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Ares-Blanco S, López-Rodríguez JA, Polentinos-Castro E, Del Cura-González I. Effect of GP visits in the compliance of preventive services: a cross-sectional study in Europe. BMC PRIMARY CARE 2024; 25:165. [PMID: 38750446 PMCID: PMC11094967 DOI: 10.1186/s12875-024-02400-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/23/2024] [Indexed: 05/19/2024]
Abstract
BACKGROUND Performing cardiovascular and cancer screenings in target populations can reduce mortality. Visiting a General Practitioner (GP) once a year is related to an increased likelihood of preventive care. The aim of this study was to analyse the influence of visiting a GP in the last year on the delivery of preventive services based on sex and household income. METHODS Cross-sectional study using data collected from the European Health Interview Survey 2013-2015 of individuals aged 40-74 years from 29 European countries. The variables included: sociodemographic factors (age, sex, and household income (HHI) quintiles [HHI 1: lowest income, HHI 5: more affluent]), lifestyle factors, comorbidities, and preventive care services (cardiometabolic, influenza vaccination, and cancer screening). Descriptive statistics, bivariate analyses and multilevel models (level 1: citizen, level 2: country) were performed. RESULTS 242,212 subjects were included, 53.7% were female. The proportion of subjects who received any cardiometabolic screening (92.4%) was greater than cancer screening (colorectal cancer: 44.1%, gynaecologic cancer: 40.0%) and influenza vaccination. Individuals who visited a GP in the last year were more prone to receive preventive care services (cardiometabolic screening: adjusted OR (aOR): 7.78, 95% CI: 7.43-8.15; colorectal screening aOR: 1.87, 95% CI: 1.80-1.95; mammography aOR: 1.76, 95% CI: 1.69-1.83 and Pap smear test: aOR: 1.89, 95% CI:1.85-1.94). Among those who visited a GP in the last year, the highest ratios of cardiometabolic screening and cancer screening benefited those who were more affluent. Women underwent more blood pressure measurements than men regardless of the HHI. Men were more likely to undergo influenza vaccination than women regardless of the HHI. The highest differences between countries were observed for influenza vaccination, with a median odds ratio (MOR) of 6.36 (under 65 years with comorbidities) and 4.30 (over 65 years with comorbidities), followed by colorectal cancer screening with an MOR of 2.26. CONCLUSIONS Greater adherence to preventive services was linked to individuals who had visited a GP at least once in the past year. Disparities were evident among those with lower household incomes who visited a GP. The most significant variability among countries was observed in influenza vaccination and colorectal cancer screening.
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Affiliation(s)
- Sara Ares-Blanco
- Federica Montseny Health Centre, Gerencia Asistencial Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain.
- Medical Specialties and Public Health, School of Health Sciences, Rey Juan Carlos University, Alcorcón, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain.
- Chronicity, Primary Care, and Health Promotion Networks (RICAPPS), ISCIII, Madrid, Spain.
| | - Juan A López-Rodríguez
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- General Ricardos Health Centre, Gerencia Asistencial Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Primary Care Research Unit, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Chronicity, Primary Care, and Health Promotion Networks (RICAPPS), ISCIII, Madrid, Spain
- Medical Specialties and Public Health Department, School of Health Sciences, Rey Juan Carlos, University, Alcorcón, Madrid, Spain
| | - Elena Polentinos-Castro
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Primary Care Research Unit, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Chronicity, Primary Care, and Health Promotion Networks (RICAPPS), ISCIII, Madrid, Spain
- Medical Specialties and Public Health Department, School of Health Sciences, Rey Juan Carlos, University, Alcorcón, Madrid, Spain
| | - Isabel Del Cura-González
- Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
- Primary Care Research Unit, Gerencia de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain
- Chronicity, Primary Care, and Health Promotion Networks (RICAPPS), ISCIII, Madrid, Spain
- Medical Specialties and Public Health Department, School of Health Sciences, Rey Juan Carlos, University, Alcorcón, Madrid, Spain
- Aging Research Center, Karolinksa Instituted, Stockholm, Sweden
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Halm EA, Nair RG, Hu E, Wang L, Lykken JM, Ortiz C, Kim EJ, Santini NO, Moran B, Skinner CS. Improving Colorectal Cancer Screening in a Regional Safety-Net Health System over a 10-Year Period: Lessons for Population Health. J Gen Intern Med 2024; 39:978-984. [PMID: 37932541 PMCID: PMC11074086 DOI: 10.1007/s11606-023-08477-w] [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: 05/08/2023] [Accepted: 10/11/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Despite national policy efforts to increase colorectal cancer (CRC) screening, rates in vulnerable populations remain suboptimal. Many types of interventions have been employed, but their impact on improving population-level rates of CRC screening over time is uncertain. OBJECTIVE Assess the impact of 10 years of different in-reach and outreach strategies to improve CRC screening and identify factors associated with being screen up-to-date (SUTD). DESIGN Observational cohort study. PARTICIPANTS Patients aged 50-74 years from 12 community-based primary care clinics in an integrated, regional safety-net health system. INTERVENTIONS Multiple system-level interventions were implemented over time (visit-based electronic health record [EHR] reminders, quality measurement, annual preventive service letters, and mailed fecal immunohistochemical stool tests [FIT]). MAIN MEASURES CRC SUTD rates by calendar year among those with a primary care (PC) visit in the prior 1 and 3 years and their multivariable correlates. KEY RESULTS The sample included 31,786-40,405 patients/year. In 2011, mean age was 58.9, 63.9% were women, 37.0% were Hispanic, 39.3% Black, 16.8% White, and 6.6% Asian/Other, and 60.5% were uninsured/Medicaid. Three-quarters of patients had ≥ 1 PC visit in the prior year. Lower-intensity interventions (EHR reminders, quality measurement, annual prevention letters) had limited impact on SUTD rates (2-3% rise). Implementing system-wide mailed FIT increased rates from 51.2 to 61.9% among those with a PC visit in the past year (40.5 to 46.8% with a PC visit ≤ 3 years). Stopping mailed FIT due to COVID wiped out these gains. Higher screening rates were associated with the following: older age; female; more comorbidities, PC clinic visits, and prior FITs; and better insurance coverage. Hispanics had the highest SUTD rates followed by Asians, Blacks, and Whites (p < 0.05). CONCLUSIONS Implementation of a system-wide mailed FIT program had the greatest impact on SUTD rates. Lower-intensity interventions (EHR reminders, quality measurement, and patient letters) had limited effects.
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Affiliation(s)
- Ethan A Halm
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
| | - Rasmi G Nair
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ellen Hu
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lei Wang
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jacquelyn M Lykken
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Cynthia Ortiz
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Eric J Kim
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | - Celette Sugg Skinner
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Grewal US, Aggarwal M, Gaddam SJ, Kumar P, Garikipati SC, Fei N. Availability of Primary Care Physicians and Racial Disparities in Colorectal Cancer-Related Mortality in the United States. J Gastrointest Cancer 2024; 55:171-174. [PMID: 37418113 DOI: 10.1007/s12029-023-00956-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the United States (US), however racial disparities in outcomes persist. We sought to assess the correlation of availability of primary care physicians (PCPs) and racial disparities in CRC-related mortality. METHODS We studied the correlation between age-adjusted incidence and mortality rates of CRC among all 50 states and the District of Columbia (D.C.) from the Center for Disease Control (CDC) Wide-Ranging Online Data for Epidemiologic Research (WONDER) with the number of actively practicing PCPs in all 50 states and D.C. from the Association of American Medical Colleges (AAMC) State Physician Workforce Data Report. Pearson's coefficient was used to study correlations and the two-sample t test was used for comparing state-level PCP/CRC ratios between the two groups. Statistical analysis was performed using VassarStats. RESULTS The mean AAMR per 100,000 population for CRC was significantly higher among AA versus White populations (t = 5.79, p < 0.001). Higher state-wide PCP per CRC case ratio correlated with lower state-wide CRCrelated mortality (r = -0.36, p = 0.011). The mean PCP per CRC case ratio was significantly lower among AA compared to White populations (t = -15.95, p < 0.0001). Higher PCP per CRC case ratio correlated with lower CRC-related mortality among both White (r = -0.64, p < 0.0001) and AA (r = -0.57, p = 0.0002) populations. CONCLUSIONS These findings suggest that racial disparities in CRC-related mortality may at least in part be related to lower availability of PCPs. Efforts focused on the development of strategies focused on improving access to primary care may help bridge racial disparities in CRC-related outcomes.
