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Rivera Rivera JN, AuBuchon KE, Schubel LC, Starling C, Tran J, Locke M, Grady M, Mete M, Blumenthal HJ, Galarraga JE, Arem H. Supporting ColoREctal Equitable Navigation (SCREEN): a protocol for a stepped-wedge cluster randomized trial for patient navigation in primary care. Implement Sci Commun 2024; 5:60. [PMID: 38831365 PMCID: PMC11149321 DOI: 10.1186/s43058-024-00598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Black individuals in the United States (US) have a higher incidence of and mortality from colorectal cancer (CRC) compared to other racial groups, and CRC is the second leading cause of death among Hispanic/Latino populations in the US. Patient navigation is an evidence-based approach to narrow inequities in cancer screening among Black and Hispanic/Latino patients. Despite this, limited healthcare systems have implemented patient navigation for screening at scale. METHODS We are conducting a stepped-wedge cluster randomized trial of 15 primary care clinics with six steps of six-month duration to scale a patient navigation program to improve screening rates among Black and Hispanic/Latino patients. After six months of baseline data collection with no intervention we will randomize clinics, whereby three clinics will join the intervention arm every six months until all clinics cross over to intervention. During the intervention roll out we will conduct training and education for clinics, change infrastructure in the electronic health record, create stakeholder relationships, assess readiness, and deliver iterative feedback. Framed by the Practical, Robust Implementation Sustainment Model (PRISM) we will focus on effectiveness, reach, provider adoption, and implementation. We will document adaptations to both the patient navigation intervention and to implementation strategies. To address health equity, we will engage multilevel stakeholder voices through interviews and a community advisory board to plan, deliver, adapt, measure, and disseminate study progress. Provider-level feedback will include updates on disparities in screening orders and completions. DISCUSSION Primary care clinics are poised to close disparity gaps in CRC screening completion but may lack an understanding of the magnitude of these gaps and how to address them. We aim to understand how to tailor a patient navigation program for CRC screening to patients and providers across diverse clinics with wide variation in baseline screening rates, payor mix, proximity to specialty care, and patient volume. Findings from this study will inform other primary care practices and health systems on effective and sustainable strategies to deliver patient navigation for CRC screening among racial and ethnic minorities. TRIAL REGISTRATION NCT06401174.
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Affiliation(s)
- Jessica N Rivera Rivera
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA
| | - Katarina E AuBuchon
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Laura C Schubel
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA
| | - Claire Starling
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA
| | - Jennifer Tran
- Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Marjorie Locke
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Melanie Grady
- MedStar Health Institute for Quality and Safety, Washington, DC, USA
| | - Mihriye Mete
- Department of Behavioral Health Research, MedStar Health Research Institute, Washington, DC, USA
- Department of Psychiatry, Georgetown University School of Medicine, Washington, DC, USA
| | - H Joseph Blumenthal
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Washington, DC, USA
| | | | - Hannah Arem
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA.
- Department of Oncology, Georgetown University, Washington, DC, USA.
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Keppel GA, Ike B, Leroux BG, Ko LK, Osterhage KP, Jacobs JD, Cole AM. Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening. Contemp Clin Trials 2024; 141:107539. [PMID: 38615750 PMCID: PMC11098679 DOI: 10.1016/j.cct.2024.107539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/01/2024] [Accepted: 04/11/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas. OBJECTIVES Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC. METHODS CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization. DISCUSSION Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs. TRIAL REGISTRATION National Clinical Trial Identifier: NCT05453630. TRIAL REGISTRATION ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.
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Affiliation(s)
- Gina A Keppel
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Brooke Ike
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Brian G Leroux
- Department of Biostatistics, University of Washington School of Public Health, Seattle, WA, USA
| | - Linda K Ko
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Katie P Osterhage
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Jeffrey D Jacobs
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Allison M Cole
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Quaye AN, Hisey WM, Mackenzie TA, Robinson CM, Richard JM, Anderson JC, Warters RD, Butterly LF. Association between Colonoscopy Sedation Type and Polyp Detection: A Registry-based Cohort Study. Anesthesiology 2024; 140:1088-1097. [PMID: 38629957 PMCID: PMC11096037 DOI: 10.1097/aln.0000000000004955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
BACKGROUND Colorectal cancer is a leading cause of cancer-related death. Adenomas and serrated polyps are precursors of colorectal cancer, with serrated polyps being more difficult to detect during colonoscopy. The relationship between propofol use and polyp detection remains unclear. The authors investigated the association of propofol-based versus mild-moderate sedation on adenoma and serrated polyp detection during colonoscopy. METHODS This retrospective cohort study used observational data from the New Hampshire Colonoscopy Registry. Patients aged greater than 50 yr with screening or surveillance colonoscopies between January 1, 2015, and February 28, 2020, were included. Exclusions were diagnostic examinations, no sedation, missing pathology data, and poor bowel preparation. Multivariate logistic regression was used to evaluate differences in polyp detection between propofol and moderate sedation in the full sample while adjusting for covariates. Propensity score adjustment and clustering at the endoscopist level were used in a restricted sample analysis that included endoscopists and facilities with between 5% and 95% propofol sedation use. RESULTS A total of 54,063 colonoscopies were analyzed in the full sample and 18,998 in the restricted sample. Serrated polyp prevalence was significantly higher using propofol (9,957 of 29,312; 34.0% [95% CI, 33.4 to 34.5%]) versus moderate sedation (6,066 of 24,751; 24.5% [95% CI, 24.0 to 25.1%]) in the full sample and restricted samples (1,410 of 4,661; 30.3% [95% CI, 28.9 to 31.6%] vs. 3,690 of 14,337; 25.7% [95% CI, 25.0 to 26.5%]). In the full sample multivariate logistic regression, propofol was associated with higher neoplasm (adjusted odds ratio, 1.25 [95% CI, 1.21 to 1.29]), adenoma (odds ratio, 1.07 [95% CI, 1.03 to 1.11]), and serrated polyp detection (odds ratio, 1.51 [95% CI, 1.46 to 1.57]). In the restricted sample using inverse probability of treatment weighted propensity score adjustment and clustering at the endoscopist level, an attenuated but statistically significant effect size was observed for serrated polyps (odds ratio, 1.13 [95% CI, 1.07 to 1.19]), but not for adenomas (odds ratio, 1.00 [95% CI, 0.95 to 1.05]) or any neoplastic lesion (odds ratio, 1.03 [95% CI, 0.98 to 1.08]). CONCLUSIONS Propofol sedation during colonoscopy may be associated with improved detection of serrated polyps, but not adenomas. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Aurora N Quaye
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine; Division of Anesthesiology, Spectrum Healthcare Partners, South Portland, Maine; Assistant Professor of Anesthesiology, Tufts University School of Medicine, Boston, Massachusetts
| | - William M Hisey
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire
| | - Todd A Mackenzie
- Professor of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Christina M Robinson
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire
| | - Janelle M Richard
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine
| | - Joseph C Anderson
- Professor of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; White River Junction VA Medical Center, White River Junction, Vermont
| | - Robert D Warters
- Department of Anesthesiology and Perioperative Medicine, Maine Medical Center, Portland, Maine; Division of Anesthesiology, Spectrum Healthcare Partners, South Portland, Maine
| | - Lynn F Butterly
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire; Professor of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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4
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Masoud SJ, Seo JE, Singh E, Woody RL, Muhammed M, Webster W, Mantyh CR. Social Vulnerability Index and Survivorship after Colorectal Cancer Resection. J Am Coll Surg 2024; 238:693-706. [PMID: 38441160 DOI: 10.1097/xcs.0000000000000961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
BACKGROUND Race and socioeconomic status incompletely identify patients with colorectal cancer (CRC) at the highest risk for screening, treatment, and mortality disparities. Social vulnerability index (SVI) was designed to delineate neighborhoods requiring greater support after external health stressors, summarizing socioeconomic, household, and transportation barriers by census tract. SVI is implicated in lower cancer center use and increased complications after colectomy, but its influence on long-term prognosis is unknown. Herein, we characterized relationships between SVI and CRC survival. STUDY DESIGN Patients undergoing resection of stage I to IV CRC from January 2010 to May 2023 within an academic health system were identified. Clinicopathologic characteristics were abstracted using institutional National Cancer Database and NSQIP. Addresses from electronic health records were geocoded to SVI. Overall survival and cancer-specific survival were compared using Kaplan-Meier and Cox proportional hazards methods. RESULTS A total of 872 patients were identified, comprising 573 (66%) patients with colon tumor and 299 (34%) with rectal tumor. Patients in the top SVI quartile (32%) were more likely to be Black (41% vs 13%, p < 0.001), carry less private insurance (39% vs 48%, p = 0.02), and experience greater comorbidity (American Society of Anesthesiologists physical status III: 86% vs 71%, p < 0.001), without significant differences by acuity, stage, or CRC therapy. In multivariable analysis, high SVI remained associated with higher all-cause (hazard ratio 1.48, 95% CI 1.12 to 1.96, p < 0.01) and cancer-specific survival mortality (hazard ratio 1.71, 95% CI 1.10 to 2.67, p = 0.02). CONCLUSIONS High SVI was independently associated with poorer prognosis after CRC resection beyond the perioperative period. Acknowledging needs for multi-institutional evaluation and elaborating causal mechanisms, neighborhood-level vulnerability may inform targeted outreach in CRC care.
