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Mehta SJ, Volpp KG, Troxel AB, Teel J, Reitz CR, Purcell A, Shen H, McNelis K, Snider CK, Asch DA. Remote Blood Pressure Monitoring With Social Support for Patients With Hypertension: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2413515. [PMID: 38829618 PMCID: PMC11148689 DOI: 10.1001/jamanetworkopen.2024.13515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/25/2024] [Indexed: 06/05/2024] Open
Abstract
Importance Hypertension management has traditionally been based on office visits. Integrating remote monitoring into routine clinical practices and leveraging social support might improve blood pressure (BP) control. Objective To evaluate the effectiveness of a bidirectional text monitoring program focused on BP control and medication adherence with and without social support in adults with hypertension. Design, Setting, and Participants This randomized clinical trial included adults aged 18 to 75 treated at an academic family medicine practice in Philadelphia in 2018 and 2019. Patients had been seen at least twice in the prior 24 months and had at least 2 elevated BP measurements (>150/90 mm Hg or >140/90 mm Hg for patients aged 18-59 years or with diabetes or chronic kidney disease) during visits. All participants had a cell phone with text messaging, offered at least 1 support partner, and were taking maintenance medications to treat hypertension. Patients were randomized 2:2:1 to remote monitoring of BP and medication adherence (RM), remote monitoring of BP and medication adherence with feedback provided to a social support partner (SS), or usual care (UC). Data were analyzed on an intention-to-treat basis between October 14, 2019, and May 30, 2020, and were revisited from May 23 through June 2, 2023. Interventions The RM and SS groups received an automatic home BP monitor, 3 weekly texts requesting BP measurements, 1 weekly text inquiring about medication adherence, and a weekly text with feedback. In the SS arm, support partners received a weekly progress report. The UC group received UC through their primary care practice. Clinicians caring for the patients in the intervention groups received nudges via electronic health records to adjust medications when 3 of 10 reported BP measurements were elevated. Patients were followed up for 4 months. Main Outcomes and Measures The primary outcome was systolic BP at 4 months measured during the final follow-up visit. Secondary outcomes included achievement of normotension and diastolic BP. Results In all, 246 patients (mean [SD] age, 50.9 [11.4] years; 175 females [71.1%]; 223 Black individuals [90.7%] and 13 White individuals [5.3%]) were included in the intention-to-treat analysis: 100 patients in the RM arm, 97 in the SS arm, and 49 in the UC arm. Compared with the UC arm, there was no significant difference in systolic or diastolic BP at the 4-month follow-up visit in the RM arm (systolic BP adjusted mean difference, -5.25 [95% CI, -10.65 to 0.15] mm Hg; diastolic BP adjusted mean difference, -1.94 [95% CI, -5.14 to 1.27] mm Hg) or the SS arm (systolic BP adjusted mean difference, -0.91 [95% CI, -6.37 to 4.55] mm Hg; diastolic BP adjusted mean difference, -0.63 [95% CI, -3.77 to 2.51] mm Hg). Of the 206 patients with a final BP measurement at 4 months, BP was controlled in 49% (41 of 84) of patients in the RM arm, 31% (27 of 87) of patients in the SS arm, and 40% (14 of 35) of patients in the UC arm; these rates did not differ significantly between the intervention arms and the UC group. Conclusions and Relevance In this randomized clinical trial, neither remote BP monitoring nor remote BP monitoring with social support improved BP control compared with UC in adults with hypertension. Additional efforts are needed to examine whether interventions directed at helping patients remember to take their BP medications can lead to improved BP control. Trial Registration ClinicalTrials.gov Identifier: NCT03416283.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia
| | - Andrea B. Troxel
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York
| | - Joseph Teel
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine R. Reitz
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Alison Purcell
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Humphrey Shen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kiernan McNelis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia
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Ahadinezhad B, Maleki A, Akhondi A, Kazemi M, Yousefy S, Rezaei F, Khosravizadeh O. Are behavioral economics interventions effective in increasing colorectal cancer screening uptake: A systematic review of evidence and meta-analysis? PLoS One 2024; 19:e0290424. [PMID: 38315699 PMCID: PMC10843112 DOI: 10.1371/journal.pone.0290424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/08/2023] [Indexed: 02/07/2024] Open
Abstract