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Affiliation(s)
- Udhayvir Singh Grewal
- Division of Hematology, Oncology and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA
| | - Manik Aggarwal
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Shiva Jashwanth Gaddam
- Division of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Prabhat Kumar
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Cleveland, OH, USA
| | | | - Naomi Fei
- Division of Hematology, Oncology and Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
- University of Iowa Holden Comprehensive Cancer Center, Iowa City, IA, USA.
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Brenner AT, Waters AR, Wangen M, Rohweder C, Odebunmi O, Marciniak MW, Ferrari RM, Wheeler SB, Shah PD. Patient preferences for the design of a pharmacy-based colorectal cancer screening program. Cancer Causes Control 2023; 34:99-112. [PMID: 37072526 PMCID: PMC10113122 DOI: 10.1007/s10552-023-01687-x] [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: 11/03/2022] [Accepted: 03/20/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE To assess preferences for design of a pharmacy-based colorectal cancer (CRC) screening program (PharmFIT™) among screening-eligible adults in the United States (US) and explore the impact of rurality on pharmacy use patterns (e.g., pharmacy type, prescription pick-up preference, service quality rating). METHODS We conducted a national online survey of non-institutionalized US adults through panels managed by Qualtrics, a survey research company. A total of 1,045 adults (response rate 62%) completed the survey between March and April 2021. Sampling quotas matched respondents to the 2010 US Census and oversampled rural residents. We assessed pharmacy use patterns by rurality and design preferences for learning about PharmFIT™; receiving a FIT kit from a pharmacy; and completing and returning the FIT kit. RESULTS Pharmacy use patterns varied, with some notable differences across rurality. Rural respondents used local, independently owned pharmacies more than non-rural respondents (20.4%, 6.3%, p < 0.001) and rated pharmacy service quality higher than non-rural respondents. Non-rural respondents preferred digital communication to learn about PharmFIT™ (36% vs 47%; p < 0.001) as well as digital FIT counseling (41% vs 49%; p = 0.02) more frequently than rural participants. Preferences for receiving and returning FITs were associated with pharmacy use patterns: respondents who pick up prescriptions in-person preferred to get their FIT (OR 7.7; 5.3-11.2) and return it in-person at the pharmacy (OR 1.7; 1.1-2.4). CONCLUSION Pharmacies are highly accessible and could be useful for expanding access to CRC screening services. Local context and pharmacy use patterns should be considered in the design and implementation of PharmFIT™.
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Affiliation(s)
- Alison T Brenner
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Austin R Waters
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mary Wangen
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Catherine Rohweder
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Olufeyisayo Odebunmi
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Macary Weck Marciniak
- Eshelman School of Pharmacy, 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, University of North Carolina at Chapel Hill, 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, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Parth D Shah
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
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Yalçın Gürsoy M, Bulut Ayaz C. Does Health Literacy Affect Colorectal Cancer Screening Rates? J Community Health Nurs 2023; 40:147-156. [PMID: 36920110 DOI: 10.1080/07370016.2022.2140589] [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: 03/16/2023]
Abstract
This study aims to determine the relationship between adult colorectal cancer screening behaviors and health literacy levels. This cross-sectional study aims to determine the relationship between adult colorectal cancer screening behaviors and health literacy levels. Of the participants, only a small proportion had undergone this screening (9.3%). Having an intestinal disease (OR = 23) and having a relative with colorectal cancer (OR = 8) had the highest effect on colorectal screening. There were significant differences between the colorectal screening groups concerning most THLS-32 subgroup scores, including the THLS-32 total score. Health literacy affects colorectal cancer screening rates. Primary care workers, especially community health nurses, are in an ideal position to increase health literacy and thereby increase cancer screening rates.
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Affiliation(s)
- Melike Yalçın Gürsoy
- PhD, Health Sciences Faculty, Nursing Department, Çanakkale Onsekiz Mart University, Canakkale, Turkey
| | - Canan Bulut Ayaz
- RN, Nurse, Kütahya Health Sciences University Hospital, Kutahya, Turkey
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Erlendsdottir M, Crawford FW. Randomized controlled trials of biomarker targets. Clin Trials 2023; 20:47-58. [PMID: 36373783 PMCID: PMC9974557 DOI: 10.1177/17407745221131820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Randomized controlled trials are used to estimate the causal effect of a treatment on a health outcome of interest in a patient population. Often the specified treatment in a randomized controlled trial is a medical intervention-such as a drug or procedure-experienced directly by the patient. Sometimes the "treatment" in a randomized controlled trial is a target-such as a goal biomarker measurement-that the patient's physician attempts to reach using available medications or procedures. Large randomized controlled trials of biomarker targets are common in clinical research, and trials have been conducted to compare targets in the management of hypertension, diabetes, anemia, and acute respiratory distress syndrome. However, different randomized controlled trials intended to evaluate the same biomarker targets have produced conflicting recommendations, and meta-analyses that aggregate results of trials of biomarker targets have been inconclusive. METHODS We use causal reasoning to explain why randomized controlled trials of biomarker targets can arrive at conflicting or misleading conclusions. We describe four key threats to the validity of trials of targets: (1) intention-to-treat analysis can be misleading when a direct effect of target assignment on the outcome exists due to lack of blinding; (2) incomparability in results across trials of targets; (3) time-varying adaptive treatment strategies; and (4) Goodhart's law, "when a measure becomes a target, it ceases to be a good measure." RESULTS We illustrate these findings using evidence from 15 randomized controlled trials of blood pressure targets for management of hypertension. Randomized trials of blood pressure targets exhibit substantial variation in the trial patient populations and antihypertensives used to achieve the blood pressure targets assigned in the trials. The trials did not compare or account for time-varying treatment strategies used to reach the randomized targets. Possible "off-target" effects of antihypertensive medications needed to reach lower blood pressure targets may explain the absence of a clear benefit from intensive blood pressure control. DISCUSSION Researchers should critically assess meta-analyses of trials of targets for variation in the types, distributions, and off-target effects of therapies studied. Trial investigators should release detailed information about the biomarker targets compared in new randomized trials, as well as confounders, treatments delivered, and outcomes. New randomized controlled trials should experimentally compare treatment algorithms incorporating biomarkers, rather than targets alone. Causal inference methodology that adjusts for time-varying confounding should be used to compare time-varying treatment strategies in observational settings.
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Affiliation(s)
| | - Forrest W. Crawford
- Department of Biostatistics, Yale School of Public Health,Department of Statistics & Data Science, Yale University,Department of Ecology & Evolutionary Biology, Yale University,Yale School of Management
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Liu PH, Sanford NN, Liang PS, Singal AG, Murphy CC. Persistent Disparities in Colorectal Cancer Screening: A Tell-Tale Sign for Implementing New Guidelines in Younger Adults. Cancer Epidemiol Biomarkers Prev 2022; 31:1701-1709. [PMID: 35765830 PMCID: PMC9444917 DOI: 10.1158/1055-9965.epi-21-1330] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 02/11/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In May 2021, the U.S. Preventive Services Task Force began recommending initiating colorectal cancer screening at age 45 (vs. 50) years. METHODS We estimated prevalence of colorectal cancer screening (by colonoscopy, sigmoidoscopy, CT colonography, or stool-based tests) in adults ages 50 to 75 years using data from the National Health Interview Survey in 2000, 2003, 2005, 2008, 2010, 2013, 2015, and 2018. For each survey year, we estimated prevalence by age, race/ethnicity, educational attainment, family income, and health insurance. We also compared increases in prevalence of screening from 2000 to 2018 in 5-year age groups (50-54, 55-59, 60-64, 65-69, and 70-75 years). RESULTS Overall, prevalence of colorectal cancer screening increased from 36.7% in 2000 to 66.1% in 2018. Screening prevalence in 2018 was lowest for age 50 to 54 years (47.6%), Hispanics (56.5%), Asians (57.1%), and participants with less than a high school degree (53.6%), from low-income families (56.6%), or without insurance (39.7%). Increases in prevalence over time differed by five-year age group. For example, prevalence increased from 28.2% in 2000 to 47.6% in 2018 (+19.4%; 95% CI, 13.1-25.6) for age 50 to 54 years but from 46.4% to 78.0% (+31.6%; 95% CI, 25.4%-37.7%) for age 70 to 75 years. This pattern was consistent across race/ethnicity, educational attainment, family income, and health insurance. CONCLUSIONS Prevalence of colorectal cancer screening remains low in adults ages 50 to 54 years. IMPACT As new guidelines are implemented, care must be taken to ensure screening benefits are realized equally by all population groups, particularly newly eligible adults ages 45 to 49 years. See related commentary by Brawley, p. 1671.
