONS

A&F interventions to improve healthcare professional practice include a moderate range of BCTs, focusing predominantly on providing behavioural feedback, sharing guidelines, peer comparison data, education, and leveraging credible sources. We encourage the use of our A&F-specific list of BCTs to improve knowledge of what is being delivered in A&F interventions. Our study provides a basis for exploring which BCTs are associated with intervention effectiveness.

TRIAL REGISTRATIONS

N/A.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

BACKGROUND

Health care professionals (HCPs) use clinical practice guidelines (CPGs) to make evidence-informed decisions regarding patient care. Although a large number of cancer-related CPGs exist, it is unknown which CPG dissemination and implementation strategies are effective for improving HCP behaviour and patient outcomes in a cancer care context. This review aimed to determine the effectiveness of CPG dissemination and/or implementation strategies among HCPs in a cancer care context.

METHODS

A comprehensive search of five electronic databases was conducted. Studies were limited to the dissemination and/or implementation of a CPG targeting both medical and/or allied HCPs in cancer care. Two reviewers independently coded strategies using the Mazza taxonomy, extracted study findings, and assessed study quality.

RESULTS

The search strategy identified 33 studies targeting medical and/or allied HCPs. Across the 33 studies, 23 of a possible 49 strategies in the Mazza taxonomy were used, with a mean number of 3.25 (SD = 1.45) strategies per intervention. The number of strategies used per intervention was not associated with positive outcomes. Educational strategies (n = 24), feedback on guideline compliance (n = 11), and providing reminders (n = 10) were the most utilized strategies. When used independently, providing reminders and feedback on CPG compliance corresponded with positive significant changes in outcomes. Further, when used as part of multi-strategy interventions, group education and organizational strategies (e.g. creation of an implementation team) corresponded with positive significant changes in outcomes.

CONCLUSIONS

Future CPG dissemination and implementation interventions for cancer care HCPs may benefit from utilizing the identified strategies. Research in this area should aim for better alignment between study objectives, intervention design, and evaluation measures, and should seek to incorporate theory in intervention design, so that behavioural antecedents are considered and measured; doing so would enhance the field's understanding of the causal mechanisms by which interventions lead, or do not lead, to changes in outcomes at all levels.

Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis

IMPORTANCE

Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused.

OBJECTIVE

To identify interventions associated with increasing CRC screening rates and their effect sizes.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening.

STUDY SELECTION

Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults.

DATA EXTRACTION AND SYNTHESIS

At least 2 investigators independently extracted data and appraised each study's risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention.

MAIN OUTCOMES AND MEASURES

The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs).

RESULTS

The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%).

CONCLUSIONS AND RELEVANCE

Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.

Physician Intervention and Chinese Americans' Colorectal Cancer Screening

OBJECTIVE

We conducted a cluster-randomized trial evaluating an intervention that trained Chinese-American primary care physicians to increase their Chinese patients' colorectal cancer (CRC) screening.

METHODS

Twenty-five physicians (13 randomized to the intervention arm and 12 to the control arm) and 479 of their patients (aged 50-75 and nonadherent to CRC screening guidelines) were enrolled. The intervention, guided by Social Cognitive Theory, included a communication guide and 2 in-office training sessions to enhance physicians' efficacy in com- municating CRC screening with patients. Patients' CRC screening rates (trial outcome) and rating of physician communication before intervention and at 12-month follow-up were assessed. Intention-to-treat analysis for outcome evaluation was conducted.

RESULTS

Screening rates were slightly higher in the intervention vs. the control arm (24.4% vs. 17.7%, p = .24). In post hoc analyses, intervention arm patients who perceived better communication were more likely to be screened than those who did not (OR = 1.09, 95% CI: 1.03, 1.15). This relationship was not seen in the control arm.

CONCLUSIONS

This physician-focused intervention had small, non-significant effects in increasing Chinese patients' CRC screening rates. Physician communication appeared to explain intervention efficacy. More intensive interventions are needed to enhance Chinese patients' CRC screening.

A Randomized Trial to Compare Alternative Educational Interventions to Increase Colorectal Cancer Screening in a Hard-to-Reach Urban Minority Population with Health Insurance

This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.