Various interventions have been investigated to improve the uptake of colorectal cancer screening. In this paper, the authors have attempted to provide a pooled estimate of the effect size of the BE interventions running a systematic review based meta-analysis. In this study, all the published literatures between 2000 and 2022 have been reviewed. Searches were performed in PubMed, Scopus and Cochrane databases. The main outcome was the demanding the one of the colorectal cancer screening tests. The quality assessment was done by two people so that each person evaluated the studies separately and independently based on the individual participant data the modified Jadad scale. Pooled effect size (odds ratio) was estimated using random effects model at 95% confidence interval. Galbraith, Forrest and Funnel plots were used in data analysis. Publication bias was also investigated through Egger's test. All the analysis was done in STATA 15. From the initial 1966 records, 38 were included in the final analysis in which 72612 cases and 71493 controls have been studied. About 72% have been conducted in the USA. The heterogeneity of the studies was high based on the variation in OR (I2 = 94.6%, heterogeneity X2 = 670.01 (d.f. = 36), p < 0.01). The random effect pooled odds ratio (POR) of behavioral economics (BE) interventions was calculated as 1.26 (95% CI: 1.26 to 1.43). The bias coefficient is noteworthy (3.15) and statistically significant (p< 0.01). According to the results of this meta-analysis, health policy and decision makers can improve the efficiency and cost effectiveness of policies to control this type of cancer by using various behavioral economics interventions. It's noteworthy that due to the impossibility of categorizing behavioral economics interventions; we could not perform by group analysis.
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Affiliation(s)
- Bahman Ahadinezhad
- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Aisa Maleki
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Amirali Akhondi
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | - Sama Yousefy
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Fatemeh Rezaei
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Omid Khosravizadeh
- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
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Mehta SJ, McDonald C, Reitz C, Kastuar S, Snider CK, Okorie E, McNelis K, Shaikh H, Cook TS, Goldberg DS, Rothstein K. A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance. Hepatol Commun 2024; 8:e0349. [PMID: 38099859 PMCID: PMC10727671 DOI: 10.1097/hc9.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Shivani Kastuar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Evelyn Okorie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Kiernan McNelis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Hamzah Shaikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tessa S. Cook
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - David S. Goldberg
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kenneth Rothstein
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Richardson-Parry A, Silva M, Valderas JM, Donde S, Woodruff S, van Vugt J. Video Interventions for Reducing Health Inequity in Cancer Screening Programmes: a Systematic Review. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01749-5. [PMID: 37603223 DOI: 10.1007/s40615-023-01749-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Health equity can lead to disparities in cancer screening, treatment, and mortality. This systematic review aims to identify and describe interventions that used video or DVD formats to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates compared to usual care conditions. METHODS We searched PubMed, Web of Science, Embase, and Cochrane databases for randomized control trials (RCTs) published until 18/01/2023 that compared intervention versus usual care control groups, with the percentage of cancer screening uptake during follow-up as an outcome. The risk of Bias was assessed with the Cochrane Collaboration tool. RESULTS After screening 4201 abstracts, 192 full texts were assessed for eligibility and 18 were included that focused on colorectal (n = 9), cervical (n = 5), breast (n = 5), and prostate (n = 1) cancer screening. All were based in the USA except one and most focused on ethnicity/race, while some included low-income populations. Most of the video interventions used to increase cervical cancer screening reported positive results. Studies aimed at increasing mammography uptake were mostly effective only in specific groups of participants, such as low-income or less-educated African American women. Results for colorectal cancer screening were conflicting. Videos that were culturally tailored or used emotive format were generally more effective than information-only videos. CONCLUSIONS Video interventions to increase cancer screening among populations with low screening uptake show some positive effects, though results are mixed. Interventions that use individual and cultural tailoring of the educational material should be further developed and investigated outside of the USA.