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Affiliation(s)
- Po-Hong Liu
- Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nina N. Sanford
- Department of Radiation Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Peter S. Liang
- Department of Medicine, NYU Langone Health, New York, NY,Department of Medicine, VA New York Harbor Health Care System, New York, NY
| | - Amit G. Singal
- Division of Digestive and Liver Diseases, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, TX
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Singal AG, Chen Y, Sridhar S, Mittal V, Fullington H, Shaik M, Waljee AK, Tiro J. Novel Application of Predictive Modeling: A Tailored Approach to Promoting HCC Surveillance in Patients With Cirrhosis. Clin Gastroenterol Hepatol 2022; 20:1795-1802.e2. [PMID: 33662594 PMCID: PMC9048842 DOI: 10.1016/j.cgh.2021.02.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/16/2021] [Accepted: 02/22/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE There has been increased interest in interventions to promote hepatocellular carcinoma (HCC) surveillance given low utilization and high proportions of late stage detection. Accurate prediction of patients likely versus unlikely to respond to interventions could allow a cost-effective approach to outreach and facilitate targeting more intensive interventions to likely non-responders. DESIGN We conducted a secondary analysis of a randomized clinical trial evaluating a mailed outreach strategy to promote HCC surveillance among 1200 cirrhosis patients at a safety-net health system between December 2014 and March 2017. We developed regularized logistic regression (RLR) and gradient boosting machine (GBM) algorithm models to predict surveillance completion during each of the 3 screening rounds in a training set (n = 960). Model performance was assessed using multiple performance metrics in an independent test set (n = 240). RESULTS Among 1200 patients, surveillance was completed in 41-47% of patients over the three rounds. The RLR and GBM models demonstrated good discriminatory accuracy, with area under receiver operating characteristic (AUROC) curves of 0.67 and 0.66 respectively in the first surveillance round and improved to 0.77 by the third surveillance round after incorporating prior screening behavior as a feature. Additional performance characteristics including the Brier score, Hosmer-Lemeshow test and reliability diagrams were also evaluated. The most important variables for the predictive model were prior screening completion status and past primary care contact. CONCLUSIONS Predictive models can help stratify patients' likelihood to respond to surveillance outreach invitations, facilitating tailored strategies to maximize effectiveness and cost-effectiveness of HCC surveillance population health programs.
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Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas,Department of Population Sciences, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas,Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas
| | - Yixing Chen
- Mendoza College of Business, University of Notre Dame, Notre Dame, Indiana
| | - Shrihari Sridhar
- Mays Business School, Texas A&M University, College Station, Texas
| | - Vikas Mittal
- Jones Graduate School of Business, Rice University, Houston, Texas
| | - Hannah Fullington
- Department of Population Sciences, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas
| | - Muzeeb Shaik
- Mays Business School, Texas A&M University, College Station, Texas
| | - Akbar K. Waljee
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan,VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan,Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), Ann Arbor, Michigan
| | - Jasmin Tiro
- Department of Population Sciences, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas,Harold C. Simmons Cancer Center, University of Texas Southwestern Medical Center and Parkland Health & Hospital, Dallas, Texas
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Davis MM, Schneider JL, Petrik AF, Miech EJ, Younger B, Escaron AL, Rivelli JS, Thompson JH, Nyongesa D, Coronado GD. Clinic Factors Associated With Mailed Fecal Immunochemical Test (FIT) Completion: The Difference-Making Role of Support Staff. Ann Fam Med 2022; 20:123-129. [PMID: 35346927 PMCID: PMC8959740 DOI: 10.1370/afm.2772] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/22/2021] [Accepted: 08/17/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Mailed fecal immunochemical test (FIT) programs can facilitate colorectal cancer (CRC) screening. We sought to identify modifiable, clinic-level factors that distinguish primary care clinics with higher vs lower FIT completion rates in response to a centralized mailed FIT program. METHODS We used baseline observational data from 15 clinics within a single urban federally qualified health center participating in a pragmatic trial to optimize a mailed FIT program. Clinic-level data included interviews with leadership using a guide informed by the Consolidated Framework for Implementation Research (CFIR) and FIT completion rates. We used template analysis to identify explanatory factors and configurational comparative methods to identify specific combinations of clinic-level conditions that uniquely distinguished clinics with higher and lower FIT completion rates. RESULTS We interviewed 39 clinic leaders and identified 58 potential explanatory factors representing clinic workflows and the CFIR inner setting domain. Clinic-level FIT completion rates ranged from 30% to 56%. The configurational model for clinics with higher rates (≥37%) featured any 1 of the following 3 factors related to support staff: (1) adding back- or front-office staff in past 12 months, (2) having staff help patients resolve barriers to CRC screening, and (3) having staff hand out FITs/educate patients. The model for clinics with lower rates involved the combined absence of these same 3 factors. CONCLUSIONS Three factors related to support staff differentiated clinics with higher and lower FIT completion rates. Adding nonphysician support staff and having those staff provide enabling services might help clinics optimize mailed FIT screening programs.
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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 & Science University, Portland, Oregon
| | | | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Edward J Miech
- Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana
| | - Brittany Younger
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California
| | - Anne L Escaron
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Jamie H Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Denis Nyongesa
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Lorvick J, Hemberg JL, Browne EN, Comfort ML. Routine and preventive health care use in the community among women sentenced to probation. HEALTH & JUSTICE 2022; 10:5. [PMID: 35122518 PMCID: PMC8817638 DOI: 10.1186/s40352-022-00167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 01/03/2022] [Indexed: 05/12/2023]
Abstract
BACKGROUND Women involved in the criminal legal (CL) system in the United States have much higher levels of chronic and infectious illness than women in the general population. Over 80% of women in the CL system are on community supervision, which means they receive health care in community settings. While the use of Emergency Department care among CL involved populations has been examined fairly extensively, less is known about engagement in routine and preventive medical care among people on community supervision. METHODS We conducted a longitudinal study of health care utilization among women with Medicaid who were currently or previously sentenced to probation in Alameda County, CA (N = 328). At baseline, 6- and 12-months, we interviewed participants about every medical care visit in the six months prior, and about potential influences on health care utilization based on the Behavioral Model for Vulnerable Populations (BMVP). Associations between BMVP factors and utilization of routine or preventive care were estimated using Poisson regression models with robust standard errors. Generalized estimating equations (GEE) were used account for repeated measures over time. RESULTS A diagnosis of one or more chronic illnesses was reported by 82% of participants. Two-thirds (62%) of women engaged in routine or preventive care in the six months prior to interview. A quarter of women engaging in routine or preventive care did not have a primary care provider (PCP). Having a PCP doubled the likelihood of using routine or preventive care (adjusted Relative Risk [adjRR] 2.27, p < 0.001). Subsistence difficulty (adjRR 0.74, p = 0.01) and unmet mental health care need (adjRR 0.83, p = 0.001) were associated with a lower likelihood of using routine or preventive care. CONCLUSION Findings underscore the importance of meeting the basic needs of women on community supervision and of connecting them with primary health care providers.