Testing Interventions to Motivate and Educate (TIME): A multi-level intervention to improve colorectal cancer screening

Objective

To test the effectiveness of a colorectal cancer (CRC) screening intervention directed at three levels (clinic, provider, patient) in a primary care setting.

Method

We conducted a group randomized trial (Clinical Trials registration no. NCT01568151) among 10 primary care clinics in Columbus, Ohio that were randomized to a study condition (intervention or usual care). We determined the effect of a multi-level, stepped behavioral intervention on receipt of a CRC screening test among average-risk patients from these clinics over the study period.

Results

Patients (n = 527) who were outside of CRC screening recommendations were recruited. Overall, 35.4% of participants in the intervention clinics had received CRC screening by the end of the study compared to 35.1% of participants who were in the usual care clinics. Time to CRC screening was also similar across arms (HR = 0.97, 95% CI = 0.65–1.45).

Conclusion

The multi-level intervention was not effective in increasing CRC screening among participants who needed a test, perhaps due to low participation of patients in the stepped intervention. Future studies utilizing evidence-based strategies to encourage CRC screening are needed.

•

This study tested the effectiveness of a multi-level CRC screening intervention.

•

There was no difference in receipt of CRC screening between study arms.

•

Innovative strategies need to be developed to improve CRC screening rates.

Nudging guideline-concordant antibiotic prescribing: a randomized clinical trial

IMPORTANCE

"Nudges" that influence decision making through subtle cognitive mechanisms have been shown to be highly effective in a wide range of applications, but there have been few experiments to improve clinical practice.

OBJECTIVE

To investigate the use of a behavioral "nudge" based on the principle of public commitment in encouraging the judicious use of antibiotics for acute respiratory infections (ARIs).

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial in 5 outpatient primary care clinics. A total of 954 adults had ARI visits during the study timeframe: 449 patients were treated by clinicians randomized to the posted commitment letter (335 in the baseline period, 114 in the intervention period); 505 patients were treated by clinicians randomized to standard practice control (384 baseline, 121 intervention).

INTERVENTIONS

The intervention consisted of displaying poster-sized commitment letters in examination rooms for 12 weeks. These letters, featuring clinician photographs and signatures, stated their commitment to avoid inappropriate antibiotic prescribing for ARIs.

MAIN OUTCOMES AND MEASURES

Antibiotic prescribing rates for antibiotic-inappropriate ARI diagnoses in baseline and intervention periods, adjusted for patient age, sex, and insurance status.

RESULTS

Baseline rates were 43.5% and 42.8% for control and poster, respectively. During the intervention period, inappropriate prescribing rates increased to 52.7% for controls but decreased to 33.7% in the posted commitment letter condition. Controlling for baseline prescribing rates, we found that the posted commitment letter resulted in a 19.7 absolute percentage reduction in inappropriate antibiotic prescribing rate relative to control (P = .02). There was no evidence of diagnostic coding shift, and rates of appropriate antibiotic prescriptions did not diminish over time.

CONCLUSIONS AND RELEVANCE

Displaying poster-sized commitment letters in examination rooms decreased inappropriate antibiotic prescribing for ARIs. The effect of this simple, low-cost intervention is comparable in magnitude to costlier, more intensive quality-improvement efforts.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT01767064.

Better colon cancer care for extremely poor Canadian women compared with American women

Extremely poor Canadian women were recently observed to be largely advantaged on most aspects of breast cancer care as compared with similarly poor, but much less adequately insured, women in the United States. This historical study systematically replicated the protective effects of single- versus multipayer health care by comparing colon cancer care among cohorts of extremely poor women in California and Ontario between 1996 and 2011. The Canadian women were again observed to have been largely advantaged. They were more likely to have received indicated surgery and chemotherapy, and their wait times for care were significantly shorter. Consequently, the Canadian women were much more likely to experience longer survival times. Regression analyses indicated that health insurance nearly completely explained the Canadian advantages. Implications for contemporary and future reforms of U.S. health care are discussed.

An automated intervention with stepped increases in support to increase uptake of colorectal cancer screening: a randomized trial

BACKGROUND

Screening decreases colorectal cancer (CRC) incidence and mortality, yet almost half of age-eligible patients are not screened at recommended intervals.