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Affiliation(s)
| | - Mitchell Silva
- Esperity, Veldkapelgaarde 30b1.30.30, 1200, Brussels, Belgium
| | - Jose Maria Valderas
- Department of Family Medicine, National University Health System and Yong Loo Lin School of Medicine, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
| | - Shaantanu Donde
- Viatris, Building 4, Trident Place, Mosquito Way, Hatfield, AL10 9UL, UK
| | | | - Joris van Vugt
- Viatris, Krijgsman 20, Amstelveen, 1186DM, The Netherlands
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Richardson-Parry A, Silva M, Valderas JM, Donde S, Woodruff S, van Vugt J. Interactive or tailored digital interventions to increase uptake in cervical, breast, and colorectal cancer screening to reduce health inequity: a systematic review. Eur J Cancer Prev 2023; 32:396-409. [PMID: 37144585 PMCID: PMC10249608 DOI: 10.1097/cej.0000000000000796] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Significant health inequities exist in screening uptake for certain types of cancer. The review question was to identify and describe interactive, tailored digital, computer, and web-based interventions to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates versus usual care. METHODS We searched four medical literature databases for randomized control trials (RCTs) published until 12 January 2023 that evaluated interventions aimed at increasing the percentage of breast, prostate, cervical, or colorectal cancer screening uptake. Meta-analysis was not conducted due to heterogeneity among studies. RESULTS After screening 4200 titles and abstracts, 17 studies were included. Studies focused on colorectal ( n = 10), breast ( n = 4), cervical ( n = 2), and prostate ( n = 1) cancer screening. All were based in the USA except two. Most studies focused on ethnicity/race, while some included low-income populations. Intervention types were heterogeneous and used computer programs, apps, or web-based methods to provide tailored or interactive information to participants about screening risks and options. Some studies found positive effects for increasing cancer screening uptake in the intervention groups compared to usual care, but results were heterogeneous. CONCLUSION Interventions that use individual and cultural tailoring of cancer screening educational material should be further developed and investigated outside of the USA. Designing effective digital intervention strategies, with components that can be adapted to remote delivery may be an important strategy for reducing health inequities in cancer screening during the coronavirus disease 2019 pandemic.
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Affiliation(s)
| | | | - Jose M. Valderas
- Department of Family Medicine, National University Health System and Yong Loo Lin School of Medicine, Centre for Research in Health Systems Performance, Singapore, Singapore
| | - Shaantanu Donde
- European Developed Markets Medical Affairs Viatris, Hatfield, UK
| | - Seth Woodruff
- North America Medical Affairs, Viatris, New York, USA
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Breedlove SR, McCraney P, Chalmers S. A patient reminder to improve colorectal cancer screenings. J Am Assoc Nurse Pract 2023; 35:386-391. [PMID: 36857537 DOI: 10.1097/jxx.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 01/06/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND Colorectal cancer screenings detect the early, treatable, and often curable stages of the disease. Screenings are now recommended beginning at 45 years of age. Health care providers are expected to have patient's complete screenings, and reimbursement rates can be affected if results are not documented. LOCAL PROBLEM An independent review of expected organizational core measures revealed inadequate colorectal cancer screenings completed and no formal patient outreach program for patients who had not completed ordered screenings. The lack of a formal reminder to patients resulted in a cumulative completion rate of 19%. METHODS A phone call intervention was designed to notify patients of the need to complete colorectal cancer screenings. A preimplementation and postimplementation design was used to compare completed colorectal cancer screenings. INTERVENTION Patients with ordered colorectal cancer screenings received one reminder phone call to complete the screening. Preintervention and postintervention completion rates were evaluated using data from the electronic medical record. RESULTS Results revealed a colorectal cancer screening rate of 19% preimplementation and 43% postimplementation and reflected a 61.9% increase in cumulative completion rates over a 12-week intervention period. CONCLUSION The colorectal cancer patient reminder intervention showed clinical significance in improving completion rates of colorectal cancer screenings. The intervention was a successful method to improve patient compliance with the expected screening and helped improve provider core measure expectations.