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Affiliation(s)
- Jennifer Lorvick
- Community Health and Implementation Research Program, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
| | - Jordana L. Hemberg
- Community Health and Implementation Research Program, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
| | - Erica N. Browne
- Women’s Global Health Imperative, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
| | - Megan L. Comfort
- Applied Justice Research Program, RTI International, Berkeley Office, 2150 Shattuck Ave, Suite 800, Berkeley, CA 94704 USA
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11
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Murphy CC, Halm EA, Zaki T, Johnson C, Yekkaluri S, Quirk L, Singal AG. Colorectal Cancer Screening and Yield in a Mailed Outreach Program in a Safety-Net Healthcare System. Dig Dis Sci 2022; 67:4403-4409. [PMID: 34800219 PMCID: PMC8605769 DOI: 10.1007/s10620-021-07313-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/26/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Screening with fecal immunochemical testing (FIT) reduces colorectal cancer mortality; however, screening remains low in underserved populations. Mailed outreach, including an invitation letter, FIT, and test instructions, is an evidence-based strategy to improve screening. AIMS To examine screening completion and yield in a mailed outreach program in a safety-net healthcare system. METHODS We identified and mailed outreach invitations to patients due for screening in a large safety-net system between September 1, 2018, and August 31, 2019. We examined: (1) screening completion, the proportion of patients completing FIT or screening colonoscopy within 6 months of the mailed invitation; and (2) timely diagnostic colonoscopy, the proportion of patients completing colonoscopy within 6 months of positive FIT. RESULTS We mailed 14,879 invitations to 13,190 patients. Nearly half (n = 6098, 46.2%) of patients completed screening: 4,896 (80.3%) completed FIT through mailed outreach; 1,114 (18.3%) FIT through usual care; and 88 (1.4%) screening colonoscopy through usual care. Of patients with a positive FIT (n = 289), 50.5% completed diagnostic colonoscopy within 6 months, 10.7% within 6-12 months, and 4.8% after 12 months. A total of 8 cancers and 83 advanced adenomas were detected in the 191 patients completing diagnostic colonoscopy. CONCLUSION After implementing and scaling up mailed outreach in a safety-net system, about half of patients completed screening, and the majority did so through mailed outreach. However, many patients failed to complete diagnostic colonoscopy after positive FIT. Results highlight the importance of adapting mailed outreach programs to local contexts and constraints of healthcare systems, in order to support efforts to improve CRC screening in underserved populations.
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Affiliation(s)
- Caitlin C. Murphy
- School of Public Health, University of Texas Health Science Center at Houston, 7000 Fannin St., Ste. 2618, Houston, TX 77030 USA
| | - Ethan A. Halm
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Timothy Zaki
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Carmen Johnson
- Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Sruthi Yekkaluri
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Lisa Quirk
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
| | - Amit G. Singal
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX USA
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12
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Wang A, Lee B, Patel S, Whitaker E, Issaka RB, Somsouk M. Selection of patients for large mailed fecal immunochemical test colorectal cancer screening outreach programs: A systematic review. J Med Screen 2021; 28:379-388. [PMID: 33683155 DOI: 10.1177/0969141321997482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Digital health care offers an opportunity to scale and personalize cancer screening programs, such as mailed outreach for colorectal cancer (CRC) screening. However, studies that describe the patient selection strategy and process for CRC screening are limited. Our objective was to evaluate implementation strategies for selecting patients for CRC screening programs in large health care systems. METHODS We conducted a systematic review of 30 studies along with key informant surveys and interviews to describe programmatic implementation strategies for selecting patients for CRC screening. PubMed and Embase were searched since inception through December 2018, and hand searches were performed of the retrieved reference lists but none were incorporated (n = 0). No language exclusions were applied. RESULTS Common criteria for outreach exclusion included: being up-to-date with routine CRC screening (n = 22), comorbidities (n = 20), and personal history (n = 22) or family history of cancer (n = 9). Key informant surveys and interviews were performed (n = 28) to understand data sources and practices for patient outreach selection, and found that 13 studies leveraged electronic medical care records, 10 studies leveraged a population registry (national, municipal, community, health), 4 studies required patient opt-in, and 1 study required primary care provider referral. Broad ranges in fecal immunochemical test completion were observed in community clinic (n = 8, 31.0-59.6%), integrated health system (n = 5, 21.2-82.7%), and national regional CRC screening programs (n = 17, 23.0-64.7%). Six studies used technical codes, and four studies required patient self-reporting from a questionnaire to participate. CONCLUSION This systematic review provides health systems with the diverse outreach practices and technical tools to support efforts to automate patient selection for CRC screening outreach.
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Affiliation(s)
- Andrew Wang
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Briton Lee
- Department of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Shreya Patel
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Evans Whitaker
- University of California San Francisco Medical Library, University of California, San Francisco, CA, USA
| | - Rachel B Issaka
- Clinical Research and Public Health Science Divisions, Fred Hutchinson, Seattle, WA, USA.,Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Ma Somsouk
- Division of Gastroenterology, University of California, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, CA, USA
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13
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Zhan FB, Morshed N, Kluz N, Candelaria B, Baykal-Caglar E, Khurshid A, Pignone MP. Spatial Insights for Understanding Colorectal Cancer Screening in Disproportionately Affected Populations, Central Texas, 2019. Prev Chronic Dis 2021; 18:E20. [PMID: 33661726 PMCID: PMC7938962 DOI: 10.5888/pcd18.200362] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Colorectal cancer (CRC) screening can reduce morbidity and mortality; however, important disparities exist in CRC uptake. Our study examines the associations of distance to care and frequency of using primary care and screening. METHODS To examine the distribution of screening geographically and according to several demographic features, we used individual patient-level data, dated September 30, 2018, from a large urban safety-net health system in Central Texas. We used spatial cluster analysis and logistic regression adjusted for age, race, sex, socioeconomic status, and health insurance status. RESULTS We obtained screening status data for 13,079 age-eligible patients from the health system's electronic medical records. Of those eligible, 55.1% were female, and 55.9% identified as Hispanic. Mean age was 58.1 years. Patients residing more than 20 miles from one of the system's primary care clinics was associated with lower screening rates (odds ratio [OR], 0.63; 95% CI, 0.43-0.93). Patients with higher screening rates included those who had a greater number of primary care-related (nonspecialty) visits within 1 year (OR, 6.90; 95% CI, 6.04-7.88) and those who were part of the county-level medical assistance program (OR, 1.61; 95% CI, 1.40-1.84). Spatial analysis identified an area where the level of CRC screening was particularly low. CONCLUSION Distance to primary care and use of primary care were associated with screening. Priorities in targeted interventions should include identifying and inviting patients with limited care engagements.
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Affiliation(s)
- F Benjamin Zhan
- LiveStrong Cancer Institutes, Dell Medical School, University of Texas, Austin, Texas
- Texas Center for Geographic Information Science, Department of Geography, Texas State University, San Marcos, TX 78666.
| | - Niaz Morshed
- Texas Center for Geographic Information Science, Department of Geography, Texas State University, San Marcos, Texas
| | - Nicole Kluz
- Departments of Internal Medicine and Population Health, University of Texas Dell Medical School, Austin, Texas
| | - Bretta Candelaria
- Departments of Internal Medicine and Population Health, University of Texas Dell Medical School, Austin, Texas
| | | | - Anjum Khurshid
- Departments of Internal Medicine and Population Health, University of Texas Dell Medical School, Austin, Texas
| | - Michael P Pignone
- LiveStrong Cancer Institutes, Dell Medical School, University of Texas, Austin, Texas
- Departments of Internal Medicine and Population Health, University of Texas Dell Medical School, Austin, Texas
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14
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Mojica CM, Lind B, Gu Y, Coronado GD, Davis MM. Predictors of Colorectal Cancer Screening Modality Among Newly Age-Eligible Medicaid Enrollees. Am J Prev Med 2021; 60:72-79. [PMID: 33223363 PMCID: PMC8493888 DOI: 10.1016/j.amepre.2020.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates. METHODS Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013-June 2015) to explore predictors of colonoscopy screening (versus fecal testing). RESULTS Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4-6 (OR=1.57, 95% CI=1.15, 2.15), 7-10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0-3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening. CONCLUSIONS Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality.
