A cluster-randomized trial of a primary care informatics-based system for breast cancer screening

Community collaboration to advance racial/ethnic equity in colorectal Cancer screening: Protocol for a multilevel intervention to improve screening and follow-up in community Health centers

INTRODUCTION

Colorectal cancer (CRC) screening utilization is low among low-income, uninsured, and minority populations that receive care in community health centers (CHCs). There is a need for evidence-based interventions to increase screening and follow-up care in these settings.

METHODS

A multilevel, multi-component pragmatic cluster randomized controlled trial is being conducted at 8 CHCs in two metropolitan areas (Boston and Los Angeles), with two arms: (1) Mailed FIT outreach with text reminders, and (2) Mailed FIT-DNA with patient support. We also include an additional CHC in Rapid City (South Dakota) that follows a parallel protocol for FIT-DNA but is not randomized due to lack of a comparison group. Eligible individuals in participating clinics are primary care patients ages 45-75, at average-risk for CRC, and overdue for CRC screening. Participants with abnormal screening results are offered navigation for follow-up colonoscopy and CRC risk assessment.

RESULTS

The primary outcome is the completion rate of CRC screening at 90 days. Secondary outcomes include the screening completion rate at 180 days and the rate of colonoscopy completion within 6 months among participants with an abnormal result. Additional goals are to enhance our understanding of facilitators and barriers to CRC risk assessment in CHC settings.

CONCLUSIONS

This study assesses the effectiveness of two multilevel interventions to increase screening participation and follow-up after abnormal screening in under-resourced clinical settings, informing future efforts to address CRC disparities.

TRIAL REGISTRATION

NCT05714644.

Primary care practice-based interventions and their effect on participation in population-based cancer screening programs: a systematic narrative review

AIM

To provide a systematic synthesis of primary care practice-based interventions and their effect on participation in population-based cancer screening programs.

BACKGROUND

Globally, population-based cancer screening programs (bowel, breast, and cervical) have sub-optimal participation rates. Primary healthcare workers (PHCWs) have an important role in facilitating a patient's decision to screen; however, barriers exist to their engagement. It remains unclear how to best optimize the role of PHCWs to increase screening participation.

METHODS

A comprehensive search was conducted from January 2010 until November 2023 in the following databases: Medline (OVID), EMBASE, and CINAHL. Data extraction, quality assessment, and synthesis were conducted. Studies were separated by whether they assessed the effect of a single-component or multi-component intervention and study type.

FINDINGS

Forty-nine studies were identified, of which 36 originated from the USA. Fifteen studies were investigations of single-component interventions, and 34 studies were of multi-component interventions. Interventions with a positive effect on screening participation were predominantly multi-component, and most included combinations of audit and feedback, provider reminders, practice-facilitated assessment and improvement, and patient education across all screening programs. Regarding bowel screening, provision of screening kits at point-of-care was an effective strategy to increase participation. Taking a 'whole-of-practice approach' and identifying a 'practice champion' were found to be contextual factors of effective interventions.The findings suggest that complex interventions comprised of practitioner-focused and patient-focused components are required to increase cancer screening participation in primary care settings. This study provides novel understanding as to what components and contextual factors should be included in primary care practice-based interventions.

Cluster-randomized trials of cancer screening interventions: Has use of appropriate statistical methods increased over time?

BACKGROUND

In a cluster randomized trial, groups of individuals (e.g., clinics, schools) are randomized to conditions. The design and analysis of cluster randomized trials can require more care than individually randomized trials. Past reviews have noted deficiencies in the use of appropriate statistical methods for such trials.

METHODS

We reviewed cluster randomized trials of cancer screening interventions published 1995-2019 to determine whether appropriate statistical methods had been used for sample size calculation and outcome analysis and whether they reported intraclass correlation coefficient (ICC) values. This work expanded a previous review of articles published 1995-2010.