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Affiliation(s)
- Shirley Rene' Breedlove
- Department of Nursing, University of North Georgia, Dahlonega, Georgia, Piedmont Healthcare, Commerce and Homer, Georgia
| | - Paige McCraney
- Department of Nursing, University of North Georgia, Dahlonega, Georgia, Rising Medical Solutions, Care Management, Chicago, Illinois
| | - Sharon Chalmers
- Department of Nursing, University of North Georgia, Dahlonega, Georgia
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Costantini L, Del Riccio M, Piccoli E, Lavecchia V, Corradini E, Bonaccorsi G, Martucci G, Lavserack G. Use of digital technologies to support cancer screening in community health promotion interventions: scoping review. Health Promot Int 2023; 38:7033125. [PMID: 36757345 DOI: 10.1093/heapro/daac189] [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: 02/10/2023] Open
Abstract
The scoping review investigated how digital technologies have helped to increase cancer screening uptake in communities including adolescents, adults and elderly people during the COVID-19 outbreak between January 2020 and June 2021. Thirteen studies were identified as being relevant, mostly addressing underserved or minority communities with the purpose to increase screening uptake, delivering health education or investigating social and cultural barriers to cancer screening. The interventions effectively used digital technologies such as mobile apps and messengers mobile apps, messaging and Web platforms. The limitations imposed by COVID-19 on social interaction can be supported with digital solutions to ensure the continuity of cancer screening programs. However, more research is needed to clarify the exact nature of effectiveness, especially in large-scale interventions.
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Affiliation(s)
- Luigi Costantini
- School of Community Medicine and Primary Care, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Del Riccio
- School of Hygiene and Preventive Medicine, Department of Health Sciences, University of Florence, Florence, Italy
| | - Elisa Piccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Vincenzo Lavecchia
- School of Community Medicine and Primary Care, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Corradini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | | | - Gianfranco Martucci
- Regional Center for Multimedial Learning in Health Promotion, Italian League Against Tumors, Reggio Emilia, Italy
| | - Glenn Lavserack
- Department of Sociology and Social Research, University of Trento, Trento, Italy
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Richardson-Parry A, Baas C, Donde S, Ferraiolo B, Karmo M, Maravic Z, Münter L, Ricci-Cabello I, Silva M, Tinianov S, Valderas JM, Woodruff S, van Vugt J. Interventions to reduce cancer screening inequities: the perspective and role of patients, advocacy groups, and empowerment organizations. Int J Equity Health 2023; 22:19. [PMID: 36707816 PMCID: PMC9880917 DOI: 10.1186/s12939-023-01841-6] [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: 10/27/2022] [Accepted: 01/21/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Health inequities lead to low rates of cancer screening in certain populations, such as low-income and ethnic minority groups. Different interventions to address this have been developed with mixed results. However, interventions are not always developed in collaboration with the people they target. The aim of our article is to present the viewpoint of patients, survivors, advocates, and lay persons on interventions to increase cancer screening from a health inequity perspective. METHODS We prepared talking points to guide discussions between coauthors, who included representatives from nine patient and survivor advocacy groups, organizations working for citizen/patient empowerment, and health equity experts. Perspectives and opinions were first collected through video conferencing meetings and a first draft of the paper was prepared. All authors, read through, revised, and discussed the contents to reach an agreement on the final perspectives to be presented. RESULTS Several themes were identified: it is important to not view screening as a discrete event; barriers underlying an individual's access and willingness to undergo screening span across a continuum; individually tailored interventions are likely to be more effective than a one-size fits-all approach because they may better accommodate the person's personal beliefs, knowledge, behaviors, and preferences; targeting people who are unknown to medical services and largely unreachable is a major challenge; including professional patient advocacy groups and relevant lay persons in the cocreation of interventions at all stages of design, implementation, and evaluation is essential along with relevant stakeholders (healthcare professionals, researchers, local government and community organizations etc). CONCLUSIONS Interventions to address cancer screening inequity currently do not adequately solve the issue, especially from the viewpoint of patients, survivors, and lay persons. Several core pathways should be focused on when designing and implementing interventions: advancing individually tailored interventions; digital tools and social media; peer-based approaches; empowerment; addressing policy and system barriers; better design of interventions; and collaboration, including the involvement of patients and patient advocacy organizations.