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Affiliation(s)
- Cynthia M Mojica
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon.
| | - Bonnie Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | | | - Melinda M Davis
- Department of Family Medicine, School of Public Health, Oregon Health & Science University, Portland, Oregon; 5Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon
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15
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A Motivational Interviewing Intervention to Promote CRC Screening: A Pilot Study. Cancer Nurs 2020; 45:E229-E237. [PMID: 33252406 DOI: 10.1097/ncc.0000000000000905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Appalachian Kentuckians suffer a disproportionate incidence and mortality from colorectal cancer (CRC) and are screened at lower rates (35%) compared with 47% of Kentuckians. OBJECTIVE The aim of this study was to evaluate the efficacy of a motivational interviewing intervention delivered by trained Lay Health Advisors on CRC screening. METHOD Eligible participants recruited from an emergency department (ED) completed a baseline survey and were randomized to either the control or the motivational interviewing intervention provided by Lay Health Advisors. Follow-up surveys were administered 3 and 6 months after baseline. To evaluate potential differences in treatment and control groups, t tests, χ, and Mann-Whitney U tests were used. RESULTS At either the 3- or 6-month assessment, there was no difference in the CRC screening by group (χ = 0.13, P = .72). There was a significant main effect for the study group in the susceptibility to CRC model; regardless of time, those in the intervention group reported approximately 1-point higher perceived susceptibility to CRC, compared with controls (est. b = 0.68, P = .038). Age and financial adequacy had a significant effect related to CRC screening. Older participants (est. b = 0.09, P = .014) and those who reported financial inadequacy (est. b = 2.34, P = .002) reported more screening barriers. CONCLUSION This pilot study elucidated important factors influencing the uptake of CRC for an ED transient population and this may be useful in the design of future interventions using motivational interviewing in EDs. IMPLICATIONS FOR PRACTICE Nurses can provide information about CRC screening guidelines and provide referrals to appropriate screening resources in the community.
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16
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Barlow WE, Beaber EF, Geller BM, Kamineni A, Zheng Y, Haas JS, Chao CR, Rutter CM, Zauber AG, Sprague BL, Halm EA, Weaver DL, Chubak J, Doria-Rose VP, Kobrin S, Onega T, Quinn VP, Schapira MM, Tosteson ANA, Corley DA, Skinner CS, Schnall MD, Armstrong K, Wheeler CM, Silverberg MJ, Balasubramanian BA, Doubeni CA, McLerran D, Tiro JA. Evaluating Screening Participation, Follow-up, and Outcomes for Breast, Cervical, and Colorectal Cancer in the PROSPR Consortium. J Natl Cancer Inst 2020; 112:238-246. [PMID: 31292633 DOI: 10.1093/jnci/djz137] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/11/2019] [Accepted: 07/03/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cancer screening is a complex process encompassing risk assessment, the initial screening examination, diagnostic evaluation, and treatment of cancer precursors or early cancers. Metrics that enable comparisons across different screening targets are needed. We present population-based screening metrics for breast, cervical, and colorectal cancers for nine sites participating in the Population-based Research Optimizing Screening through Personalized Regimens consortium. METHODS We describe how selected metrics map to a trans-organ conceptual model of the screening process. For each cancer type, we calculated calendar year 2013 metrics for the screen-eligible target population (breast: ages 40-74 years; cervical: ages 21-64 years; colorectal: ages 50-75 years). Metrics for screening participation, timely diagnostic evaluation, and diagnosed cancers in the screened and total populations are presented for the total eligible population and stratified by age group and cancer type. RESULTS The overall screening-eligible populations in 2013 were 305 568 participants for breast, 3 160 128 for cervical, and 2 363 922 for colorectal cancer screening. Being up-to-date for testing was common for all three cancer types: breast (63.5%), cervical (84.6%), and colorectal (77.5%). The percentage of abnormal screens ranged from 10.7% for breast, 4.4% for cervical, and 4.5% for colorectal cancer screening. Abnormal breast screens were followed up diagnostically in almost all (96.8%) cases, and cervical and colorectal were similar (76.2% and 76.3%, respectively). Cancer rates per 1000 screens were 5.66, 0.17, and 1.46 for breast, cervical, and colorectal cancer, respectively. CONCLUSIONS Comprehensive assessment of metrics by the Population-based Research Optimizing Screening through Personalized Regimens consortium enabled systematic identification of screening process steps in need of improvement. We encourage widespread use of common metrics to allow interventions to be tested across cancer types and health-care settings.
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Affiliation(s)
| | - Elisabeth F Beaber
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Berta M Geller
- Departments of Family Medicine, and the University of Vermont Cancer Center, University of Vermont, Burlington, VT
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Yingye Zheng
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Dana Farber, Harvard Cancer Institute, Harvard School of Public Health, Boston, MA
| | - Chun R Chao
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Ann G Zauber
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brian L Sprague
- Departments of Surgery and Radiology, University of Vermont, Burlington, VT
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center, Dallas, TX
| | - Donald L Weaver
- Department of Pathology and the UVM Cancer Center, University of Vermont, Burlington, VT
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - V Paul Doria-Rose
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA.,Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Sarah Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD
| | - Tracy Onega
- Departments of Biomedical Data Science, Epidemiology, and the Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Marilyn M Schapira
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, and CMC VA Medical Center, Philadelphia, PA
| | - Anna N A Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice and Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Mitchell D Schnall
- Department of Radiology, University of Pennsylvania, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Katrina Armstrong
- General Medicine Division, MA General Hospital, Harvard Medical School, Boston, MA
| | - Cosette M Wheeler
- Departments of Pathology and Obstetrics and Gynecology, University of New Mexico Health Science Center, Albuquerque, NM.,University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | | | - Bijal A Balasubramanian
- Simmons Comprehensive Cancer Center, Dallas, TX.,UTHealth School of Public Health, Dallas, TX
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Dale McLerran
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jasmin A Tiro
- Simmons Comprehensive Cancer Center, Dallas, TX.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX
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17
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Hostetter J, Schwarz N, Klug M, Wynne J, Basson MD. Primary care visits increase utilization of evidence-based preventative health measures. BMC FAMILY PRACTICE 2020; 21:151. [PMID: 32718313 PMCID: PMC7385977 DOI: 10.1186/s12875-020-01216-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 07/09/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary care visits can serve many purposes and potentially influence health behaviors. Although previous studies suggest that increasing primary care provider numbers may be beneficial, the mechanism responsible for the association is unclear, and have not linked primary care access to specific preventative interventions. We investigated the association between the number of times patients accessed their primary care provider team and the likelihood they received selected preventative health interventions. METHODS Patients with complete data sets from Sanford Health were categorized based on the number of primary care visits they received in a specified time period and the preventative health interventions they received. Patient characteristics were used in a propensity analysis to control for variables. Relative risks and 95% confidence intervals were calculated to estimate the likelihood of obtaining preventative measures based on number of primary care visits compared with patients who had no primary care visits during the specified time period. RESULTS The likelihood of a patient receiving three specified preventative interventions was increased by 127% for vaccination, 122% for colonoscopy, and 75% for mammography if the patient had ≥ 1 primary care visit per year. More primary care visits correlated with increasing frequency of vaccinations, but increased primary care visits beyond one did not correlate with increasing frequency of mammography or colonoscopy. CONCLUSIONS One or more primary care visits per year is associated with increased likelihood of specific evidence-based preventative care interventions that improve longitudinal health outcomes and decrease healthcare costs. Increasing efforts to track and increase the number of primary care visits by clinics and health systems may improve patient compliance with select preventative measures.
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Affiliation(s)
- Jeffrey Hostetter
- Department of Family and Community Medicine, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Nolan Schwarz
- School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Marilyn Klug
- Department of Population Health, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Joshua Wynne
- Department of Internal Medicine, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
| | - Marc D. Basson
- Department of Surgery, School of Medicine & Health Sciences, University of North Dakota, Grand Forks, USA
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18
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Ghai NR, Jensen CD, Merchant SA, Schottinger JE, Lee JK, Chubak J, Kamineni A, Halm EA, Skinner CS, Haas JS, Green BB, Cannizzaro NT, Schneider JL, Corley DA. Primary Care Provider Beliefs and Recommendations About Colorectal Cancer Screening in Four Healthcare Systems. Cancer Prev Res (Phila) 2020; 13:947-958. [PMID: 32669318 DOI: 10.1158/1940-6207.capr-20-0109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/01/2020] [Accepted: 07/08/2020] [Indexed: 12/31/2022]
Abstract
Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers' perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017-2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40-49, 50-74, and ≥75 years. For patients 50-74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40-49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e., <50 and ≥75 years). Evidence addressing these beliefs may be relevant if cancer screening recommendations are modified to include older and/or younger patients.