RESULTS

Our search identified 88 articles published 1995-2020 that reported outcomes of cluster randomized trials of breast, cervix, and colorectal cancer screening interventions. There was increased reporting of the trials' sample size calculations over time, with the percentage increasing from 31% in 1995-2004 to 77% in 2014-2019. However, the percentage of calculations failing to account for cluster randomization did not change over time and was 17% of studies in 2014-2019. There was a nonsignificant trend towards increased use of outcome analysis methods that accounted for the cluster randomized design. However, in lower impact journals, use of appropriate analysis methods was only 80% in 2014-2019. Only 33% of studies reported ICC values in 2014-2019.

CONCLUSION

For cluster randomized trials with cancer screening outcomes, there have been improvements in the reporting of sample size calculations but methodological and reporting deficiencies persist. Efforts to disseminate, adopt and report the use of appropriate statistical methodologies are still needed.

Mining Electronic Health Records to Promote the Reach of Digital Interventions for Cancer Prevention Through Proactive Electronic Outreach: Protocol for the Mixed Methods OptiMine Study

BACKGROUND

Digital behavior change interventions have demonstrated effectiveness for smoking cessation and reducing alcohol intake, which ultimately reduce cancer risk. Leveraging electronic health records (EHR) to identify at-risk patients and increasing the reach of digital interventions through proactive electronic outreach provide a novel approach that may increase the number of individuals who engage with evidence-based treatment.

OBJECTIVE

This study aims to increase the reach of digital behavior change interventions by implementing a proactive electronic message system for smoking cessation and alcohol reduction among a large, at-risk population identified through an acute hospital EHR.

METHODS

This protocol describes a 3-phase, mixed-methods implementation study to assess the acceptability, feasibility, and reach of a proactive electronic message system to digital interventions using a hospital's EHR system to identify eligible patients. In Phase 1, we will conduct focus group discussions with patients and hospital staff to assess the overall acceptability of the electronic message system. In Phase 2, we will conduct a descriptive analysis of the patient population in the hospital EHR regarding target risk behaviors and other person-level characteristics to determine the project's feasibility and potential reach. In Phase 3, we will send proactive messages to patients identified as smokers or risky drinkers. Messages will encourage and provide access to behavior change mobile apps via an embedded link; the primary outcome will be the proportion of participants who click on the link to access information about the apps.

RESULTS

At the time of initial protocol submission, data collection was complete, but analysis had not begun. This study was funded by Cancer Research UK from April 2019 to March 2020. Health Research Authority approval was granted in June 2019.

CONCLUSIONS

Increasing the reach of digital behavior change interventions can improve population health by reducing the burden of preventable death and disease.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/23669.

Mobile health application for remote oral cancer surveillance

BACKGROUND

To determine the effectiveness of a mobile phone-based remote oral cancer surveillance program (Oncogrid) connecting primary care dental practitioners and frontline health care workers (FHW) with oral cancer specialists.

METHODS

The study population (N = 3,440) included a targeted cohort (n = 2,000) and an opportunistic cohort (n = 1,440) screened by FHW and dental professionals, respectively. The authors compared the screening efficacy in both groups, with specialist diagnosis considered the reference standard. The outcomes measured were lesion detection and capture of interpretable images of the oral cavity.

RESULTS

In the targeted cohort, among 51 of 81 (61%) interpretable images, 23 of 51 (45%) of the lesions were confirmed by specialists, while the opportunistic cohort showed 100% concordance with the specialists (106 of 106). Sixty-two of 129 (48%) of the recommended patients underwent biopsy; 1 of 23 (4%) were in the targeted cohort, and 61 of 106 (57%) were in the opportunistic cohort. Ninety percent of the lesions were confirmed to be malignant or potentially malignant.

CONCLUSIONS

The mobile health-based approach adopted in this study aided remote early detection of oral cancer by primary care dental practitioners in a resource-constrained setting. Further optimization of this program is required to adopt the system for FHW. Evaluation of its efficacy in a larger population is also warranted.

PRACTICAL IMPLICATIONS

The increased efficiency of early detection by dentists, when assisted by a remote mobile health-based approach, is a step toward a more effective oral cancer screening program.

Multilevel Intervention Raises Latina Participation in Mammography Screening: Findings from ¡Fortaleza Latina!