OBJECTIVE

To determine whether interventions using electronic health records (EHRs), automated mailings, and stepped increases in support improve CRC screening adherence over 2 years.

DESIGN

4-group, parallel-design, randomized, controlled comparative effectiveness trial with concealed allocation and blinded outcome assessments. (ClinicalTrials.gov: NCT00697047)

SETTING

21 primary care medical centers.

PATIENTS

4675 adults aged 50 to 73 years not current for CRC screening.

INTERVENTION

Usual care, EHR-linked mailings ("automated"), automated plus telephone assistance ("assisted"), or automated and assisted plus nurse navigation to testing completion or refusal ("navigated"). Interventions were repeated in year 2.

MEASUREMENTS

The proportion of participants current for screening in both years, defined as colonoscopy or sigmoidoscopy (year 1) or fecal occult blood testing (FOBT) in year 1 and FOBT, colonoscopy, or sigmoidoscopy (year 2).

RESULTS

Compared with those in the usual care group, participants in the intervention groups were more likely to be current for CRC screening for both years with significant increases by intensity (usual care, 26.3% [95% CI, 23.4% to 29.2%]; automated, 50.8% [CI, 47.3% to 54.4%]; assisted, 57.5% [CI, 54.5% to 60.6%]; and navigated, 64.7% [CI, 62.5% to 67.0%]; P < 0.001 for all pair-wise comparisons). Increases in screening were primarily due to increased uptake of FOBT being completed in both years (usual care, 3.9% [CI, 2.8% to 5.1%]; automated, 27.5% [CI, 24.9% to 30.0%]; assisted, 30.5% [CI, 27.9% to 33.2%]; and navigated, 35.8% [CI, 33.1% to 38.6%]).

LIMITATION

Participants were required to provide verbal consent and were more likely to be white and to participate in other types of cancer screening, limiting generalizability.

CONCLUSION

Compared with usual care, a centralized, EHR-linked, mailed CRC screening program led to twice as many persons being current for screening over 2 years. Assisted and navigated interventions led to smaller but significant stepped increases compared with the automated intervention only. The rapid growth of EHRs provides opportunities for spreading this model broadly.

Comparison of population-averaged and cluster-specific models for the analysis of cluster randomized trials with missing binary outcomes: a simulation study

Abstracts

Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English proficiency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODS All adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual clinician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the outreach protocol. Outcome measures were compared using the Fisher exact test. RESULTS Analyses were based on 104 patients assigned to the outreach intervention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P <.001). Nearly all of the screenings were by FOBT. The groups did not differ significantly with respect to the percentage of patients making a clinician visit or the percentage for whom a clinician placed an order for a screening test. CONCLUSIONS The mailing of FOBT kits directly to patients was efficacious for promoting colorectal cancer screening among a population with high levels of poverty, limited English proficiency, and racial and ethnic diversity. Non-visit-based outreach to patients may be an important strategy to address suboptimal rates of colorectal cancer screening among populations most at risk for not being screened.

Multilevel interventions: measurement and measures

BACKGROUND

Multilevel intervention research holds the promise of more accurately representing real-life situations and, thus, with proper research design and measurement approaches, facilitating effective and efficient resolution of health-care system challenges. However, taking a multilevel approach to cancer care interventions creates both measurement challenges and opportunities.

METHODS

One-thousand seventy two cancer care articles from 2005 to 2010 were reviewed to examine the state of measurement in the multilevel intervention cancer care literature. Ultimately, 234 multilevel articles, 40 involving cancer care interventions, were identified. Additionally, literature from health services, social psychology, and organizational behavior was reviewed to identify measures that might be useful in multilevel intervention research.

RESULTS

The vast majority of measures used in multilevel cancer intervention studies were individual level measures. Group-, organization-, and community-level measures were rarely used. Discussion of the independence, validity, and reliability of measures was scant.

DISCUSSION

Measurement issues may be especially complex when conducting multilevel intervention research. Measurement considerations that are associated with multilevel intervention research include those related to independence, reliability, validity, sample size, and power. Furthermore, multilevel intervention research requires identification of key constructs and measures by level and consideration of interactions within and across levels. Thus, multilevel intervention research benefits from thoughtful theory-driven planning and design, an interdisciplinary approach, and mixed methods measurement and analysis.