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Affiliation(s)
- Nirupa R Ghai
- Department of Patient Care Services, Kaiser Permanente Southern California, Pasadena, CA.
| | | | - Sophie A Merchant
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Joanne E Schottinger
- Department of Quality and Clinical Analysis, Kaiser Permanente Southern California, Pasadena, CA
| | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Ethan A Halm
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX.,Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Celette Sugg Skinner
- Simmons Comprehensive Cancer Center and Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Dana Farber Harvard Cancer Institute, Harvard School of Public Health, Boston, MA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA
| | - Nancy T Cannizzaro
- Department Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Douglas A Corley
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
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19
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Goldshore MA, Mehta SJ, Fletcher W, Tzanis G, Doubeni CA, Paulson EC. An RCT of Fecal Immunochemical Test Colorectal Cancer Screening in Veterans Without Recent Primary Care. Am J Prev Med 2020; 59:41-48. [PMID: 32564804 PMCID: PMC7388415 DOI: 10.1016/j.amepre.2020.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 01/07/2023]
Abstract
INTRODUCTION The use of screening can prevent death from colorectal cancer, yet people without regular healthcare visits may not realize the benefits of this preventive intervention. The objective of this study was to determine the effectiveness of a mailed screening invitation or mailed fecal immunochemical test in increasing colorectal cancer screening uptake in veterans without recent primary care encounters. STUDY DESIGN Three-arm pragmatic randomized trial. SETTING/PARTICIPANTS Participants were screening-eligible veterans aged 50-75 years, without a recent primary care visit who accessed medical services at the Corporal Michael J. Crescenz Veteran Affairs Medical Center between January 1, 2017, and July 31, 2017. All data were analyzed from March 1, 2018, to July 31, 2018. INTERVENTION Participants were randomized to (1) usual opportunistic screening during a healthcare visit (n=260), (2) mailed invitation to screen and reminder phone calls (n=261), or (3) mailed fecal immunochemical test outreach plus reminder calls (n=61). MAIN OUTCOME MEASURES The main outcome under investigation was the completion of colorectal cancer screening within 6 months after randomization. RESULTS Of 782 participants in the trial, 53.9% were aged 60-75 years and 59.7% were African American. The screening rate was higher in the mailed fecal immunochemical test group (26.1%) compared with usual care (5.8%) (rate difference=20.3%, 95% CI=14.3%, 26.3%; RR=4.52, 95% CI=2.7, 7.7) or screening invitation (7.7%) (rate difference=18.4%, 95% CI=12.2%, 24.6%; RR=3.4, 95% CI=2.1, 5.4). Screening completion rates were similar between invitation and usual care (rate difference=1.9%, 95% CI= -2.4%, 6.2%; RR=1.3, 95% CI=0.7, 2.5). CONCLUSIONS Mailed fecal immunochemical test screening promotes colorectal cancer screening participation among veterans without a recent primary care encounter. Despite the addition of reminder calls, an invitation letter was no more effective in screening participation than screening during outpatient appointments. TRIAL REGISTRATION This study is registered at clinicaltrials.gov NCT02584998.
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Affiliation(s)
- Matthew A Goldshore
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Woodrow Fletcher
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - George Tzanis
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Chyke A Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota; Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
| | - E Carter Paulson
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania; Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Valery JR, Applewhite A, Manaois A, Dimuna J, Sher T, Heckman MG, Brushaber DE, Stancampiano F. A Retrospective Analysis of Gender-Based Difference in Adherence to Initial Colon Cancer Screening Recommendations. J Prim Care Community Health 2020; 11:2150132720931321. [PMID: 32484009 PMCID: PMC7268106 DOI: 10.1177/2150132720931321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background: Colorectal cancer (CRC) is the fourth leading cause of cancer-related death in the United States, despite being largely preventable and treatable. Improving overall screening rates among both men and women is considered an important and effective strategy toward reducing morbidity and mortality from CRC. In order to optimize screening strategies, factors associated with decreased compliance need to be understood. This study aimed to compare initial CRC screening rates between males and females in a population of patients who presented for an annual physical examination. Methods: A retrospective chart review study of 380 patients designed to compare rates of initial CRC screening between males and females was conducted. Patients who were seen at our institution for an annual physical examination and were between 51 and 60 years of age were included. Results: There was no evidence of a difference in the rate of initial colon cancer screening between females (83.0%) and males (80.9%) in either unadjusted analysis (odds ratio = 1.16, P = .59) or in multivariable analysis adjusting for potential confounding variables (odds ratio = 1.16, P = .61). Conclusions: There was no significant difference in the rate of initial CRC screening between males and females who presented for an annual physical examination. This suggests that designing interventions to improve screening specific to gender may not be needed in a population of patients who attend routine preventive health examinations. Further study is needed in the general population to examine for gender-based differences in initial CRC screening among patients who do not regularly follow up for preventive examinations.
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Affiliation(s)
| | | | - Alyssa Manaois
- Mayo Clinic School of Health Sciences, Jacksonville, FL, USA
| | - John Dimuna
- Mayo Clinic School of Health Sciences, Jacksonville, FL, USA
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Joseph DA, King JB, Dowling NF, Thomas CC, Richardson LC. Vital Signs: Colorectal Cancer Screening Test Use - United States, 2018. MMWR-MORBIDITY AND MORTALITY WEEKLY REPORT 2020; 69:253-259. [PMID: 32163384 PMCID: PMC7075255 DOI: 10.15585/mmwr.mm6910a1] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) is the second leading cause of cancer death in the United States of cancers that affect both men and women. Despite strong evidence that screening for CRC reduces incidence and mortality, CRC screening prevalence is below the national target. This report describes current CRC screening prevalence by age, various demographic factors, and state. METHODS Data from the 2018 Behavioral Risk Factor Surveillance System survey were analyzed to estimate the percentages of adults aged 50-75 years who reported CRC screening consistent with the United States Preventive Services Task Force recommendation. RESULTS In 2018, 68.8% of adults were up to date with CRC screening. The percentage up to date was 79.2% among respondents aged 65-75 years and 63.3% among those aged 50-64 years. CRC screening prevalence was lowest among persons aged 50-54 years (50.0%) and increased with age. Among respondents aged 50-64 years, CRC screening prevalence was lowest among persons without health insurance (32.6%) and highest among those with reported annual household income of ≥$75,000 (70.8%). Among respondents aged 65-75 years, CRC screening prevalence was lowest among those without a regular health care provider (45.6%), and highest among those with reported annual household income ≥$75,000 (87.1%). Among states, CRC screening prevalence was highest in Massachusetts (76.5%) and lowest in Wyoming (57.8%). DISCUSSION CRC screening prevalence is lower among adults aged 50-64 years, although most reported having a health care provider and health insurance. Concerted efforts are needed to inform persons aged <50 years about the benefit of screening so that screening can start at age 50 years.
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Affiliation(s)
- Djenaba A Joseph
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Jessica B King
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Nicole F Dowling
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Cheryll C Thomas
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC
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Colorectal Cancer Screening in People With and Without HIV in an Integrated Health Care Setting. J Acquir Immune Defic Syndr 2020; 81:284-291. [PMID: 31194703 DOI: 10.1097/qai.0000000000002024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND As people with HIV (PWH) live longer, age-appropriate colorectal cancer (CRC) screening is increasingly important. Limited data exist on CRC screening and outcomes comparing PWH and persons without HIV. SETTING Large integrated health care system. METHODS This study included PWH and demographically matched persons without HIV who were aged 50-75 years during 2005-2016 and had no previous CRC screening. We evaluated time to first CRC screening (fecal test, sigmoidoscopy, or colonoscopy). We also assessed detection of adenoma and CRC with sigmoidoscopy or colonoscopy by HIV status, accounting for CRC risk factors including sex, age, race/ethnicity, number of outpatient visits, smoking, body mass index, type-2 diabetes, and inflammatory bowel disease. Among PWH, we evaluated whether CD4 count (<200/200-499/≥500 cells/µL) was associated with adenoma and CRC. RESULTS Among 3177 PWH and 29,219 persons without HIV, PWH were more likely to be screened (85.6% vs. 79.1% within 5 years, P < 0.001). Among those with sigmoidoscopy or colonoscopy, adenoma was detected in 161 (19.6%) PWH and 1498 (22.6%) persons without HIV, and CRC was detected in 4 (0.5%) PWH and 69 (1.0%) persons without HIV. In adjusted analyses, we found no difference in prevalence of either adenoma or CRC by HIV status (adjusted prevalence ratio = 0.97, 95% confidence interval: 0.83 to 1.12). Lower CD4 count did not increase likelihood of adenoma or CRC. CONCLUSIONS Within an integrated health care system with an organized CRC screening program, we found no disparities in CRC screening uptake or outcomes among people with and without HIV, and CD4 count did not influence CRC risk among PWH.