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Affiliation(s)
- Sabran J Masoud
- From the Department of Surgery, Duke University Medical Center, Durham, NC (Masoud, Mantyh)
| | - Jein E Seo
- Duke University School of Medicine, Durham, NC (Seo, Singh)
| | - Eden Singh
- Duke University School of Medicine, Durham, NC (Seo, Singh)
| | | | | | | | - Christopher R Mantyh
- From the Department of Surgery, Duke University Medical Center, Durham, NC (Masoud, Mantyh)
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Glaser KM, Crabtree-Ide CR, McNulty AD, Attwood KM, Flores TF, Krolikowski AM, Robillard KT, Reid ME. Improving Guideline-Recommended Colorectal Cancer Screening in a Federally Qualified Health Center (FQHC): Implementing a Patient Navigation and Practice Facilitation Intervention to Promote Health Equity. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:126. [PMID: 38397617 PMCID: PMC10887785 DOI: 10.3390/ijerph21020126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Colorectal cancer (CRC) screening is effective in the prevention and early detection of cancer. Implementing evidence-based screening guidelines remains a challenge, especially in Federally Qualified Health Centers (FQHCs), where current rates (43%) are lower than national goals (80%), and even lower in populations with limited English proficiency (LEP) who experience increased barriers to care related to systemic inequities. METHODS This quality improvement (QI) initiative began in 2016, focused on utilizing patient navigation and practice facilitation to addressing systemic inequities and barriers to care to increase CRC screening rates at an urban FQHC, with two clinical locations (the intervention and control sites) serving a diverse population through culturally tailored education and navigation. RESULTS Between August 2016 and December 2018, CRC screening rates increased significantly from 31% to 59% at the intervention site (p < 0.001), with the most notable change in patients with LEP. Since 2018 through December 2022, navigation and practice facilitation expanded to all clinics, and the overall CRC screening rates continued to increase from 43% to 50%, demonstrating the effectiveness of patient navigation to address systemic inequities. CONCLUSIONS This multilevel intervention addressed structural inequities and barriers to care by implementing evidence-based guidelines into practice, and combining patient navigation and practice facilitation to successfully increase the CRC screening rates at this FQHC.
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Affiliation(s)
- Kathryn M. Glaser
- Department of Cancer Prevention and Populations Science, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA;
| | - Christina R. Crabtree-Ide
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; (C.R.C.-I.); (T.F.F.); (M.E.R.)
| | - Alyssa D. McNulty
- Department of Cancer Prevention and Populations Science, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA;
| | - Kristopher M. Attwood
- Department of Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA;
| | - Tessa F. Flores
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; (C.R.C.-I.); (T.F.F.); (M.E.R.)
| | | | - Kevin T. Robillard
- Department of Internal Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA;
| | - Mary E. Reid
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY 14263, USA; (C.R.C.-I.); (T.F.F.); (M.E.R.)
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Steiner JF, Nguyen AP, Schuster KS, Goodrich G, Barrow J, Steiner CA, Zeng C. Associations between Missed Colonoscopy Appointments and Multiple Prior Adherence Behaviors in an Integrated Healthcare System: An Observational Study. J Gen Intern Med 2024; 39:36-44. [PMID: 37550443 PMCID: PMC10817878 DOI: 10.1007/s11606-023-08355-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Missed colonoscopy appointments delay screening and treatment for gastrointestinal disorders. Prior nonadherence with other care components may be associated with missed colonoscopy appointments. OBJECTIVE To assess variability in prior adherence behaviors and their association with missed colonoscopy appointments. DESIGN Retrospective cohort study. PARTICIPANTS Patients scheduled for colonoscopy in an integrated healthcare system between January 2016 and December 2018. MAIN MEASURES Prior adherence behaviors included: any missed outpatient appointment in the previous year; any missed gastroenterology clinic or colonoscopy appointment in the previous 2 years; and not obtaining a bowel preparation kit pre-colonoscopy. Other sociodemographic, clinical, and system characteristics were included in a multivariable model to identify independent associations between prior adherence behaviors and missed colonoscopy appointments. KEY RESULTS The median age of the 57,590 participants was 61 years; 52.8% were female and 73.4% were white. Of 77,684 colonoscopy appointments, 3,237 (4.2%) were missed. Individuals who missed colonoscopy appointments were more likely to have missed a previous primary care appointment (62.5% vs. 38.4%), a prior gastroenterology appointment (18.4% vs. 4.7%) or not to have picked up a bowel preparation kit (42.4% vs. 17.2%), all p < 0.001. Correlations between the three adherence measures were weak (phi < 0.26). The rate of missed colonoscopy appointments increased from 1.8/100 among individuals who were adherent with all three prior care components to 24.6/100 among those who were nonadherent with all three care components. All adherence variables remained independently associated with nonadherence with colonoscopy in a multivariable model that included other covariates; adjusted odds ratios (with 95% confidence intervals) were 1.6 (1.5-1.8) for outpatient appointments, 1.9 (1.7-2.1) for gastroenterology appointments, and 3.1 (2.9-3.4) for adherence with bowel preparation kits, respectively. CONCLUSIONS Three prior adherence behaviors were independently associated with missed colonoscopy appointments. Studies to predict adherence should use multiple, complementary measures of prior adherence when available.
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Affiliation(s)
- John F Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA.
- Colorado Permanente Medical Group, Denver, CO, USA.
| | - Anh P Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Kelly S Schuster
- Department of Gastroenterology, Kaiser Permanente Colorado, Denver, CO, USA
| | - Glenn Goodrich
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Jennifer Barrow
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
| | - Claudia A Steiner
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA
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O'Leary MC, Reuland DS, Randolph C, Ferrari RM, Brenner AT, Wheeler SB, Farr DE, Newcomer MK, Crockett SD. Reach and effectiveness of a centralized navigation program for patients with positive fecal immunochemical tests requiring follow-up colonoscopy. Prev Med Rep 2023; 34:102211. [PMID: 37214164 PMCID: PMC10196769 DOI: 10.1016/j.pmedr.2023.102211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/14/2023] [Accepted: 04/13/2023] [Indexed: 05/24/2023] Open
Abstract
Completion rates for follow-up colonoscopies after an abnormal fecal immunochemical test (FIT) are suboptimal in federally qualified health center (FQHC) settings. We implemented a screening intervention that included mailed FIT outreach to North Carolina FQHC patients from June 2020 to September 2021 and centralized patient navigation to support patients with abnormal FITs in completing follow-up colonoscopy. We evaluated the reach and effectiveness of navigation using electronic medical record data and navigator call logs detailing interactions with patients. Reach assessments included the proportion of patients successfully contacted by phone and who agreed to participate in navigation, intensity of navigation provided (including types of barriers to colonoscopy identified and total navigation time), and differences in these measures by socio-demographic characteristics. Effectiveness outcomes included colonoscopy completion, timeliness of follow-up colonoscopy (i.e., within 9 months), and bowel prep adequacy. Among 514 patients who completed a mailed FIT, 38 patients had an abnormal result and were eligible for navigation. Of these, 26 (68%) accepted navigation, 7 (18%) declined, and 5 (13%) could not be contacted. Among navigated patients, 81% had informational needs, 38% had emotional barriers, 35% had financial barriers, 12% had transportation barriers, and 42% had multiple barriers to colonoscopy. Median navigation time was 48.5 min (range: 24-277 min). Colonoscopy completion differed across groups - 92% of those accepting navigation completed colonoscopy within 9 months, versus 43% for those declining navigation. We found that centralized navigation was widely accepted in FQHC patients with abnormal FIT, and was an effective strategy, resulting in high colonoscopy completion rates.
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Affiliation(s)
- Meghan C. O'Leary
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel S. Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Connor Randolph
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Alison T. Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Medicine, Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Deeonna E. Farr
- College of Health and Human Performance, East Carolina University, Greenville, NC, USA
| | | | - Seth D. Crockett
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Gastroenterology and Hepatology, Oregon Health & Science University, Portland, OR, USA
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8
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Zauber AG, Winawer SJ, O'Brien MJ, Mills GM, Allen JI, Feld AD, Jordan PA, Fleisher M, Orlow I, Meester RGS, Lansdorp-Vogelaar I, Rutter CM, Knudsen AB, Mandelson M, Shaukat A, Mendelsohn RB, Hahn AI, Lobaugh SM, Soto Palmer B, Serrano V, Kumar JR, Fischer SE, Chen JC, Bayuga-Miller S, Kuk D, O'Connell K, Church TR. Randomized Trial of Facilitated Adherence to Screening Colonoscopy vs Sequential Fecal-Based Blood Test. Gastroenterology 2023; 165:252-266. [PMID: 36948424 PMCID: PMC10330012 DOI: 10.1053/j.gastro.2023.03.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 03/01/2023] [Accepted: 03/08/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND & AIMS Colorectal cancer (CRC) screening guidelines include screening colonoscopy and sequential high-sensitivity fecal occult blood testing (HSgFOBT), with expectation of similar effectiveness based on the assumption of similar high adherence. However, adherence to screening colonoscopy compared with sequential HSgFOBT has not been reported. In this randomized clinical trial, we assessed adherence and pathology findings for a single screening colonoscopy vs sequential and nonsequential HSgFOBTs. METHODS Participants aged 40-69 years were enrolled at 3 centers representing different clinical settings. Participants were randomized into a single screening colonoscopy arm vs sequential HSgFOBT arm composed of 4-7 rounds. Initial adherence to screening colonoscopy and sequential adherence to HSgFOBT, follow-up colonoscopy for positive HSgFOBT tests, crossover to colonoscopy, and detection of advanced neoplasia or large serrated lesions (ADN-SERs) were measured. RESULTS There were 3523 participants included in the trial; 1761 and 1762 participants were randomized to the screening colonoscopy and HSgFOBT arms, respectively. Adherence was 1473 (83.6%) for the screening colonoscopy arm vs 1288 (73.1%) for the HSgFOBT arm after 1 round (relative risk [RR], 1.14; 95% CI, 1.10-1.19; P ≤ .001), but only 674 (38.3%) over 4 sequential HSgFOBT rounds (RR, 2.19; 95% CI, 2.05-2.33). Overall adherence to any screening increased to 1558 (88.5%) in the screening colonoscopy arm during the entire study period and 1493 (84.7%) in the HSgFOBT arm (RR, 1.04; 95% CI, 1.02-1.07). Four hundred thirty-six participants (24.7%) crossed over to screening colonoscopy during the first 4 rounds. ADN-SERs were detected in 121 of the 1473 participants (8.2%) in the colonoscopy arm who were adherent to protocol in the first 12 months of the study, whereas detection of ADN-SERs among those who were not sequentially adherent (n = 709) to HSgFOBT was subpar (0.6%) (RR, 14.72; 95% CI, 5.46-39.67) compared with those who were sequentially adherent (3.3%) (n = 647) (RR, 2.52; 95% CI, 1.61-3.98) to HSgFOBT in the first 4 rounds. When including colonoscopies from HSgFOBT patients who were never positive yet crossed over (n = 1483), 5.5% of ADN-SERs were detected (RR, 1.50; 95% CI, 1.15-1.96) in the first 4 rounds. CONCLUSIONS Observed adherence to sequential rounds of HSgFOBT was suboptimal compared with a single screening colonoscopy. Detection of ADN-SERs was inferior when nonsequential HSgFOBT adherence was compared with sequential adherence. However, the greatest number of ADN-SERs was detected among those who crossed over to colonoscopy and opted to receive a colonoscopy. The effectiveness of an HSgFOBT screening program may be enhanced if crossover to screening colonoscopy is permitted. CLINICALTRIALS gov, Number: NCT00102011.