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Affiliation(s)
- Afua Richardson-Parry
- Viatris Global Healthcare UK, Building 4, Trident Place, Mosquito Way, Hatfield, London, AL10 9UL UK
| | - Carole Baas
- grid.470316.7Alamo Breast Cancer Foundation, 909 Midland Creek Drive, Southlake, TX 76092 USA
| | - Shaantanu Donde
- Viatris Global Healthcare, Building 4, Trident Place, Mosquito Way, Hatfield, London, AL10 9UL UK
| | - Bianca Ferraiolo
- Cittadinanzattiva - Active Citizenship Network, Rue Philippe Le Bon 46, 1000 Brussels, Belgium
| | - Maimah Karmo
- grid.430731.2Tigerlily Foundation, 42020 Village Center Plaza, #120-156, Stone Ridge, 20105 USA
| | - Zorana Maravic
- Digestive Cancers Europe, Rue de la Loi 235/27, 1040 Brussels, Belgium
| | - Lars Münter
- Danish Committee for Health Education, Classensgade 71, 5, 2100 Copenhagen, Denmark
| | - Ignacio Ricci-Cabello
- grid.507085.fBalearic Islands Health Research Institute (IdISBa) and CIBER de Epidemiología y Salud Pública (CIBERESP), C/ Escola Graduada 3, 07002 Palma, Balearic Islands Spain
| | - Mitchell Silva
- Esperity, Clos Chapelle-aux-Champs 30, 1200 Brussels, Belgium
| | - Stacey Tinianov
- Advocates for Collaborative Education, 824 Windsor Street, Santa Cruz, CA 95062 USA
| | - Jose M. Valderas
- grid.4280.e0000 0001 2180 6431National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228 Singapore
| | | | - Joris van Vugt
- Viatris, Aalsterweg 172, 5644 RH Eindhoven, The Netherlands
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Karlitz JJ, Fendrick AM, Bhatt J, Coronado GD, Jeyakumar S, Smith NJ, Plescia M, Brooks D, Limburg P, Lieberman D. Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population. Popul Health Manag 2021; 25:343-351. [PMID: 34958279 PMCID: PMC9232231 DOI: 10.1089/pop.2021.0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Outreach, including patient navigation, has been shown to increase the uptake of colorectal cancer (CRC) screening in underserved populations. This analysis evaluates the cost-effectiveness of triennial multi-target stool DNA (mt-sDNA) versus outreach, with or without a mailed annual fecal immunochemical test (FIT), in a Medicaid population. A microsimulation model estimated the incremental cost-effectiveness ratio using quality-adjusted life years (QALY), direct costs, and clinical outcomes in a cohort of Medicaid beneficiaries aged 50–64 years, over a lifetime time horizon. The base case model explored scenarios of either 100% adherence or real-world reported adherence (51.3% for mt-sDNA, 21.1% for outreach with FIT and 12.3% for outreach without FIT) with or without real-world adherence for follow-up colonoscopy (66.7% for all). Costs and outcomes were discounted at 3.0%. At 100% adherence to both screening tests and follow-up colonoscopy, mt-sDNA costed more and was less effective compared with outreach with or without FIT. When real-world adherence rates were considered for screening strategies (with 100% adherence for follow-up colonoscopy), mt-sDNA resulted in the greatest reduction in incidence and mortality from CRC (41.5% and 45.8%, respectively) compared with outreach with or without FIT; mt-sDNA also was cost-effective versus outreach with and without FIT ($32,150/QALY and $22,707/QALY, respectively). mt-sDNA remained cost-effective versus FIT, with or without outreach, under real-world adherence rates for follow-up colonoscopy. Outreach or navigation interventions, with associated real-world adherence rates to screening tests, should be considered when evaluating the cost-effectiveness of CRC screening strategies in underserved populations.