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Mojica CM, Bradley SM, Lind BK, Gu Y, Coronado GD, Davis MM. Initiation of Colorectal Cancer Screening Among Medicaid Enrollees. Am J Prev Med 2020; 58:224-231. [PMID: 31786031 PMCID: PMC7359742 DOI: 10.1016/j.amepre.2019.09.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Few studies have explored how individual- and practice-level factors influence colorectal cancer screening initiation among Medicaid enrollees newly age eligible for colorectal cancer screening (i.e., turning 50 years). This study explored colorectal cancer screening initiation among newly age-eligible Medicaid enrollees in Oregon. METHODS Medicaid claims data (January 2013 to June 2015) were used to conduct multivariable logistic regression (in 2018 and 2019) to explore individual- and practice-level factors associated with colorectal cancer screening initiation among 9,032 Medicaid enrollees. RESULTS A total of 17% of Medicaid enrollees initiated colorectal cancer screening; of these, 64% received a colonoscopy (versus fecal testing). Colorectal cancer screening initiation was positively associated with turning 50 years in 2014 (versus 2013; OR=1.21), being Hispanic (versus non-Hispanic white; OR=1.41), urban residence (versus rural; OR=1.23), and having 4 to 7 (OR=1.90) and 8 or more (OR=2.64) primary care visits compared with 1 to 3 visits in the year after turning 50 years. Having 3 or more comorbidities was inversely associated with initiation (OR=0.75). The odds of screening initiation were also higher for practices with 3 to 4 (OR=1.26) and 8 or more (OR=1.34) providers compared with 1 to 2 providers, and negatively associated with percentage of Medicaid panel age eligible for colorectal cancer screening (OR=0.92). CONCLUSIONS Both individual- and practice-level factors are associated with disparities in colorectal cancer screening initiation among Oregon Medicaid enrollees. Future work promoting colorectal cancer screening might focus on additional barriers to the timely initiation of colorectal cancer screening and explore the effect of practice in-reach and population outreach strategies.
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Affiliation(s)
- Cynthia M Mojica
- School of Social and Behavioral Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon.
| | - Savannah M Bradley
- Moores Cancer Center, University of California, San Diego, La Jolla, California
| | - Bonnie K Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | | | - Melinda M Davis
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon; Oregon Health & Science University-Portland State University School of Public Health, Portland, Oregon; Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon
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O’Leary MC, Lich KH, Gu Y, Wheeler SB, Coronado GD, Bartelmann SE, Lind BK, Mayorga ME, Davis MM. Colorectal cancer screening in newly insured Medicaid members: a review of concurrent federal and state policies. BMC Health Serv Res 2019; 19:298. [PMID: 31072316 PMCID: PMC6509857 DOI: 10.1186/s12913-019-4113-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 04/22/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) screening is underutilized by Medicaid enrollees and the uninsured. Multiple national and state policies were enacted from 2010 to 2014 to increase access to Medicaid and to promote CRC screening among Medicaid enrollees. We aimed to determine the impact of these policies on screening initiation among newly enrolled Oregon Medicaid beneficiaries age-eligible for CRC screening. METHODS We identified national and state policies affecting Medicaid coverage and preventive services in Oregon during 2010-2014. We used Oregon Medicaid claims data from 2010 to 2015 to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening (a prevention milestone, and an age at which guideline-concordant screening can be assessed within a single year) during each year from 2010 to 2014. We calculated risk ratios to assess whether first year of Medicaid enrollment and/or year turned 50 was associated with CRC screening initiation. RESULTS We identified 14,576 Oregon Medicaid enrollees who turned 50 during 2010-2014; 2429 (17%) completed CRC screening within 12 months after turning 50. Individuals newly enrolled in Medicaid in 2013 or 2014 were 1.58 and 1.31 times more likely, respectively, to initiate CRC screening than those enrolled by 2010. A primary care visit in the calendar year, having one or more chronic conditions, and being Hispanic was also associated with CRC screening initiation. DISCUSSION The increased uptake of CRC screening in 2013 and 2014 is associated with the timing of policies such as Medicaid expansion, enhanced federal matching for preventive services offered to Medicaid enrollees without cost sharing, and formation of Medicaid accountable care organizations, which included CRC screening as an incentivized quality metric.
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Affiliation(s)
- Meghan C. O’Leary
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
| | - Kristen Hassmiller Lich
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR USA
| | - Stephanie B. Wheeler
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1105E McGavran-Greenberg Hall, Chapel Hill, NC 27599 USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
- Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC USA
| | | | | | - Bonnie K. Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR USA
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR USA
| | - Maria E. Mayorga
- Edward P. Fitts Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC USA
| | - Melinda M. Davis
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR USA
- Department of Family Medicine, Oregon Health & Science University, Portland, OR USA
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR USA
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Smith RA, Andrews KS, Brooks D, Fedewa SA, Manassaram-Baptiste D, Saslow D, Wender RC. Cancer screening in the United States, 2019: A review of current American Cancer Society guidelines and current issues in cancer screening. CA Cancer J Clin 2019; 69:184-210. [PMID: 30875085 DOI: 10.3322/caac.21557] [Citation(s) in RCA: 355] [Impact Index Per Article: 71.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Each year, the American Cancer Society publishes a summary of its guidelines for early cancer detection, data and trends in cancer screening rates, and select issues related to cancer screening. In this issue of the journal, the current American Cancer Society cancer screening guidelines are summarized, and the most current data from the National Health Interview Survey are provided on the utilization of cancer screening for men and women and on the adherence of men and women to multiple recommended screening tests.