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Affiliation(s)
- Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Sidney J Winawer
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael J O'Brien
- Department of Pathology and Laboratory Medicine, Boston University Medical Center, Boston, Massachusetts
| | | | - John I Allen
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Andrew D Feld
- Department of Gastroenterology, Kaiser Permanente Washington, Seattle, Washington
| | - Paul A Jordan
- Department of Medicine, Louisiana State University Health, Shreveport, Louisiana
| | - Martin Fleisher
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Irene Orlow
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Reinier G S Meester
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Carolyn M Rutter
- Biostatistics Program, Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Hutchinson Institute for Cancer Outcomes Research, Seattle, Washington
| | - Amy B Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | - Aasma Shaukat
- Division of Gastroenterology, Department of Medicine Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis, Minnesota; Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota; Division of Gastroenterology, Department of Medicine, NYU Langone Health, New York, New York
| | - Robin B Mendelsohn
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne I Hahn
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Stephanie M Lobaugh
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Julie R Kumar
- Investigative Initiative Trials and Compassionate Use Studies, Novartis, East Hanover, New Jersey
| | - Sara E Fischer
- Department of Government, Georgetown University, Washington, District of Columbia
| | - Jennifer C Chen
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sharon Bayuga-Miller
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Kelli O'Connell
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Timothy R Church
- Division of Gastroenterology, Department of Medicine Environmental Health Sciences, University of Minnesota School of Public Health, Minneapolis, Minnesota; Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
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9
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Coronado GD, Ferrari RM, Barnes A, Castañeda SF, Cromo M, Davis MM, Doescher MP, English K, Hatcher J, Kim KE, Kobrin S, Liebovitz D, Mishra SI, Nodora JN, Norton WE, Oliveri JM, Reuland DS, Subramanian S, Thompson JH, Paskett ED. Characteristics of patient navigation programs in the Cancer Moonshot ACCSIS colorectal cancer screening initiative. J Natl Cancer Inst 2023; 115:680-694. [PMID: 36810931 PMCID: PMC10248850 DOI: 10.1093/jnci/djad032] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Although patient navigation has shown promise for increasing participation in colorectal cancer screening and follow-up, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative. METHODS We developed a data collection template organized by ACCSIS framework domains. The template was populated by a representative from each of the 8 ACCSIS research projects. We report standardized descriptions of 1) the socio-ecological context in which the navigation program was being conducted, 2) navigation program characteristics, 3) activities undertaken to facilitate program implementation (eg, training), and 4) outcomes used in program evaluation. RESULTS ACCSIS patient navigation programs varied broadly in their socio-ecological context and settings, the populations they served, and how they were implemented in practice. Six research projects adapted and implemented evidence-based patient navigation programs; the remaining projects developed new programs. Five projects began navigation when patients were due for initial colorectal cancer screening; 3 projects began navigation later in the screening process, when patients were due for follow-up colonoscopy after an abnormal stool-test result. Seven projects relied on existing clinical staff to deliver the navigation; 1 hired a centralized research navigator. All project researchers plan to evaluate the effectiveness and implementation of their programs. CONCLUSIONS Our detailed program descriptions may facilitate cross-project comparisons and guide future implementation and evaluation of patient navigation programs in clinical practice.
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Affiliation(s)
| | - Renée M Ferrari
- Lineberger Comprehensive Cancer Center, Carolina Cancer Screening Initiative, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - Autumn Barnes
- Research Triangle International, Research Triangle Park, NC, USA
| | - Sheila F Castañeda
- Department of Psychology, South Bay Latino Research Center, San Diego State University, Chula Vista, CA, USA
| | - Mark Cromo
- Department of Internal Medicine, Healthy Kentucky Research Building, University of Kentucky, Lexington, KY, USA
| | - Melinda M Davis
- Department of Family Medicine and School of Public Health, Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland, OR, USA
| | - Mark P Doescher
- Department of Family and Preventive Medicine, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Kevin English
- Albuquerque Area Southwest Tribal Epidemiology Center, Albuquerque Area Indian Health Board, Inc, Albuquerque, NM, USA
| | - Jenna Hatcher
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ, USA
| | | | - Sarah Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - David Liebovitz
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shiraz I Mishra
- University of New Mexico Comprehensive Cancer Center and Departments of Pediatrics and Family and Community Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jesse N Nodora
- Department of Family Medicine and Public Health, Moores UC San Diego Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Wynne E Norton
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Jill M Oliveri
- Comprehensive Cancer Center, Ohio State University, Columbus, OH, USA
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, Carolina Cancer Screening Initiative, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Electra D Paskett
- Department of Internal Medicine, College of Medicine and Comprehensive Cancer Center, Ohio State University, Columbus, OH, USA
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10
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Liu MC, Anderson JC, Hisey W, MacKenzie TA, Robinson CM, Butterly LF. Using New Hampshire Colonoscopy Registry data to assess United States and European post-polypectomy surveillance guidelines. Endoscopy 2023; 55:423-431. [PMID: 36316016 PMCID: PMC10292179 DOI: 10.1055/a-1970-5377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Our goal was to compare the updated European Society of Gastrointestinal Endoscopy (ESGE) and United States Multi-Society Task Force on Colorectal Cancer (USMSTF) high risk groups in predicting metachronous advanced neoplasia on first follow-up colonoscopy and long-term colorectal cancer (CRC). METHODS We compared advanced metachronous neoplasia risk (serrated polyps ≥ 1 cm or with dysplasia, advanced adenomas [≥ 1 cm, villous, high grade dysplasia], CRC) on first surveillance colonoscopy in patients with high risk findings according to ESGE versus USMSTF guidelines. We also compared the positive and negative predictive values (PPV, NPV) of both guidelines for metachronous neoplasia. RESULTS The risk for metachronous neoplasia in our sample (n = 20 458) was higher in the high risk USMSTF (3 year) (13.6 %; 95 %CI 12.3-14.9) and ESGE groups (13.6 %; 95 %CI 12.3-15.0) compared with the lowest risk USMSTF (5.1 %; 95 %CI 4.7-5.5; P < 0.001) and ESGE categories (6.3 %; 95 %CI 6.0-6.7; P < 0.001), respectively. Adding other groups such as USMSTF 5-10-year and 3-5-year groups to the 3-year category resulted in minimal change in the PPV and NPV for metachronous advanced neoplasia. High risk ESGE (hazard ratio [HR] 3.03, 95 %CI 1.97-4.65) and USMSTF (HR 3.07, 95 %CI 2.03-4.66) designations were associated with similar long-term CRC risk (CRC per 100 000 person-years: USMSTF 3-year group 3.54, 95 %CI 2.68-4.68; ESGE high risk group: 3.43, 95 %CI 2.57-4.59). CONCLUSION Performance characteristics for the ESGE and USMSTF recommendations are similar in predicting metachronous advanced neoplasia and long-term CRC. The addition of risk groups, such as the USMSTF 5-10-year and 3-5-year groups to the USMSTF 3-year category did not alter the PPV or NPV significantly.
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Affiliation(s)
- Margaret C. Liu
- Department of Gastroenterology and Hepatology,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
- Mayo Clinic Arizona, Gastroenterology, Scottsdale, Arizona, United States
| | - Joseph C. Anderson
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States
- Section of Gastroenterology, White River Junction VAMC, White River Junction, Vermont, United States
- University of Connecticut Health Center, Gastro Farmington, Connecticut, United States
| | - William Hisey
- Department of Gastroenterology and Hepatology,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Todd A. MacKenzie
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire,United States
| | - Christina M. Robinson
- Department of Gastroenterology and Hepatology,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
| | - Lynn F. Butterly
- Department of Gastroenterology and Hepatology,Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, United States
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States
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11
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Filicko A, Huennekens K, Davis K, Dolan BM, Williams BR, Feinglass J, Grobman WA, Kominiarek MA, Yee LM. Primary Care Clinician Perspectives on Patient Navigation to Improve Postpartum Care for Patients with Low Income. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 3:1006-1015. [PMID: 36636317 PMCID: PMC9811840 DOI: 10.1089/whr.2022.0064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 12/23/2022]
Abstract
Background Birthing individuals experience significant physical and psychosocial transitions during the postpartum period. Despite amplified health needs, many individuals do not successfully transition from obstetric to primary care. Patient navigation provides a patient-centered solution that has been applied to other health care specialties resulting in improved care coordination and patient engagement for populations in greatest need. Our objective was to understand primary care clinician perspectives regarding the role of navigators in improving postpartum care for individuals with low income. Methods In this qualitative investigation, we conducted focus groups with primary care clinicians from family and internal medicine specialties. Semistructured interview guides addressed clinician perceptions of navigator roles during the postpartum period and recommendations for navigator training. Focus group discussions were digitally recorded, transcribed, and analyzed via a constant comparative method. Results Twenty-eight primary care clinicians, including 26 physicians and 2 advanced practice registered nurses, participated in 8 focus groups. Participants reported favorable attitudes toward implementation of a postpartum patient navigation program. Themes regarding useful navigation services included streamlining obstetric to primary care transition, enhancing visit effectiveness, creating personalized postpartum care, and providing patient- and clinician-focused education. Recommendations for navigator training included education on basic medical concerns that are common in the postpartum period, health information privacy and electronic health record use, health care systems, and community resources. Clinical Trial Registration number: NCT03922334. Conclusions Primary care clinicians were highly receptive to the concept of patient navigation as a process to improve health in the postpartum period through enhanced care coordination and improved patient knowledge, engagement, and self-efficacy.