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Affiliation(s)
- Jordan J Karlitz
- Division of Gastroenterology, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado, USA
| | - A Mark Fendrick
- Division of General Medicine and Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, Michigan, USA
| | - Jay Bhatt
- Chicago School of Public Health, University of Illinois, Chicago, Illinois, USA
| | | | | | | | - Marcus Plescia
- Associate of State and Territorial Health Officials, Atlanta, Georgia, USA
| | | | - Paul Limburg
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
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Facciorusso A, Demb J, Mohan BP, Gupta S, Singh S. Addition of Financial Incentives to Mailed Outreach for Promoting Colorectal Cancer Screening: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2122581. [PMID: 34432010 PMCID: PMC8387849 DOI: 10.1001/jamanetworkopen.2021.22581] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Although screening decreases incidence of and mortality from colorectal cancer (CRC), screening rates are low. Health-promoting financial incentives may increase uptake of cancer screening. OBJECTIVE To evaluate the relative and absolute benefit associated with adding financial incentives to the uptake of CRC screening. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to July 31, 2020. Keywords and Medical Subject Headings terms were used to identify published studies on the topic. The search strategy identified 835 studies. STUDY SELECTION Randomized clinical trials (RCTs) were selected that involved adults older than 50 years who were eligible for CRC screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone, and who reported screening completion by using recommended tests at different time points. Observational or nonrandomized studies and a few RCTs were excluded. DATA EXTRACTION AND SYNTHESIS The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Data were abstracted and risk of bias was assessed by 2 independent reviewers. Random-effects meta-analysis was conducted, heterogeneity was examined through subgroup analysis and metaregression, and quality of evidence was appraised. MAIN OUTCOMES AND MEASURES The primary outcome was CRC screening completion within 12 months of receiving the intervention. RESULTS A total of 8 RCTs that were conducted in the United States and reported between January 1, 2014, and December 31, 2020, were included. The trials involved 110 644 participants, of whom 53 444 (48.3%) were randomized to the intervention group (received financial incentives) and 57 200 (51.7%) were randomized to the control group (received no financial incentives). Participants were predominantly male, with 59 113 men (53.4%). Low-quality evidence (rated down for risk of bias and heterogeneity) suggested that adding financial incentives may be associated with a small benefit of increasing CRC screening vs no financial incentives (odds ratio [OR], 1.25; 95% CI, 1.05-1.49). With mailed outreach having a 30% estimated CRC screening completion rate, adding financial incentives may increase the rate to 33.5% (95% CI, 30.8%-36.2%). On metaregression, the magnitude of benefit decreased as the proportion of participants with low income and/or from racial/ethnic minority groups increased. No significant differences were observed by type of behavioral economic intervention (fixed amount: OR, 1.26 [95% CI, 1.05-1.52] vs lottery: OR, 1.06 [95% CI, 0.80-1.40]; P = .32), amount of incentive (≤$5: OR, 1.09 [95% CI, 1.01-1.18] vs >$5: OR, 1.25 [95% CI, 1.02-1.54]; P = .22), or screening modality (stool-based test: OR, 1.14 [95% CI, 0.92-1.41] vs colonoscopy: OR, 1.63 [95% CI, 1.01-2.64]; P = .18). CONCLUSIONS AND RELEVANCE Adding financial incentives appeared to be associated with a small benefit of increasing CRC screening uptake, with marginal benefits in underserved populations with adverse social determinants of health. Alternative approaches to enhancing CRC screening uptake are warranted.