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Affiliation(s)
- Robert A Smith
- Vice-President, Cancer Screening, and Director, Center for Quality Cancer Screening and Research, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Kimberly S Andrews
- Director, Guidelines Process, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Durado Brooks
- Vice President, Cancer Control Interventions, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Stacey A Fedewa
- Senior Principal Scientist, Surveillance and Health Services Research, American Cancer Society, Atlanta, GA
| | | | - Debbie Saslow
- Senior Director, Human Papillomavirus-Related and Women's Cancers, Cancer Control Department, American Cancer Society, Atlanta, GA
| | - Richard C Wender
- Chief Cancer Control Officer, American Cancer Society, Atlanta, GA
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Abstract
BACKGROUND Quantifying bone mineral density (BMD) on CT using commercial software demonstrates good-to-excellent correlations with dual-energy x-ray absorptiometry (DEXA) results. However, previous techniques to measure Hounsfield units (HUs) within the proximal femur demonstrate less successful correlation with DEXA results. An effective method of measuring HUs of the proximal femur from CT colonoscopy might allow for opportunistic osteoporosis screening. QUESTIONS/PURPOSES (1) Do proximal femur HU measurements from CT colonoscopy correlate with proximal femur DEXA results? (2) How effective is our single HU measurement technique in estimating the likelihood of overall low BMD? (3) Does the relationship between our comprehensive HU measurement and DEXA results change based on age, sex, or time between studies? METHODS This retrospective study investigated the measurement of HU of the femur obtained on CT colonoscopy studies compared with DEXA results. Between 2010 and 2017, five centers performed 9085 CT colonoscopy studies; of those, 277 (3%) also had available DEXA results and were included in this study, whereas 8809 (97%) were excluded for inadequate CT imaging, lack of DEXA screening, or lack of proximal femur DEXA results. The median number of days between CT colonoscopy and DEXA scan was 595 days; no patient was excluded based on time between scans because bone remodeling is a long-term process and this allowed subgroup analysis based on time between scans. Two reviewers performed HU measurements at four points within the proximal femur on the CT colonoscopy imaging and intraclass correlation coefficients were used to evaluate interrater reliability. We used Pearson correlation coefficients to compare the comprehensive (average of eight measurements) and a single HU measurement with each DEXA result-proximal femur BMD, proximal femur T-score, femoral neck BMD, and femoral neck T-score-to identify the best measurement technique within this study. Based on their lowest DEXA T-score, we stratified patients to a diagnosis of osteoporosis, osteopenia, or normal BMD. We then calculated the area under the receiver operator characteristic curves (AUCs) to evaluate the classification ability of a single HU value to identify possible threshold(s) for detecting low BMD. For each subgroup analysis, we calculated Pearson correlation coefficients between DEXA and HUs and evaluated each subgroup's contribution to the overall predictive model using an interaction test in a linear regression model. RESULTS The Pearson correlation coefficient between both the comprehensive and single HU measurements was highest compared with the proximal femur T-score at 0.75 (95% confidence interval [CI], 0.69-0.80) and 0.74 (95% CI, 0.68-0.79), respectively. Interobserver reliability, measured with intraclass correlation coefficients, for the comprehensive and single HU measurements was 0.97 (95% CI, 0.72-0.99) and 0.96 (95% CI, 0.89-0.98), respectively. Based on DEXA results, 20 patients were osteoporotic, 167 had osteopenia, and 90 patients had normal BMD. The mean comprehensive HU for patients with osteoporosis was 70 ± 30 HUs; for patients with osteopenia, it was 110 ± 36 HUs; and for patients with normal BMD, it was 158 ± 43 HUs (p < 0.001). The AUC of the single HU model was 0.82 (95% CI, 0.77-0.87). A threshold of 214 HUs is 100% sensitive and 59 HUs is 100% specific to identify low BMD; a threshold of 113 HUs provided 73% sensitivity and 76% specificity. When stratified by decade age groups, each decade age group demonstrated a positive correlation between the comprehensive HU and proximal femur T-score, ranging between 0.71 and 0.83 (95% CI, 0.59-0.91). Further subgroup analysis similarly demonstrated a positive correlation between the comprehensive HU and proximal femur T-score when stratified by > 6 months or < 6 months between CT and DEXA (0.75; 95% CI, 0.62-0.84) as well as when stratified by sex (0.70-0.76; 95% CI, 0.48-0.81). The linear regression model demonstrated that the overall positive correlation coefficient between HUs and the proximal femur T-score is not influenced by any subgroup. CONCLUSIONS Our measurement technique provides a reproducible measurement of HUs within the proximal femur HUs on CT colonoscopy. Hounsfield units of the proximal femur based on this technique can predict low BMD. These CT scans are frequently performed before initial DEXA scans are done and therefore may lead to earlier recognition of low BMD. Future research is needed to validate these results in larger studies and to determine if these results can anticipate future fracture risk. LEVEL OF EVIDENCE Level III, diagnostic study.
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Mehta SJ, Khan T, Guerra C, Reitz C, McAuliffe T, Volpp KG, Asch DA, Doubeni CA. A Randomized Controlled Trial of Opt-in Versus Opt-Out Colorectal Cancer Screening Outreach. Am J Gastroenterol 2018; 113:1848-1854. [PMID: 29925915 PMCID: PMC6768589 DOI: 10.1038/s41395-018-0151-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/14/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES METHODS:: RESULTS:: Patients randomized to opt-in agreed to participate 23.1% of the time, and only 2.5% of those in opt-out chose not to participate. FIT kits were mailed to 22.4% and 93% of patients in opt-in and opt-out arms, respectively. In intention-to-screen analysis, patients in the opt-out arm had a higher FIT completion rate (29.1%) than in the opt-in arm (9.6%) (absolute difference 19.5%; 95% confidence interval, 10.9-27.9%; P < .001). Results were similar in subgroup analysis of those sent initial messaging through the EHR portal (9.5% opt-in versus 37.5% in opt-out). CONCLUSIONS .
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Affiliation(s)
- Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Tanya Khan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Carmen Guerra
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Chyke A Doubeni
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
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Adherence to colorectal cancer screening measured as the proportion of time covered. Gastrointest Endosc 2018; 88:323-331.e2. [PMID: 29477302 PMCID: PMC6050149 DOI: 10.1016/j.gie.2018.02.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Colorectal cancer (CRC) screening can reduce CRC incidence and mortality, but measuring screening adherence over time is challenging. We examined adherence using a novel measure characterizing the proportion of time covered (PTC) by screening tests. METHODS Eligible patients were age 50 to 60 years and followed at a large, safety-net health care system between January 2010 and September 2014. We estimated PTC as the number of days up to date with screening divided by the number of days from cohort entry until study end, CRC diagnosis, or death. We estimated mean and median PTC and used least-significant difference tests to assess differences in adherence by patient characteristics. RESULTS Of 18,257 patients, most were non-Hispanic black (40.5%) or Hispanic (34.9%) and/or female (62.4%). Approximately 40% (n = 7559) were never screened during the study period; the remaining 10,698 patients completed 19,105 screening examinations (14,481 fecal immunochemical tests [FITs], 4393 colonoscopies, 94 sigmoidoscopies, and 137 barium enemas). Overall, the mean PTC was 29.1% (95% confidence interval [CI], 28.6%-29.5%). Among those who completed at least one screening test (n = 10,698), the mean PTC was 49.0% (95% CI, 48.5%-49.5%). The most common reasons for non-adherence were lack of repeat FIT and no diagnostic colonoscopy after abnormal results for the FIT. The mean PTC increased with the number of primary care visits (0 visits, 21%; 1 visit, 29%; 2-3 visits, 35%; ≥4 visits, 37%; all P < .05). CONCLUSIONS PTC provides a reliable estimate of screening adherence, capturing breakdowns in the CRC screening process amenable to intervention. Repeat FIT and diagnostic colonoscopy are important intervention targets that may increase adherence in underserved populations.
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Schiff GD, Bearden T, Hunt LS, Azzara J, Larmon J, Phillips RS, Singer S, Bennett B, Sugarman JR, Bitton A, Ellner A. Primary Care Collaboration to Improve Diagnosis and Screening for Colorectal Cancer. Jt Comm J Qual Patient Saf 2017. [PMID: 28648219 DOI: 10.1016/j.jcjq.2017.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colorectal cancer (CRC) is a leading cause of cancer death, reducible by screening and early diagnosis, yet many patients fail to receive recommended screening. As part of an academic improvement collaborative, 25 primary care practices worked to improve CRC screening and diagnosis. METHODS The project featured triannual learning sessions, monthly conference calls, practice coach support, and monthly reporting. The project phases included literature review and interviews with national leaders/organizations, development of driver diagrams to identify key factors and change ideas, project launch and practice team planning, and a practice improvement phase. RESULTS The project activities included (1) inventory of barriers and best practices, (2) driver diagram to drive improvements, (3) list of changes to try, (4) compilation of lessons learned, and (5) five key changes to optimize screening and follow-up. Practices leveraged prior transformation efforts to track patients for screening and follow-up during and between office visits. By mapping processes, testing changes, and collecting data, sites targeted opportunities to improve quality, safety, efficiency, and patient and care team experience. Successful change interventions centered around partnering with gastroenterology, engaging leadership, leveraging registries and health information technology, promoting alternative screening options, and partnering with and supporting patients. Several practices achieved improvement in screening rates, while others demonstrated no change from baseline during the 10-month testing and implementation phase (July 2014-April 2015). CONCLUSION The collaborative effectively engaged teams in a broad set of process improvements with key lessons learned related to barriers, information technology challenges, outreach challenges/strategies, and importance of stakeholder and patient engagement.
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Capsule Commentary on Halm et al., Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach. J Gen Intern Med 2016; 31:1220. [PMID: 27384534 PMCID: PMC5023616 DOI: 10.1007/s11606-016-3791-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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