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in women in the United States, and Latinas have relatively low rates of screening participation. The Multilevel Intervention to Increase Latina Participation in Mammography Screening study (¡Fortaleza Latina!) sought to assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington who seek care at a safety net health center.

METHODS

The study enrolled 536 Latinas ages 42 to 74 who had a primary care clinic visit in the previous 5 years and had not obtained a mammogram in the previous 2 years. Participants were block-randomized within clinic to either (i) a control arm (usual care) or (ii) a promotora-led, motivational interviewing intervention that included a home visit and telephone follow-up. At the clinic level, two of four participating clinics were provided additional mammography services delivered by a mobile mammography unit.

RESULTS

Rates of screening mammography 1 year post-randomization were 19.6% in the intervention group and 11.0% in the usual care group (P < 0.01), based on medical record data. No significant differences in participants' mammography screening were observed in clinics randomized to additional mammography services versus usual care (15.8% vs. 14.4%; P = 0.68).

CONCLUSION

This multilevel intervention of promotora-delivered motivational interviewing and free mammography services modestly raised rates of participation in breast cancer screening among Latinas.

IMPACT

Our findings can inform future efforts to boost mammography participation in safety net practices. Cancer Epidemiol Biomarkers Prev; 25(4); 584-92. ©2016 AACR SEE ALL ARTICLES IN THIS CEBP FOCUS SECTION, "MULTILEVEL APPROACHES TO ADDRESSING CANCER HEALTH DISPARITIES".

The impact of health information technology on cancer care across the continuum: a systematic review and meta-analysis

INTRODUCTION

Health information technology (HIT) has the potential to play a significant role in the management of cancer. The purpose of this review is to identify and examine empirical studies that investigate the impact of HIT in cancer care on different levels of the care continuum.

METHODS

Electronic searches were performed in four academic databases. The authors used a three-step search process to identify 122 studies that met specific inclusion criteria. Next, a coding sheet was used to extract information from each included article to use in an analysis. Logistic regression was used to determine study-specific characteristics that were associated with positive findings.

RESULTS

Overall, 72.4% of published analyses reported a beneficial effect of HIT. Multivariate analysis found that the impact of HIT differs across the cancer continuum with studies targeting diagnosis and treatment being, respectively, 77 (P = .001) and 39 (P = .039) percentage points less likely to report a beneficial effect when compared to those targeting prevention. In addition, studies targeting HIT to patients were 31 percentage points less likely to find a beneficial effect than those targeting providers (P = .030). Lastly, studies assessing behavior change as an outcome were 41 percentage points less likely to find a beneficial effect (P = .006), while studies targeting decision making were 27 percentage points more likely to find a beneficial effect (P = .034).

CONCLUSION

Based on current evidence, HIT interventions seem to be more successful when targeting physicians, care in the prevention phase of the cancer continuum, and/or decision making. An agenda for future research is discussed.

Email for clinical communication between healthcare professionals

BACKGROUND

Email is one of the most widely used methods of communication, but its use in healthcare is still uncommon. Where email communication has been utilised in health care, its purposes have included clinical communication between healthcare professionals, but the effects of using email in this way are not well known. We updated a 2012 review of the use of email for two-way clinical communication between healthcare professionals.

OBJECTIVES

To assess the effects of email for clinical communication between healthcare professionals on healthcare professional outcomes, patient outcomes, health service performance, and service efficiency and acceptability, when compared to other forms of communicating clinical information.

SEARCH METHODS

We searched: the Cochrane Consumers and Communication Review Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 9 2013), MEDLINE (OvidSP) (1946 to August 2013), EMBASE (OvidSP) (1974 to August 2013), PsycINFO (1967 to August 2013), CINAHL (EbscoHOST) (1982 to August 2013), and ERIC (CSA) (1965 to January 2010). We searched grey literature: theses/dissertation repositories, trials registers and Google Scholar (searched November 2013). We used additional search methods: examining reference lists and contacting authors.