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Affiliation(s)
- Abigail Filicko
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kaitlin Huennekens
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Family Medicine, Swedish First Hill, Seattle, Washington, USA
| | - Ka'Derricka Davis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brigid M. Dolan
- Division of General Internal Medicine and Geriatrics, Department of Medicine and Medical Education, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brittney R. Williams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Joe Feinglass
- Division of General Internal Medicine and Geriatrics, Department of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - William A. Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Michelle A. Kominiarek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lynn M. Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Address correspondence to: Lynn M. Yee, MD, MPH, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, 250 East Superior Street, #5-2175, Chicago, IL 60611, USA.
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12
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Cross-sectional adherence with the multi-target stool DNA test for colorectal cancer screening in a medicaid population. Prev Med Rep 2022; 30:102032. [DOI: 10.1016/j.pmedr.2022.102032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 10/20/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022] Open
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13
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Anderson JC, Robinson CM, Hisey W, Limburg PJ, Butterly LF. Colonoscopy Findings in FIT+ and mt-sDNA+ Patients versus in Colonoscopy-only Patients: New Hampshire Colonoscopy Registry Data. Cancer Prev Res (Phila) 2022; 15:455-464. [PMID: 35378546 PMCID: PMC9662869 DOI: 10.1158/1940-6207.capr-21-0581] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/01/2022] [Accepted: 03/30/2022] [Indexed: 01/07/2023]
Abstract
Few studies compare fecal immunochemical test (FIT) and multi-target stool DNA (mt-sDNA) outcomes in practice. We compared colonoscopy yield following FIT+ or mt-sDNA+ tests to colonoscopies without preceding stool tests in the comprehensive population-based New Hampshire Colonoscopy Registry (NHCR). Outcomes were any neoplasia and an ordered outcome: adenocarcinoma, advanced neoplasia (adenoma/serrated polyp ≥ 1 cm/villous/high-grade dysplasia), nonadvanced neoplasia, or normal. Our total sample included 306 mt-sDNA+ (average age ± SD 67.0 ± 7.9), 276 FIT+ (66.6 ± 8.7), and 50,990 colonoscopy-only patients (61.8 ± 8.1). Among average-risk patients (N = 240 mt-sDNA+, N = 194 FIT+, N = 26,221 colonoscopy only), mt-sDNA+ patients had a higher risk for any neoplasia (67.1%) compared with FIT+ (54.6%, P = 0.00098) or colonoscopy (40.8%, P < 0.0001). Severity of findings and histology subtypes differed across the three groups (P < 0.0001 for both), with a higher yield of advanced findings in mt-sDNA+ patients. In particular, clinically relevant serrated polyps (hyperplastic polyps ≥10 mm/traditional serrated adenomas/sessile serrated polyps) were detected at a higher frequency in mt-sDNA+ patients as compared with FIT+ or colonoscopy-only patients. Even after adjustment, patients with positive mt-sDNA [OR = 2.82; 95% confidence interval (CI), 2.00-4.02] or FIT+ tests (OR = 1.67; 95% CI, 1.19-2.36) were more likely to have histologically more advanced findings than colonoscopy alone. At follow-up colonoscopy, mt-sDNA+ tests were more likely to predict neoplasia than FIT+, largely due to increased detection of serrated polyps. Prevention Relevance: Colorectal cancer screening options include colonoscopy and stool-based tests, including the fecal immunochemical test (FIT) and the multi-target stool DNA (mt-sDNA) test which, if positive, must be followed by a colonoscopy. Assessing "real-world" outcomes of colonoscopies following positive stool tests can inform their clinical use. See related Spotlight, p. 417.
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Affiliation(s)
- Joseph C. Anderson
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- White River Junction VAMC
| | - Christina M. Robinson
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- NH Colonoscopy Registry, Lebanon, New Hampshire
| | - William Hisey
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- NH Colonoscopy Registry, Lebanon, New Hampshire
| | | | - Lynn F. Butterly
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
- Department of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- NH Colonoscopy Registry, Lebanon, New Hampshire
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14
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Maxwell AE, DeGroff A, Hohl SD, Sharma KP, Sun J, Escoffery C, Hannon PA. Evaluating Uptake of Evidence-Based Interventions in 355 Clinics Partnering With the Colorectal Cancer Control Program, 2015-2018. Prev Chronic Dis 2022; 19:E26. [PMID: 35588522 PMCID: PMC9165474 DOI: 10.5888/pcd19.210258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE AND OBJECTIVES Colorectal cancer screening rates remain suboptimal in the US. The Colorectal Cancer Control Program (CRCCP) of the Centers for Disease Control and Prevention (CDC) seeks to increase screening in health system clinics through implementation of evidence-based interventions (EBIs) and supporting activities (SAs). This program provided an opportunity to assess the uptake of EBIs and SAs in 355 clinics that participated from 2015 to 2018. INTERVENTION APPROACH The 30 funded awardees of CRCCP partnered with clinics to implement at least 2 of 4 EBIs that CDC prioritized (patient reminders, provider reminders, reducing structural barriers, provider assessment and feedback) and 4 optional strategies that CDC identified as SAs (small media, professional development and provider education, patient navigation, and community health workers). EVALUATION METHODS Clinics completed 3 annual surveys to report uptake, implementation, and integration and perceived sustainability of the priority EBIs and SAs. RESULTS In our sample of 355 clinics, uptake of 4 EBIs and 2 SAs significantly increased over time. By year 3, 82% of clinics implemented patient reminder systems, 88% implemented provider reminder systems, 82% implemented provider assessment and feedback, 76% implemented activities to reduce structural barriers, 51% implemented provider education, and 84% used small media. Most clinics that implemented these strategies (>90%) considered them fully integrated into the health system or clinic operations and sustainable by year 3. Fewer clinics used patient navigation (30%) and community health workers (19%), with no increase over the years of the study. IMPLICATIONS FOR PUBLIC HEALTH Clinics participating in the CRCCP reported high uptake and perceived sustainability of EBIs that can be integrated into electronic medical record systems but limited uptake of patient navigation and community health workers, which are uniquely suited to reduce cancer disparities. Future research should determine how to promote uptake and assess cost-effectiveness of CRCCP interventions.
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Affiliation(s)
- Annette E Maxwell
- University of California Los Angeles, Los Angeles, California.,Department of Health Policy and Management, University of California, Los Angeles, 650 Charles Young Dr South, A2-125 CHS, Box 956900, Los Angeles, CA 90095-6900. E-mail:
| | - Amy DeGroff
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Juzhong Sun
- Centers for Disease Control and Prevention, Atlanta, Georgia
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15
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Coronado GD, Leo MC, Ramsey K, Coury J, Petrik AF, Patzel M, Kenzie ES, Thompson JH, Brodt E, Mummadi R, Elder N, Davis MM. Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial. Implement Sci Commun 2022; 3:42. [PMID: 35418107 PMCID: PMC9006522 DOI: 10.1186/s43058-022-00285-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Screening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer MoonshotSM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees. Methods Phase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities. Discussion This study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. Trial registration Registered at clinicaltrial.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Katrina Ramsey
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU Biostatistics and Design Program, 3181 S.W. Sam Jackson Park Road, Mail code: CB669, Portland, OR, 97239-3098, USA
| | - Jennifer Coury
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Mary Patzel
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Erin S Kenzie
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Jamie H Thompson
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Erik Brodt
- OHSU Family Medicine, OHSU School of Medicine, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Raj Mummadi
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Nancy Elder
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU Family Medicine, OHSU School of Medicine, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU Family Medicine, OHSU School of Medicine, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU-PSU School of Public Health, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
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16
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Richter JM, Li DK. Monday, Monday-I Can't See Clearly Now: How to Improve Bowel Preparation. Dig Dis Sci 2022; 67:1088-1089. [PMID: 34169432 DOI: 10.1007/s10620-021-07043-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 12/09/2022]
Affiliation(s)
- James M Richter
- Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Darrick K Li
- Section of Digestive Diseases, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
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17
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Patient navigation for hereditary colorectal cancer: Design of a randomized controlled trial to determine the effectiveness of pathways to genetic counseling. Contemp Clin Trials 2022; 116:106735. [PMID: 35331945 DOI: 10.1016/j.cct.2022.106735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/28/2022] [Accepted: 03/17/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Diagnosis of Lynch and other hereditary colorectal cancer (CRC) syndromes through germline genetic testing has important implications for treatment and risk-management, yet guideline-recommended genetic counseling referral and attendance is suboptimal. METHODS Our team developed an adapted patient navigation program-Pathways to Genetic Counseling-to address multilevel barriers to genetic counseling referral and receipt. This paper describes the methods of a randomized controlled trial (RCT) testing Pathways to Genetic Counseling's effectiveness at increasing genetic counseling attendance in the University of Washington Medicine health system. We will identify CRC patients eligible for genetic counseling (diagnosed before age 50 or at any age with evidence of inherited mismatch repair deficiency) through a combination of structured electronic health record queries and manual chart review. Patients will be randomized 1:1 prior to consent and receive either care as usual (no contact) or be invited to participate in patient navigation. We will use chart review to compare rates of genetic counseling referral and attendance within six months of randomization, regardless of patients' engagement with navigation. We plan to identify and randomize 161 eligible CRC patients over a nine-month period beginning in late 2021. DISCUSSION Our pragmatic RCT design will provide real-world data on the potential for patient navigation to address longstanding care gaps in preventive genomic medicine. If effective, we hope to pilot Pathways to Genetic Counseling in additional settings with a long-term goal of improving appropriate diagnosis of hereditary CRC syndromes and subsequent cascade screening of eligible family members.