Audit and feedback: effects on professional practice and healthcare outcomes

BACKGROUND

Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.

MAIN RESULTS

We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.

AUTHORS' CONCLUSIONS

Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: the CHOICE trial

BACKGROUND

Colorectal cancer (CRC) screening reduces CRC incidence and mortality but is underused. Effective interventions to increase screening that can be implemented broadly are needed.

METHODS

A controlled trial was conducted to evaluate a patient-level and practice-level intervention to increase the use of recommended CRC screening tests among health plan members. The patient-level intervention was a patient decision aid and included stage-targeted brochures that were mailed to health plan members. Intervention practices received academic detailing to prepare practices to facilitate CRC testing once patients were activated by the decision aid. We used patient surveys and claims data to assess CRC test completion.

RESULTS

Among 443 active participants, 75.8% were ages 52 to 59 years, 80.9% were white, 62.1% were women, and 46.4% had college degrees or greater education. Among 380 active participants with known screening status at 12 months based on survey results, 39% in the intervention group reported receiving CRC screening compared with 32.2% in the usual care group (unadjusted odds ratio [OR], 1.34; 95% confidence interval; [CI], 0.88-2.05; P = .17). After adjusting for baseline differences and accounting for clustering, the effect was somewhat larger (OR, 1.64; 95% CI, 0.98-2.73; P = .06). Claims analysis produced similar effects for active participants. The intervention was more effective in those who had incomes >$50,000 (OR, 2.16; 95% CI, 1.07-4.35) than in those who had lower incomes (OR, 1.25; 95% CI, 0.53-2.94; P = .03 for interaction).

CONCLUSIONS

Interventions combining a patient-directed decision aid and practice-directed academic detailing had a modest but statistically nonsignificant effect on CRC screening rates among active participants.

Quantifying the impact of fixed effects modeling of clusters in multiple imputation for cluster randomized trials

In cluster randomized trials (CRTs), identifiable clusters rather than individuals are randomized to study groups. Resulting data often consist of a small number of clusters with correlated observations within a treatment group. Missing data often present a problem in the analysis of such trials, and multiple imputation (MI) has been used to create complete data sets, enabling subsequent analysis with well-established analysis methods for CRTs. We discuss strategies for accounting for clustering when multiply imputing a missing continuous outcome, focusing on estimation of the variance of group means as used in an adjusted t-test or ANOVA. These analysis procedures are congenial to (can be derived from) a mixed effects imputation model; however, this imputation procedure is not yet available in commercial statistical software. An alternative approach that is readily available and has been used in recent studies is to include fixed effects for cluster, but the impact of using this convenient method has not been studied. We show that under this imputation model the MI variance estimator is positively biased and that smaller intraclass correlations (ICCs) lead to larger overestimation of the MI variance. Analytical expressions for the bias of the variance estimator are derived in the case of data missing completely at random, and cases in which data are missing at random are illustrated through simulation. Finally, various imputation methods are applied to data from the Detroit Middle School Asthma Project, a recent school-based CRT, and differences in inference are compared.

Cost-effectiveness of patient mailings to promote colorectal cancer screening

BACKGROUND

Programs to promote colorectal cancer screening are common, yet information regarding the cost-effectiveness of such efforts is limited.

OBJECTIVE

To assess the cost-effectiveness of patient mailings to increase rates of colorectal cancer screening.

RESEARCH DESIGN

Incremental cost-effectiveness analysis of a randomized, controlled trial. The intervention involved 21,860 patients aged 50 to 80 years across 11 health centers overdue for colorectal cancer screening. Patients were randomized to receive a mailing that included a tailored letter, educational brochure, and fecal occult blood test kit at baseline and 6 months follow-up.

MEASURES

We calculated the incremental cost-effectiveness of these mailings to promote colorectal cancer screening by fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy using internal cost estimates of labor and supplies.

RESULTS

Colorectal cancer screening rates were higher for patients in the intervention compared with control patients (44% vs. 38%, P < 0.001). The total cost of the intervention was approximately $5.48 per patient, resulting in a cost-effectiveness ratio of $94 per additional patient screened. This estimate ranged from $69 to $156, based on assumptions of the cost of the intervention components, magnitude of intervention effect, age range, and size of the targeted patient population.