SELECTION CRITERIA

Randomised controlled trials, quasi-randomised trials, controlled before and after studies, and interrupted time series studies examining interventions in which healthcare professionals used email for communicating clinical information in the form of: 1) unsecured email, 2) secure email, or 3) web messaging. All healthcare professionals, patients and caregivers in all settings were considered.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for inclusion, assessed the included studies' risk of bias, and extracted data. We contacted study authors for additional information and have reported all measures as per the study report.

MAIN RESULTS

The previous version of this review included one randomised controlled trial involving 327 patients and 159 healthcare providers at baseline. It compared an email to physicians containing patient-specific osteoporosis risk information and guidelines for evaluation and treatment versus usual care (no email). This study was at high risk of bias for the allocation concealment and blinding domains. The email reminder changed health professional actions significantly, with professionals more likely to provide guideline-recommended osteoporosis treatment (bone density measurement or osteoporosis medication, or both) when compared with usual care. The evidence for its impact on patient behaviours or actions was inconclusive. One measure found that the electronic medical reminder message impacted patient behaviour positively (patients had a higher calcium intake), and two found no difference between the two groups. The study did not assess health service outcomes or harms.No new studies were identified for this update.

AUTHORS' CONCLUSIONS

Only one study was identified for inclusion, providing insufficient evidence for guiding clinical practice in regard to the use of email for clinical communication between healthcare professionals. Future research should aim to utilise high-quality study designs that use the most recent developments in information technology, with consideration of the complexity of email as an intervention.

Role of practice-based research networks in comparative effectiveness research

Comparative effectiveness research fundamentally reorients how clinical evidence is generated and used with the goal of providing actionable information to decision-makers. To achieve this, it is vital that decision-makers and the research enterprise are engaged from research inception, to evidence generation and translation. Practice-based research networks are affiliated clinicians in diverse communities with the goal of conducting research to improve care. Practice-based research networks have the potential to advance all phases of the comparative effectiveness research cycle. The aim of this paper is to explore current and potential roles of practice-based research networks in conducting comparative effectiveness research.

Racial differences in cancer screening with electronic health records and electronic preventive care reminders

BACKGROUND

Health information technology (HIT) can increase preventive care. There are hopes and fears about the impact of HIT on racial disparities in cancer screening.

OBJECTIVE

To determine whether electronic health records (EHRs) or electronic preventive care reminders (e-reminders) modify racial differences in cancer screening order rates.

DESIGN

Using the 2006-2010 National Ambulatory and National Hospital Ambulatory Medical Care Surveys, we measured (1) visit-based differences in rates of age-appropriate breast, cervical and colon cancer screening orders between white and non-white subjects at primary care visits with and without EHRs, and, at visits with EHRs, with and without e-reminders, and (2) whether EHRs or e-reminders modified these differences.

MAIN OUTCOMES

Mammography (N=45,380); Pap smears (N=73,348); and sigmoidoscopy/colonoscopy (N=50,955) orders.

RESULTS

Among an estimated 2.4 billion US adult primary care visits, orders for screening for breast, cervical or colon cancer did not differ between clinics with and without EHRs or e-reminders. There was no difference in screening orders between non-white and white patients for breast (aOR=1.1; 95% CI 0.9 to 1.4) or cervical cancer (aOR=1.2; 95% CI 1.0 to 1.3). For colon cancer, non-white patients were more likely to receive screening orders than white patients overall (aOR=1.5; 95% CI 1.1 to 2.0), at visits with EHRs (aOR=1.8; 95% CI 1.1 to 2.8) and at visits with e-reminders (aOR=2.1; 95% CI 1.2 to 3.7). EHRs or e-reminders did not modify racial differences in cancer screening rates.

CONCLUSIONS

In this visit-based analysis, non-white patients had higher colon cancer screening order rates than white patients. Despite hopes and fears about HIT, EHRs and e-reminders did not ameliorate or exacerbate racial differences in cancer screening order rates.

Use of health information technology to reduce diagnostic errors

BACKGROUND

Health information technology (HIT) systems have the potential to reduce delayed, missed or incorrect diagnoses. We describe and classify the current state of diagnostic HIT and identify future research directions.