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18
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Menon U, Lance P, Szalacha LA, Candito D, Bobyock EP, Yellowhair M, Hatcher J. Adaptation of colorectal cancer screening tailored navigation content for American Indian communities and early results using the intervention. Implement Sci Commun 2022; 3:6. [PMID: 35090575 PMCID: PMC8795961 DOI: 10.1186/s43058-022-00253-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 01/04/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND American Indians (AI) experience major colorectal cancer (CRC) screening disparities with commensurate inequity in CRC mortality and other outcomes. The purpose of this report is to describe the methods and early results of adapting a previously successful intervention for the AI community. METHODS The educational content and delivery strategy of the parent intervention were adapted for AIs guided by an adaptation framework and cultural consultations with the community and clinicians. As part of the environmental scanning, we identified the need to substantively revise our data entry, collection, and tracking system and develop a REDCap database for this purpose. In this study, we staggered the implementation of the intervention in each facility to inform the process from one clinic to the next, and assess both the clinical outcomes of the tailored intervention and the implementation processes across two clinic settings, Facilities A and B. RESULTS The REDCap database is an indispensable asset, and without it we would not have been able to obtain reliable aggregate screening data while improvements to facility electronic health records are in progress. Approximately 8% (n = 678) of screening-eligible patients have been exposed to the navigator intervention. Of those exposed to the navigator intervention, 37% completed screening. CONCLUSIONS With the small numbers of patients exposed so far to the intervention, it would be premature to draw any broad conclusions yet about intervention effects. However, early screening completion rates are substantial advances on existing rates, and we have demonstrated that a tailored navigator intervention for facilitating CRC screening was readily adapted with provider and community input for application to AIs. A REDCap database for tracking of CRC screening by navigators using tablets or laptops on- or offline is easy to use and allows for generation of aggregate, anonymized screening data. TRIAL REGISTRATION There was no health intervention meeting the criteria of a clinical trial. The University of Arizona Institutional Review Board granted exemption from obtaining informed consent from patients undergoing CRC screening after administration of the tailored navigation intervention as usual care.
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Affiliation(s)
- Usha Menon
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, MDC Box 22, Tampa, FL, 33612, USA.
| | - Peter Lance
- University of Arizona Cancer Center, 1515 N. Campbell Ave, Tucson, AZ, 85724, USA
| | - Laura A Szalacha
- College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, MDC Box 22, Tampa, FL, 33612, USA.,Morsani College of Medicine, University of South Florida, 12901 Bruce B. Downs Blvd, Tampa, FL, 33612, USA
| | - Dianna Candito
- University of Arizona Cancer Center, 1515 N. Campbell Ave, Tucson, AZ, 85724, USA
| | - Emily P Bobyock
- University of Arizona Cancer Center, 1515 N. Campbell Ave, Tucson, AZ, 85724, USA
| | - Monica Yellowhair
- University of Arizona Cancer Center, 1515 N. Campbell Ave, Tucson, AZ, 85724, USA
| | - Jennifer Hatcher
- University of Arizona Cancer Center, 1515 N. Campbell Ave, Tucson, AZ, 85724, USA
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19
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Coronado GD, Rawlings AM, Petrik AF, Slaughter M, Johnson ES, Hannon PA, Cole A, Vu T, Mummadi RR. Precision Patient Navigation to Improve Rates of Follow-up Colonoscopy, An Individual Randomized Effectiveness Trial. Cancer Epidemiol Biomarkers Prev 2021; 30:2327-2333. [PMID: 34583969 PMCID: PMC9273475 DOI: 10.1158/1055-9965.epi-20-1793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/17/2021] [Accepted: 09/22/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Colorectal cancer screening by annual fecal immunochemical test (FIT) with follow-up on abnormal results is a cost-effective strategy to reduce colorectal cancer incidence and mortality. Unfortunately, many patients with abnormal results do not complete a follow-up colonoscopy. We tested whether navigation targeted to patients who are unlikely to complete the procedure may improve adherence and long-term outcomes. METHODS Study participants were patients at a large, integrated health system (Kaiser Permanente Northwest) who were ages 50 to 75 and were due for a follow-up colonoscopy after a recent abnormal FIT result. Probability of adherence to follow-up was estimated at baseline using a predictive risk model. Patients whose probability was 70% or lower were randomized to receive patient navigation or usual care, with randomization stratified by probability category (<50%, 50% < 60%, 60% < 65%, 65% ≤ 70%). We compared colonoscopy completion within 6 months between the navigation and usual care groups using Cox proportional hazards regression. RESULTS Participants (n = 415; 200 assigned to patient navigation, 215 to usual care) had a mean age of 62 years, 54% were female, and 87% were non-Hispanic white. By 6 months, 76% of the patient navigation group had completed a colonoscopy, compared with 65% of the usual care group (HR = 1.35; 95% confidence interval, 1.07-1.72; log-rank P value = 0.027). CONCLUSIONS In this randomized trial, patient navigation led to improvements in follow-up colonoscopy adherence. IMPACT More research is needed to assess the value of precision-directed navigation programs.
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Affiliation(s)
- Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
| | - Andreea M Rawlings
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Matthew Slaughter
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Eric S Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Northwest Permanente Medicine, Portland, Oregon
| | - Peggy A Hannon
- University of Washington School of Public Health, Seattle, Washington
| | - Allison Cole
- University of Washington School of Public Health, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Thuy Vu
- University of Washington School of Public Health, Seattle, Washington
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20
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Malo TL, Correa SY, Moore AA, Ferrari RM, Leeman J, Brenner AT, Wheeler SB, Tan X, Reuland DS. Centralized colorectal cancer screening outreach and patient navigation for vulnerable populations in North Carolina: study protocol for the SCORE randomized controlled trial. Implement Sci Commun 2021; 2:113. [PMID: 34620250 PMCID: PMC8499575 DOI: 10.1186/s43058-021-00194-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 07/31/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although colorectal cancer (CRC) screening is effective in reducing CRC mortality, screening rates in vulnerable populations served by community health centers (CHCs) remain below national targets. CHCs in North Carolina are challenged to reach CRC screening targets as they tend to be under-resourced, have limited capacity to implement and sustain population health interventions, and typically operate independently from one another and from regional colonoscopy providers. The Scaling Colorectal Cancer Screening Through Outreach, Referral, and Engagement (SCORE) project is designed to address barriers to CRC screening in partnership with CHCs by implementing a multilevel intervention that includes centralized support infrastructure for mailed fecal immunochemical test (FIT) outreach and patient navigation to follow-up colonoscopy. This paper describes protocols for the SCORE implementation trial. METHODS We will conduct a type 2 hybrid effectiveness-implementation trial that will assess effectiveness at increasing CRC screening and follow-up rates while also assessing implementation outcomes. The planned trial sample will include 4000 CHC patients who are at average CRC risk and due for screening. Participants will be randomized 1:1 to receive either usual care or a multilevel intervention that includes mailed FIT outreach and patient navigation support to follow-up colonoscopy for those with abnormal FIT. The primary effectiveness outcome is completion of any CRC screening test at six months after randomization. We will also conduct a multilevel assessment of implementation outcomes and determinants. DISCUSSION This hybrid effectiveness-implementation trial will evaluate the effectiveness and implementation of an intervention that provides centralized infrastructure for mailed FIT screening and patient navigation for CHCs that operate independently of other healthcare facilities. Findings from this research will enhance understanding of the effectiveness of a centralized approach and factors that determine successful implementation in vulnerable patient populations. TRIAL REGISTRATION The trial was registered on May 28, 2020, at ClinicalTrials.gov (identifier NCT04406714).
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Affiliation(s)
- Teri L. Malo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
| | - Sara Y. Correa
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
| | - Alexis A. Moore
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
| | - Renée M. Ferrari
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
| | - Jennifer Leeman
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
- School of Nursing, University of North Carolina at Chapel Hill, 120 North Medical Drive, Chapel Hill, NC 27599 USA
| | - Alison T. Brenner
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
- School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC 27599 USA
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC 27599 USA
| | - Xianming Tan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
| | - Daniel S. Reuland
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599 USA
- School of Medicine, University of North Carolina at Chapel Hill, 5034 Old Clinic Building, Chapel Hill, NC 27599 USA
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21
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Keswani RN, Crockett SD, Calderwood AH. AGA Clinical Practice Update on Strategies to Improve Quality of Screening and Surveillance Colonoscopy: Expert Review. Gastroenterology 2021; 161:701-711. [PMID: 34334168 DOI: 10.1053/j.gastro.2021.05.041] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 12/23/2022]
Abstract
The purpose of this American Gastroenterological Association Institute Clinical Practice Update was to review the available evidence and provide best practice advice regarding strategies to improve the quality of screening and surveillance colonoscopy. This review is framed around 15 best practice advice statements regarding colonoscopy quality that were agreed upon by the authors, based on a review of the available evidence and published guidelines. This is not a formal systematic review and thus no formal rating of the quality of evidence or strength of recommendation has been carried out.