CONCLUSION

Tailored patient mailings are a cost-effective approach to improve rates of colorectal cancer screening.

How to scale up primary care transformation: what we know and what we need to know?

Becoming a medical home is a radical change, requiring both a new mental model for primary care and the skills and resources to accomplish it. Although numerous reports indicate practice change is feasible--particularly with technical support and either insulation from or alignment with financial incentives--sustained transformation appears difficult. We identified the following critical success factors: leadership, financial resources, personal and organizational relationships, engagement with patients and families, competence in management, improvement methods and coaching, health information technology properly applied, care coordination support, and staff development. Each factor raises researchable questions about what policies can facilitate achieving success so that transformation becomes mainstream rather than the province of the innovative few.

Costs and cost effectiveness of a health care provider-directed intervention to promote colorectal cancer screening

PURPOSE

Colorectal cancer (CRC) screening remains underutilized in the United States. Prior studies reporting the cost effectiveness of randomized interventions to improve CRC screening have not been replicated in the setting of small physician practices. We recently conducted a randomized trial evaluating an academic detailing intervention in 264 small practices in geographically diverse New York City communities. The objective of this secondary analysis is to assess the cost effectiveness of this intervention.

METHODS

A total of 264 physician offices were randomly assigned to usual care or to a series of visits from trained physician educators. CRC screening rates were measured at baseline and 12 months. The intervention costs were measured and the incremental cost-effectiveness ratio (ICER) was derived. Sensitivity analyses were based on varying cost and effectiveness estimates.

RESULTS

Academic detailing was associated with a 7% increase in CRC screening with colonoscopy. The total intervention cost was $147,865, and the ICER was $21,124 per percentage point increase in CRC screening rate. Sensitivity analyses that varied the costs of the intervention and the average medical practice size were associated with ICERs ranging from $13,631 to $36,109 per percentage point increase in CRC screening rates.

CONCLUSION

A comprehensive, multicomponent academic detailing intervention conducted in small practices in metropolitan New York was clinically effective in improving CRC screening rates, but was not cost effective.

Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial

BACKGROUND

Screening reduces colorectal cancer mortality, but effective screening tests remain underused. Systematic reminders to patients and physicians could increase screening rates

METHODS

We conducted a randomized controlled trial of patient and physician reminders in 11 ambulatory health care centers. Participants included 21 860 patients aged 50 to 80 years who were overdue for colorectal cancer screening and 110 primary care physicians. Patients were randomly assigned to receive mailings containing an educational pamphlet, fecal occult blood test kit, and instructions for direct scheduling of flexible sigmoidoscopy or colonoscopy. Physicians were randomly assigned to receive electronic reminders during office visits with patients overdue for screening. The primary outcome was receipt of fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy over 15 months, and the secondary outcome was detection of colorectal adenomas.

RESULTS

Screening rates were higher for patients who received mailings compared with those who did not (44.0% vs 38.1%; P < .001). The effect increased with age: +3.7% for ages 50 to 59 years; +7.3% for ages 60 to 69 years; and +10.1% for ages 70 to 80 years (P = .01 for trend). Screening rates were similar among patients of physicians receiving electronic reminders and the control group (41.9% vs 40.2%; P = .47). However, electronic reminders tended to increase screening rates among patients with 3 or more primary care visits (59.5% vs 52.7%; P = .07). Detection of adenomas tended to increase with patient mailings (5.7% vs 5.2%; P = .10) and physician reminders (6.0% vs 4.9%; P = .09).

CONCLUSIONS

Mailed reminders to patients are an effective tool to promote colorectal cancer screening, and electronic reminders to physicians may increase screening among adults who have more frequent primary care visits.

Design and analysis of group-randomized trials in cancer: a review of current practices

BACKGROUND

Previous reviews have identified problems in the design and analysis of group-randomized trials in a number of areas. Similar problems may exist in cancer research, but there have been no comprehensive reviews.

METHODS

We searched Medline and PubMed for group-randomized trials focused on cancer prevention and control that were published between 2002 and 2006. We located and reviewed 75 articles to determine whether articles included evidence of taking group randomization into account in establishing the size of the trial, such as reporting the expected intraclass correlation, the group component of variance, or the variance inflation factor. We also examined the analytical approaches to determine their appropriateness.