METHODS

A multi-pronged literature search was conducted using PubMed, Web of Science, backwards and forwards reference searches and contributions from domain experts. We included HIT systems evaluated in clinical and experimental settings as well as previous reviews, and excluded radiology computer-aided diagnosis, monitor alerts and alarms, and studies focused on disease staging and prognosis. Articles were organised within a conceptual framework of the diagnostic process and areas requiring further investigation were identified.

RESULTS

HIT approaches, tools and algorithms were identified and organised into 10 categories related to those assisting: (1) information gathering; (2) information organisation and display; (3) differential diagnosis generation; (4) weighing of diagnoses; (5) generation of diagnostic plan; (6) access to diagnostic reference information; (7) facilitating follow-up; (8) screening for early detection in asymptomatic patients; (9) collaborative diagnosis; and (10) facilitating diagnostic feedback to clinicians. We found many studies characterising potential interventions, but relatively few evaluating the interventions in actual clinical settings and even fewer demonstrating clinical impact.

CONCLUSIONS

Diagnostic HIT research is still in its early stages with few demonstrations of measurable clinical impact. Future efforts need to focus on: (1) improving methods and criteria for measurement of the diagnostic process using electronic data; (2) better usability and interfaces in electronic health records; (3) more meaningful incorporation of evidence-based diagnostic protocols within clinical workflows; and (4) systematic feedback of diagnostic performance.

Population-based breast cancer screening in a primary care network

OBJECTIVES

To assess the ability of a health information technology system to facilitate population- based breast cancer screening.

STUDY DESIGN

Cohort study with 2-year follow-up after a 1-year cluster randomized trial.

METHODS

Study population was women 42 to 69 years old receiving care within a 12-practice primary care network. The management informatics system (1) identified women overdue for mammograms, (2) connected them to primary care providers using a web-based tool, (3) created automatically generated outreach letters for patients specified by providers, (4) monitored for subsequent mammography scheduling and completion, and (5) provided practice delegates with a list of women remaining unscreened for reminder phone calls. Eligible women overdue for a mammogram during a 1-year study period included those overdue at study start (prevalent cohort) and those who became overdue during follow-up (incident cohort). The main outcome measure was mammography completion rates over 3 years.

RESULTS

Among 32,688 eligible women, 9795 (30%) were overdue for screening (4487 intervention, 5308 control). Intervention patients were somewhat younger, more likely to be non-Hispanic white, and more likely to have health insurance compared with control patients. Adjusted completion rates in the prevalent cohort (n = 6697) were significantly higher among intervention patients after 3 years (51.7% vs 45.8%; P = .002). For patients in the incident cohort (n = 3098), adjusted completion rates after 2 years were 53.8% versus 48.7%, respectively (P = .052).

CONCLUSIONS

Population-based informatics systems can enable sustained increases in mammography screening rates beyond rates seen with office-based visit reminders.

Cluster randomized trials of cancer screening interventions: are appropriate statistical methods being used?

The design and analysis of cluster randomized trials can require more sophistication than individually randomized trials. However, the need for statistical methods that account for the clustered design has not always been appreciated, and past reviews have found widespread deficiencies in methodology and reporting. We reviewed cluster randomized trials of cancer screening interventions published in 1995-2010 to determine whether the use of appropriate statistical methods had increased over time. Literature searches yielded 50 articles reporting outcome analyses of cluster randomized trials of breast, cervix and colorectal cancer screening interventions. Of studies published in 1995-1999, 2000-2002, 2003-2006 and 2007-2010, 55% (6/11), 82% (9/11), 92% (12/13) and 60% (9/15) used appropriate analytic methods, respectively. Results were suggestive of a peak in 2003-2006 (p =.06) followed by a decline in 2007-2010 (p =.08). While the sample of studies was small, these results indicate that many cluster randomized trials of cancer screening interventions have had deficiencies in the application of correct statistical procedures for the outcome analysis, and that increased adoption of appropriate methods in the early and mid-2000's may not have been sustained.