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Affiliation(s)
- Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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22
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Yee LM, Williams B, Green HM, Carmona-Barrera V, Diaz L, Davis K, Kominiarek MA, Feinglass J, Zera CA, Grobman WA. Bridging the postpartum gap: best practices for training of obstetrical patient navigators. Am J Obstet Gynecol 2021; 225:138-152. [PMID: 33812809 PMCID: PMC8328879 DOI: 10.1016/j.ajog.2021.03.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/25/2021] [Accepted: 03/29/2021] [Indexed: 01/02/2023]
Abstract
The postpartum period represents a critical window of opportunity to improve maternal short- and long-term health, including optimizing postpartum recovery, providing effective contraception, caring for mood disorders, managing weight, supporting lactation, initiating preventive care, and promoting cardiometabolic health. However, inadequate postpartum care, especially for individuals facing social and structural barriers, is common in the United States and contributes to suboptimal health outcomes with lasting consequences. Patient navigation is a patient-centered intervention that uses trained personnel to identify financial, cultural, logistical, and educational obstacles to effective healthcare and to mitigate these barriers to facilitate comprehensive and timely access to needed health services. Given the emerging evidence suggesting that patient navigation may be a promising method to improve health among postpartum individuals, our team developed a postpartum patient navigator training guide to be used in the Navigating New Motherhood 2 and other obstetrical navigation programs. Navigating New Motherhood 2 is a randomized trial exploring whether patient navigation by a trained, lay postpartum navigator for individuals with a low income can improve health and patient-reported outcomes during and after the postpartum period. Hiring and training patient navigators without health professional degrees are integral components of initiating a navigation program. However, patient navigator training is highly variable, and no guideline regarding key elements in such a training program exists for obstetrics specifically. Thus, this paper aimed to describe the core principles, content, and rationale for each element in a comprehensive postpartum patient navigator training program. Training should be centered around the following 6 core elements: (1) principles of patient navigation; (2) knowledge of pregnancy and postpartum care; (3) health education and health promotion principles; (4) cultural sensitivity and health equity; (5) care coordination and community resources; and (6) electronic medical record systems. These core elements can serve as a basis for the development of adaptable curricula for several institutions and contexts. In addition, we offer recommendations for the implementation of a navigator training program. A curriculum with built-in flexibility to meet community and institutional needs may promote the effective and sustainable use of patient navigation in the postpartum context.
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Affiliation(s)
- Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Brittney Williams
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Hannah M Green
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Viridiana Carmona-Barrera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Laura Diaz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ka'Derricka Davis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michelle A Kominiarek
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joe Feinglass
- Division of General Internal Medicine and Geriatrics, Departments of Medicine and Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Chloe A Zera
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
| | - William A Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
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23
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Leach KM, Granzow ME, Popalis ML, Stoltzfus KC, Moss JL. Promoting colorectal cancer screening: A scoping review of screening interventions and resources. Prev Med 2021; 147:106517. [PMID: 33711351 PMCID: PMC8096709 DOI: 10.1016/j.ypmed.2021.106517] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/22/2021] [Accepted: 03/06/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Early detection through screening can reduce colorectal cancer (CRC) mortality, but approximately 33% of adults aged 50-75 are not getting screened as recommended. Many interventions to increase CRC screening have been tested, but clinical and community organizations may be challenged in identifying the optimum programs and program materials to increase screening and ultimately reduce CRC mortality. METHODS We conducted a scoping review to characterize existing, US-based interventions to improve CRC screening and to identify gaps in the literature. We used t-tests and correlations to analyze the relationship between project features and intervention effect sizes. RESULTS The overall effect sizes were + 16% for changes in screening by any modality. The average effect sizes were greater for projects with more components, used patient navigation, and provided free/low-cost testing. CONCLUSION Interventions varied greatly in terms of follow-up time, test modality, and data sources. Organizations seeking to implement a program aimed at increasing CRC screening should consider both intervention components and relevant program materials.
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Affiliation(s)
- Kelsey M Leach
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Marni E Granzow
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Madyson L Popalis
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Kelsey C Stoltzfus
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America
| | - Jennifer L Moss
- Penn State College of Medicine, The Pennsylvania State University, Hershey, PA, United States of America.
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24
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Davis MM, Schneider JL, Gunn R, Rivelli JS, Vaughn KA, Coronado GD. A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program. Transl Behav Med 2021; 11:540-548. [PMID: 32083287 PMCID: PMC7963281 DOI: 10.1093/tbm/ibaa010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English- and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2-3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-Based Research Network, Department of Family Medicine, and School of Public Health, Oregon Health and Science University, Mail Code, Portland, OR, USA
| | | | - Rose Gunn
- Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland, OR, USA
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Katherine A Vaughn
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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25
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Miller-Wilson LA, Rutten LJF, Van Thomme J, Ozbay AB, Limburg PJ. Cross-sectional adherence with the multi-target stool DNA test for colorectal cancer screening in a large, nationally insured cohort. Int J Colorectal Dis 2021; 36:2471-2480. [PMID: 34019124 PMCID: PMC8138513 DOI: 10.1007/s00384-021-03956-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE Colorectal cancer (CRC) is the second most deadly cancer in the USA. Early detection can improve CRC outcomes, but recent national screening rates (62%) remain below the 80% goal set by the National Colorectal Cancer Roundtable. Multiple options are endorsed for average-risk CRC screening, including the multi-target stool DNA (mt-sDNA) test. We evaluated cross-sectional mt-sDNA test completion in a population of commercially and Medicare-insured patients. METHODS Participants included individuals ages 50 years and older with commercial insurance or Medicare, with a valid mt-sDNA test shipped by Exact Sciences Laboratories LLC between January 1, 2018, and December 31, 2018 (n = 1,420,460). In 2020, we analyzed cross-sectional adherence, as the percent of successfully completed tests within 365 days of shipment date. RESULTS Overall cross-sectional adherence was 66.8%. Adherence was 72.1% in participants with Traditional Medicare, 69.1% in participants with Medicare Advantage, and 61.9% in participants with commercial insurance. Adherence increased with age: 60.8% for ages 50-64, 71.3% for ages 65-75, and 74.7% for ages 76 + years. Participants with mt-sDNA tests ordered by gastroenterologists had a higher adherence rate (78.3%) than those with orders by primary care clinicians (67.2%). Geographically, adherence rates were highest among highly rural patients (70.8%) and ordering providers in the Pacific region (71.4%). CONCLUSIONS Data from this large, national sample of insured patients demonstrate high cross-sectional adherence with the mt-sDNA test, supporting its role as an accepted, noninvasive option for average-risk CRC screening. Attributes of mt-sDNA screening, including home-based convenience and accompanying navigation support, likely contributed to high completion rates.
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26
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Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol. Implement Sci 2020; 15:96. [PMID: 33121536 PMCID: PMC7599111 DOI: 10.1186/s13012-020-01045-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022] Open
Abstract
Background Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation’s most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation. Methods This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase. Discussion There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study. Trial registration This protocol is registered at clinicaltrials.gov (NCT04514341) on 14 August 2020.
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27
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Abuelo C, Ashburner JM, Atlas SJ, Knudsen A, Morrill J, Corona P, Shtasel D, Percac-Lima S. Colorectal Cancer Screening Patient Navigation for Patients with Mental Illness and/or Substance Use Disorder: Pilot Randomized Control Trial. J Dual Diagn 2020; 16:438-446. [PMID: 32762637 DOI: 10.1080/15504263.2020.1802542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Colorectal cancer (CRC) is the second leading cause of cancer death in the US. Screening has decreased CRC mortality. However, disadvantaged patients, particularly those with mental illness or substance use disorder (SUD), are less likely to be screened. The aim of this trial was to evaluate the impact of a patient navigation program on CRC screening in patients with mental illness and/or SUD. METHODS A pilot randomized nonblinded controlled trial was conducted from January to June 2017 in an urban community health center serving a low-income population. We randomized 251 patients aged 50-74 years with mental illness and/or SUD diagnosis overdue for CRC screening to intervention (n = 126) or usual care (n = 125) stratified by mental illness, SUD, or dual diagnosis. Intervention group patients received a letter followed by a phone call from patient navigators. Navigators helped patients overcome their individual barriers to CRC screening including: education, scheduling, explanation of bowel preparation, lack of transportation or accompaniment to appointments. If patient refused colonoscopy, navigators offered fecal occult blood testing. The main measure was proportion of patients completing CRC screening in intervention and usual care groups. RESULTS Navigators contacted 85 patients (67%) in the intervention group and 26 declined to participate. In intention-to treat analysis, more patients in the intervention group received CRC screening than in the usual care group, 19% versus 10.4% (p = .04). Among 56 intervention patients who received navigation, 19 completed screening (33.9% versus 10.4% in the control group, p = .001). In the subgroup of patients with SUD, 20% in the intervention group were screened compared to none in the usual care group (p = .05). CONCLUSIONS A patient navigation program improved CRC screening rates in patients with mental illness and/or SUD. Larger studies in diverse care settings are needed to demonstrate generalizability and explore which modality of CRC screening is most acceptable and which navigator activities are most effective for this vulnerable population. TRIALS REGISTRATION NUMBER 2016P001322.
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Affiliation(s)
- Carolina Abuelo
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey M Ashburner
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Steven J Atlas
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Knudsen
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston, Massachusetts, USA
| | - James Morrill
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Derri Shtasel
- Massachusetts General Hospital, Division of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Sanja Percac-Lima
- Massachusetts General Hospital, Division of General Internal Medicine, Harvard Medical School, Boston, Massachusetts, USA
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28
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Butterly LF. Proven Strategies for Increasing Adherence to Colorectal Cancer Screening. Gastrointest Endosc Clin N Am 2020; 30:377-392. [PMID: 32439077 DOI: 10.1016/j.giec.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Although colorectal cancer (CRC) can be prevented or detected early through screening and surveillance, barriers that lower adherence to screening significantly limit its effectiveness. Therefore, implementation of interventions that address and overcome adherence barriers is critical to efforts to decrease morbidity and mortality from CRC. This article reviews the current available evidence about interventions to increase adherence to CRC screening.