RESULTS

Only 18 (24%) of the 75 articles documented appropriate methods for sample size calculations. Only 34 (45%) limited their reports to analyses judged to be appropriate. Fully 26 (34%) failed to report any analyses that were judged to be appropriate. The most commonly used inappropriate analysis was an analysis at the individual level that ignored the groups altogether. Nine articles (12%) did not provide sufficient information.

CONCLUSIONS

Many investigators who use group-randomized trials in cancer research do not adequately attend to the special design and analytic challenges associated with these trials. Failure to do so can lead to reporting type I errors as real effects, mislead investigators and policy-makers, and slow progress toward control and prevention of cancer. A collaborative effort by investigators, statisticians, and others will be required to ensure that group-randomized trials are planned and analyzed using appropriate methods so that the scientific community can have confidence in the published results.

The effects of teamwork and system support on colorectal cancer screening in primary care practices

BACKGROUND

While cancer screening is generally increasing in the U.S., colorectal cancer (CRC) screening remains low. Most CRC screening interventions focus either on patients or individual clinicians without examining the office context in which CRC screening is implemented. This study examines whether primary care practices that involve staff in general forms of health education have higher CRC screening rates than practices that do not.

METHODS

Cross-sectional data from 22 New Jersey and Pennsylvania family medicine practices were analyzed. Data include chart audits for 795 men and women eligible for CRC screening (age 50-70) and practice information surveys for each practice. Generalized estimating equations were used to determine CRC screening correlates.

RESULTS

Overall, 31.3% (n=249) of patients received CRC screening. Practices that reported using nursing or health educator staff to provide behavioral counseling to patients on topics such as diet, exercise or tobacco use were significantly more likely to also have higher CRC screening rates (z=7.30, p<0.0001). Their patients had 2.96 times increased odds of CRC screening than those in other practices (95% C.I., 2.21-3.96). Reminder system use was also associated with higher CRC screening (z=4.96, p<0.0001). In practices that used reminder systems, patients had 2.57 times increased odds of CRC screening than others (95% C.I., 1.77-3.74).

CONCLUSIONS

These findings suggest that interventions to achieve better CRC screening rates do not need to focus solely on CRC. Higher CRC rates may be achieved by capitalizing on the enhancing contributions of non-physician practice members providing more general health behavior change patient education.

Delivery of cancer screening: how important is the preventive health examination?

BACKGROUND

Patients and physicians strongly endorse the importance of preventive or periodic health examinations (PHEs). However, the extent to which PHEs contribute to the delivery of cancer screening is uncertain.

METHODS

In a retrospective cohort study, we determined the association between receipt of a PHE and cancer testing in a population-based sample of enrollees in a Washington State health plan who were aged 52 to 78 years and eligible for colorectal, breast, or prostate cancer screening in 2002-2003 (N = 64 288). Outcomes included completion of any colorectal cancer testing (fecal occult blood testing, sigmoidoscopy, colonoscopy, or barium enema), screening mammography, and prostate-specific antigen testing.

RESULTS

More than half (52.4%) of the enrollees received a PHE during the study period. After adjusting for demographics, comorbidity, number of outpatient visits, and historical preventive service use before January 1, 2002, receipt of a PHE was significantly associated with completion of colorectal cancer testing (incidence difference, 40.4% [95% confidence interval (CI), 39.4%-41.3%]; relative incidence, 3.47 [95% CI, 3.34-3.59]), screening mammography [incidence difference, 14.2% [95% CI, 12.7%-15.7%]; relative incidence, 1.23 [95% CI, 1.20-1.25]), and prostate-specific antigen testing (incidence difference, 39.4% [95% CI, 38.3%-40.5%]; relative incidence, 3.06 [95% CI, 2.95-3.18]).

CONCLUSIONS

Among managed care enrollees eligible for cancer screening, PHE receipt is associated with completion of colorectal, breast, and prostate cancer testing. In similar populations, the PHE may serve as a clinically important forum for the promotion of evidence-based colorectal cancer and breast cancer screening and of screening with relatively less empirical support, such as prostate cancer screening.