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Affiliation(s)
- Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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29
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Weiser E, Parks PD, Swartz RK, Thomme JV, Lavin PT, Limburg P, Berger BM. Cross-sectional adherence with the multi-target stool DNA test for colorectal cancer screening: Real-world data from a large cohort of older adults. J Med Screen 2020; 28:18-24. [PMID: 32054393 PMCID: PMC7905742 DOI: 10.1177/0969141320903756] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective To determine cross-sectional adherence with the multi-target stool DNA test used for colorectal cancer screening in a large, fully insured Medicare population. Methods All patients aged 65–85 with a valid multi-target stool DNA test order from 1 September 2016 to 31 August 2017 identified from the Exact Sciences Laboratories (Madison, WI; sole-source national multi-target stool DNA test provider) database were evaluated for test adherence. Cross-sectional adherence, defined as multi-target stool DNA test completion within 365 days from order date, was analyzed overall and by time to adherence, as well as by available patient (age, sex, test order date, Medicare coverage type) and provider (specialty, year of first multi-target stool DNA test order, multi-target stool DNA test order frequency, and practice location) factors. Results Among 368,494 Medicare beneficiaries (64% female), overall cross-sectional adherence was 71%. Cumulative adherence rates increased more rapidly at 30 (44%) and 60 (65%) days, followed by more gradual increases at 90 (67%), 180 (70%), and 365 (71%) days. By provider specialty, primary care clinicians represented a higher percentage of multi-target stool DNA orders than gastroenterologists (88% vs. 6%), but had a lower associated patient adherence rate (71% vs. 78%). Conclusions In this large, national sample of Medicare insured older adults, nearly three-quarters of patients adhered with a multi-target stool DNA order for colorectal cancer screening. These real-world data should inform further clinical and population health applications, reimbursement model simulations, and guideline-endorsed colorectal cancer screening strategies adherence.
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Affiliation(s)
| | | | | | | | - Philip T Lavin
- Boston Biostatistics Research Foundation, Framingham, USA
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30
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Coronado GD, Johnson ES, Leo MC, Schneider JL, Smith D, Mummadi R, Petrik AF, Thompson JH, Jimenez R. Patient randomized trial of a targeted navigation program to improve rates of follow-up colonoscopy in community health centers. Contemp Clin Trials 2020; 89:105920. [PMID: 31881390 PMCID: PMC7254876 DOI: 10.1016/j.cct.2019.105920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/18/2019] [Accepted: 12/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after a positive FIT result. Unfortunately, nearly one-half of FIT-positive patients fail to complete this essential screening component. Patient navigation may improve follow-up colonoscopy adherence. To deliver patient navigation cost-effectively, health centers could target navigation to patients who are unlikely to complete the procedure on their own. OBJECTIVES The Predicting and Addressing Colonoscopy Non-adherence in Community Settings (PRECISE) clinical trial will validate a risk model of follow-up colonoscopy adherence and test whether patient navigation raises rates of colonoscopy adherence overall and among patients in each probability stratum (low, moderate, and high probability of adherence without intervention). METHODS PRECISE is a collaboration with a large community health center whose patient population is 37% Latino. Eligible patients will be aged 50-75, have an abnormal FIT result in the past month, and be due for a follow-up colonoscopy. Patients will be randomized to patient navigation or usual care. Primary outcomes will be colonoscopy completion within one year of a positive FIT result, cost, and cost-effectiveness. Secondary outcomes will include time to colonoscopy receipt, adequacy of bowel prep, and communication of results to primary care providers. Primary and secondary outcomes will be reported overall and by probability stratum. DISCUSSION This innovative clinical trial will test the effectiveness and financial feasibility of using a precision health intervention to improve CRC screening completion in community health centers. TRIAL REGISTRATION National Clinical Trial (NCT) Identifier: NCT03925883.
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Affiliation(s)
- Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA.
| | - Eric S Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | | | - David Smith
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Raj Mummadi
- Northwest Permanente Medical Group, Portland, OR, USA
| | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Jamie H Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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DeGroff A, Gressard L, Glover-Kudon R, Rice K, Tharpe FS, Escoffery C, Gersten J, Butterly L. Assessing the implementation of a patient navigation intervention for colonoscopy screening. BMC Health Serv Res 2019; 19:803. [PMID: 31694642 PMCID: PMC6833190 DOI: 10.1186/s12913-019-4601-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/04/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND A recent study demonstrated the effectiveness of the New Hampshire Colorectal Cancer Screening Program's (NHCRCSP) patient navigation (PN) program. The PN intervention was delivered by telephone with navigators following a rigorous, six-topic protocol to support low-income patients to complete colonoscopy screening. We applied the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework to examine implementation processes and consider potential scalability of this intervention. METHODS A mixed-methods evaluation study was conducted including 1) a quasi-experimental, retrospective, comparison group study examining program effectiveness, 2) secondary analysis of NHCRCSP program data, and 3) a case study. Data for all navigated patients scheduled and notified of their colonoscopy test date between July 1, 2012 and September 30, 2013 (N = 443) were analyzed. Researchers were provided in-depth call details for 50 patients randomly selected from the group of 443. The case study included review of program documents, observations of navigators, and interviews with 27 individuals including staff, patients, and other stakeholders. RESULTS Program reach was state-wide, with navigators serving patients from across the state. The program successfully recruited patients from the intended priority population who met the established age, income, and insurance eligibility guidelines. Analysis of the 443 NHCRCSP patients navigated during the study period demonstrated effectiveness with 97.3% completing colonoscopy, zero missed appointments (no-shows), and 0.7% late cancellations. Trained and supervised nurse navigators spent an average of 124.3 min delivering the six-topic PN protocol to patients. Navigators benefited from a real-time data system that allowed for patient tracking, communication across team members, and documentation of service delivery. Evaluators identified several factors supporting program maintenance including consistent funding support from CDC, a strong program infrastructure, and partnerships. CONCLUSIONS Factors supporting implementation included funding for colonoscopies, use of registered nurses, a clinical champion, strong partnerships with primary care and endoscopy sites, fidelity to the PN protocol, significant intervention dose, and a real-time data system. Further study is needed to assess scalability to other locations.
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Affiliation(s)
- Amy DeGroff
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | | | - Rebecca Glover-Kudon
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | - Ketra Rice
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | - Felicia Solomon Tharpe
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
| | - Cam Escoffery
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Cancer Prevention and Control, Program Services Branch, 4770 Buford Hwy, NE, MS K-76, Atlanta, GA 30341 USA
- Department of Behavioral Sciences and Health Education Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, 5th Floor, Atlanta, GA 30322 USA
| | - Joanne Gersten
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, NH USA
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 USA
| | - Lynn Butterly
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, NH USA
- Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756 USA
- Department of Medicine, Geisel School of Medicine at Dartmouth, Lebanon, NH USA
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Bernardo BM, Zhang X, Beverly Hery CM, Meadows RJ, Paskett ED. The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review. Cancer 2019; 125:2747-2761. [PMID: 31034604 DOI: 10.1002/cncr.32147] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/04/2019] [Accepted: 03/27/2019] [Indexed: 12/11/2022]
Abstract
Published studies regarding patient navigation (PN) and cancer were reviewed to assess quality, determine gaps, and identify avenues for future research. The PubMed and EMBASE databases were searched for studies investigating the efficacy and cost-effectiveness of PN across the cancer continuum. Each included article was scored independently by 2 separate reviewers with the Quality Assessment Tool for Quantitative Studies. The current review identified 113 published articles that assessed PN and cancer care, between August 1, 2010, and February 1, 2018, 14 of which reported on the cost-effectiveness of PN programs. Most publications focused on the effectiveness of PN in screening (50%) and diagnosis (27%) along the continuum of cancer care. Many described the effectiveness of PN for breast cancer (52%) or colorectal cancer outcomes (51%). Most studies reported favorable outcomes for PN programs, including increased uptake of and adherence to cancer screenings, timely diagnostic resolution and follow-up, higher completion rates for cancer therapy, and higher rates of attending medical appointments. Cost-effectiveness studies showed that PN programs yielded financial benefits. Quality assessment showed that 75 of the 113 included articles (65%) had 2 or more weak components. In conclusion, this review indicates numerous gaps within the PN and cancer literature where improvement is needed. For example, more research is needed at other points along the continuum of cancer care outside of screening and diagnosis. In addition, future research into the effectiveness of PN for understudied cancers outside of breast and colorectal cancer is necessary along with an assessment of cost-effectiveness and more rigorous reporting of study designs and results in published articles.
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Affiliation(s)
- Brittany M Bernardo
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Xiaochen Zhang
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Chloe M Beverly Hery
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
| | - Rachel J Meadows
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio
| | - Electra D Paskett
- Division of Population Sciences, Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio.,Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio.,Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, Ohio.,Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
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McGregor LM, Skrobanski H, Ritchie M, Berkman L, Miller H, Freeman M, Patel N, Morris S, Rees C, von Wagner C. Using specialist screening practitioners (SSPs) to increase uptake of bowel scope (flexible sigmoidoscopy) screening: results of a feasibility single-stage phase II randomised trial. BMJ Open 2019; 9:e023801. [PMID: 30772850 PMCID: PMC6398706 DOI: 10.1136/bmjopen-2018-023801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the feasibility of specialist screening practitioners (SSPs) offering patient navigation (PN) to facilitate uptake of bowel scope screening (BSS) among patients who do not confirm or attend their appointment. DESIGN A single-stage phase II trial. SETTING South Tyneside District Hospital, Tyne and Wear, England, UK. PARTICIPANTS Individuals invited for BSS at South Tyneside District Hospital during the 6-month recruitment period were invited to participate in the study. INTERVENTION Consenting individuals were randomly assigned to either the PN intervention or usual care group in a 4:1 ratio. The intervention involved BSS non-attenders receiving a phone call from an SSP to elicit their reasons for non-attendance and offer educational, practical and emotional support as required. If requested by the patient, another BSS appointment was then scheduled. PRIMARY OUTCOME MEASURE The number of non-attenders in the intervention group who were navigated and then rebooked and attended their new BSS appointment. SECONDARY OUTCOME MEASURES Barriers to BSS attendance, patient-reported outcomes including informed choice and satisfaction with BSS and the PN intervention, reasons for study non-participation, SSPs' evaluation of the PN process and a cost analysis. RESULTS Of those invited to take part (n=1050), 152 (14.5%) were randomised into the study: PN intervention=109; usual care=43. Most participants attended their BSS appointment (PN: 79.8%; control: 79.1%) leaving 22 eligible for PN: only two were successfully contacted. SSPs were confident in delivering PN, but were concerned that low BSS awareness and information overload may have deterred patients from taking part in the study. Difficulty contacting patients was reported as a burden to their workload. CONCLUSIONS PN, as implemented, was not a feasible intervention to increase BSS uptake in South Tyneside. Interventions to increase BSS awareness may be better suited to this population. TRIAL REGISTRATION NUMBER ISRCTN13314752; Results.
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Affiliation(s)
- Lesley M McGregor
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Hanna Skrobanski
- Research Department of Behavioural Science and Health, University College London, London, UK
- School of Health Sciences, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Mary Ritchie
- South of Tyne Bowel Cancer Screening Centre, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Hayley Miller
- South of Tyne Bowel Cancer Screening Centre, Gateshead Health NHS Foundation Trust, Queen Elizabeth Hospital, Gateshead, UK
- Trinity Medical Centre, South Shields, UK
| | - Madeleine Freeman
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Nishma Patel
- Department of Applied Health Research, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Colin Rees
- South Tyneside NHS Foundation Trust, South Tyneside District Hospital, Tyne and Wear, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
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Rice K, Sharma K, Li C, Butterly L, Gersten J, DeGroff A. Cost-effectiveness of a patient navigation intervention to increase colonoscopy screening among low-income adults in New Hampshire. Cancer 2018; 125:601-609. [PMID: 30548480 DOI: 10.1002/cncr.31864] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 09/19/2018] [Accepted: 10/19/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Colonoscopy is the most widely used colorectal cancer (CRC) screening test in the United States. Through the detection and removal of potentially precancerous polyps, it can prevent CRC. However, CRC screening remains low among adults who are recommended for screening. The New Hampshire Colorectal Cancer Screening Program implemented a patient navigation (PN) intervention to increase colonoscopy screening among low-income patients in health centers in New Hampshire. In the current study, the authors examined the cost-effectiveness of this intervention. METHODS A decision tree model was constructed using Markov state transitions to calculate the costs and effectiveness associated with PN. Costs were calculated for the implementation of PN in a statewide public health program and in endoscopy centers. The main study outcome was colonoscopy screening completion. The main decision variable was the incremental cost-effectiveness ratio associated with the PN intervention compared with usual care. RESULTS The average cost per screening with PN was $1089 (95% confidence interval, $1075-$1103) compared with $894 with usual care (95% confidence interval, $886-$908). Among patients who were navigated, approximately 96.2% completed colonoscopy screening compared with 69.3% of those receiving usual care (odds ratio, 11.2; P <. 001). The incremental cost-effectiveness ratio indicated that 1 additional screening completion cost approximately $725 in a public health program and $548 in an endoscopy center with PN compared with usual care, both of which are less than the average Medicare reimbursement of $737 for a colonoscopy procedure. CONCLUSIONS PN was found to be cost-effective in increasing colonoscopy screening among low-income adults in the New Hampshire Colorectal Cancer Screening Program, even at the threshold of current Medicare reimbursement rates for colonoscopy. The results of the current study support the implementation of PN in statewide public health programs and endoscopy centers.
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Affiliation(s)
- Ketra Rice
- Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Krishna Sharma
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Chunyu Li
- Division of Global HIV and TB, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lynn Butterly
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire.,Department of Medicine, Geisel School of Medicine at Dartmouth, Dartmouth College, Lebanon, New Hampshire
| | - Joanne Gersten
- New Hampshire Colorectal Cancer Screening Program, Mary Hitchcock Memorial Hospital, Lebanon, New Hampshire
| | - Amy DeGroff
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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DeGroff A, Sharma K, Satsangi A, Kenney K, Joseph D, Ross K, Leadbetter S, Helsel W, Kammerer W, Firth R, Rockwell T, Short W, Tangka F, Wong F, Richardson L. Increasing Colorectal Cancer Screening in Health Care Systems Using Evidence-Based Interventions. Prev Chronic Dis 2018; 15:E100. [PMID: 30095405 PMCID: PMC6093266 DOI: 10.5888/pcd15.180029] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Amy DeGroff
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Mail Stop K-76, Atlanta, GA 30341.
| | - Krishna Sharma
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anamika Satsangi
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kristy Kenney
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Djenaba Joseph
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Katherine Ross
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - William Helsel
- Information Management Services, Inc, Calverton, Maryland
| | | | - Rick Firth
- Information Management Services, Inc, Calverton, Maryland
| | | | - William Short
- Information Management Services, Inc, Calverton, Maryland
| | - Florence Tangka
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Faye Wong
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa Richardson
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Beverly EA, Hamel-Lambert J, Jensen LL, Meeks S, Rubin A. A qualitative process evaluation of a diabetes navigation program embedded in an endocrine specialty center in rural Appalachian Ohio. BMC Endocr Disord 2018; 18:50. [PMID: 30053846 PMCID: PMC6064115 DOI: 10.1186/s12902-018-0278-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 07/11/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes in the United States has reached epidemic proportions and the people of Appalachia have been disproportionately affected by this disease. Strategies that complement standard diabetes care are critically important to mitigate the risk of complications, reduce health expenditures, and improve the quality of life of patients living in rural Appalachia. The purpose of this study was to conduct a qualitative process evaluation of a patient navigation program for diabetes after its first year of implementation. METHODS The process evaluation assessed how the Diabetes Navigation Program was delivered as well as how it was experienced by the navigators, providers, health administrators, and office staff at an endocrine specialty center in rural Appalachian Ohio. We employed total population sampling to conduct in-depth, face-to-face interviews with all providers, health administrators, staff, and navigators at a Diabetes Endocrine Center. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 11 software. RESULTS Seventeen individuals (providers n = 5, health administrators n = 4, office staff members n = 3, and navigators n = 5) participated in in-depth, face-to-face interviews (age = 44.7 ± 11.6 years, 82.4% female, 94.1% white, 13.3 ± 9.6 years work experience). Fidelity of implementation: The navigation team carried out most of the activities denoted in the Work Plan, therefore the program was implemented somewhat successfully. Qualitative analysis revealed three themes: 1) The navigator addresses sources of health disparities: All participants described the role of the diabetes navigator as someone who is knowledgeable about diabetes and able to identify and address health disparities. 2) The navigators are the eyes in the community and the patients' homes: Navigators offered providers and clinic staff a rare glimpse into the personal lives of patients, which led to the identification of unrecognized barriers. 3) Difficulties with cross-system integration of services: Differences in the organizational culture and vision of the specialty center and navigation office contributed to systemic barriers. CONCLUSIONS Overall, this process evaluation highlights the importance of coordinating providers, health administrators, medical office staff, and navigators to address barriers to diabetes care. Forthcoming research is needed to document the clinical effectiveness and sustainability of the Diabetes Navigation Program in rural Appalachia.
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Affiliation(s)
- Elizabeth A. Beverly
- Department of Family Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH 45701 USA
- The Diabetes Institute, Ohio University, Athens, OH 45701 USA
| | - Jane Hamel-Lambert
- Department of Pediatric Psychology, Nationwide Children’s Hospital, Westerville, OH 43081 USA
- Department of Clinical Pediatrics, Ohio State University, Columbus, OH 43210 USA
| | - Laura L. Jensen
- Department of Family Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH 45701 USA
| | - Sue Meeks
- Community Service Programs, Ohio University Heritage College of Osteopathic Medicine, Athens, OH USA
| | - Anne Rubin
- Southeastern Ohio Legal Services, Athens, OH USA
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McKenney KM, Martinez NG, Yee LM. Patient navigation across the spectrum of women's health care in the United States. Am J Obstet Gynecol 2018; 218:280-286. [PMID: 28844825 PMCID: PMC5826769 DOI: 10.1016/j.ajog.2017.08.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/10/2017] [Accepted: 08/16/2017] [Indexed: 12/12/2022]
Abstract
Patient navigation is a patient-centered intervention that uses trained personnel to identify patient-level barriers, including financial, cultural, logistical, and educational obstacles to health care and then mitigate these barriers to facilitate complete and timely access to health services. For example, to assist a woman with Medicaid who is seeking postpartum care, a patient navigator could help her schedule an appointment before her insurance benefits change, coordinate transportation and child care, give her informational pamphlets on contraception options, and accompany her to the appointment to ensure her questions are answered. Existing studies examining the efficacy of patient navigation interventions show particularly striking benefits in the realm of cancer care, including gynecological oncology; patient navigation has been demonstrated to increase access to screening, shorten time to diagnostic resolution, and improve cancer outcomes, particularly in health disparity populations, such as women of color, rural populations, and poor women. Because of the successes in cancer care at reducing disparities in health care access and health outcomes, patient navigation has the potential to improve care and reduce disparities in obstetric and benign gynecological care. We review the concept of patient navigation, offer potential roles for patient navigation in obstetrics and gynecology, and discuss areas for further investigation.
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Affiliation(s)
- Kathryn M McKenney
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Noelle G Martinez
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lynn M Yee
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL.
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Abstract
A theory-driven tailored intervention developed in partnership with the community used evidence-based practices to (a) increase knowledge about colon cancer and screening and (b) assist patients in completing screenings. During the 16 months of delivery screening, patient navigators integrated into gastroenterology clinics met all goals, which included (a) enrolling an ethnically diverse group of participants ( N = 415) through inreach (clinic-referred patients who did not schedule appointments) and community outreach, (b) facilitating screening completions for 217 of the 358 (61%) patients identified as needing screening, and (c) obtaining satisfaction ratings from 89% of participants. A random sample ( N = 214) of nonnavigated patients matched on gender and age revealed no differences between navigated and nonnavigated patients on polyps detected. Navigated males (but not females) were significantly less likely than nonnavigated males to have either poor or only fair bowel preparation quality (odds ratio = .418, p = .020, 95% confidence interval [.197, .885]). Low-quality bowel preparation can lead to incomplete readings of the colon or cancelling a colonoscopy. This intervention demonstrates that evidence-based patient navigator programs are effective in increasing screening among a hard-to-reach population and improving bowel preparation quality for males.
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Affiliation(s)
| | - John Gray
- 2 Gastroenterology Consultants, Reno, USA
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