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Affiliation(s)
| | - Joshua Demb
- Moores Cancer Center, University of California at San Diego, La Jolla
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City
| | - Samir Gupta
- Moores Cancer Center, University of California at San Diego, La Jolla
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California
- Division of Gastroenterology, University of California at San Diego, La Jolla
| | - Siddharth Singh
- Division of Gastroenterology, University of California at San Diego, La Jolla
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Huf SW, Asch DA, Volpp KG, Reitz C, Mehta SJ. Text Messaging and Opt-out Mailed Outreach in Colorectal Cancer Screening: a Randomized Clinical Trial. J Gen Intern Med 2021; 36:1958-1964. [PMID: 33511567 PMCID: PMC8298623 DOI: 10.1007/s11606-020-06415-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/08/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Routine screening reduces colorectal cancer mortality, but screening rates fall below national targets and are particularly low in underserved populations. OBJECTIVE To compare the effectiveness of a single text message outreach to serial text messaging and mailed fecal home test kits on colorectal cancer screening rates. DESIGN A two-armed randomized clinical trial. PARTICIPANTS An urban community health center in Philadelphia. Adults aged 50-74 who were due for colorectal cancer screening had at least one visit to the practice in the previously year, and had a cell phone number recorded. INTERVENTIONS Participants were randomized (1:1 ratio). Individuals in the control arm were sent a simple text message reminder as per usual practice. Those in the intervention arm were sent a pre-alert text message offering the options to opt-out of receiving a mailed fecal immunochemical test (FIT) kit, followed by up to three behaviorally informed text message reminders. MAIN MEASURES The primary outcome was participation in colorectal cancer screening at 12 weeks. The secondary outcome was the FIT kit return rate at 12 weeks. KEY RESULTS Four hundred forty participants were included. The mean age was 57.4 years (SD ± 6.1). 63.4% were women, 87.7% were Black, 19.1% were uninsured, and 49.6% were Medicaid beneficiaries. At 12 weeks, there was an absolute 17.3 percentage point increase in colorectal cancer screening in the intervention arm (19.6%), compared to the control arm (2.3%, p < 0.001). There was an absolute 17.7 percentage point increase in FIT kit return in the intervention arm (19.1%) compared to the control arm (1.4%, p < 0.001). CONCLUSIONS Serial text messaging with opt-out mailed FIT kit outreach can substantially improve colorectal cancer screening rates in an underserved population. TRIAL REGISTRATION clinicaltrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03479645 ).
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Affiliation(s)
- Sarah W Huf
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. .,The Commonwealth Fund, Harkness Fellowship, New York City, NY, USA. .,Department of Surgery and Cancer, Imperial College London, London, UK. .,Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
| | - David A Asch
- 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.,Department of Medicine, 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
- 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.,Department of Medicine, 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
- 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.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- 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.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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12
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Vernon SW, Del Junco DJ, Coan SP, Murphy CC, Walters ST, Friedman RH, Bastian LA, Fisher DA, Lairson DR, Myers RE. A stepped randomized trial to promote colorectal cancer screening in a nationwide sample of U.S. Veterans. Contemp Clin Trials 2021; 105:106392. [PMID: 33823295 DOI: 10.1016/j.cct.2021.106392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Colorectal cancer (CRC) screening (CRCS) facilitates early detection and lowers CRC mortality. OBJECTIVES To increase CRCS in a randomized trial of stepped interventions. Step 1 compared three modes of delivery of theory-informed minimal cue interventions. Step 2 was designed to more intensively engage those not completing CRCS after Step 1. METHODS Recruitment packets (60,332) were mailed to a random sample of individuals with a record of U.S. military service during the Vietnam-era. Respondents not up-to-date with CRCS were randomized to one of four Step 1 groups: automated telephone, telephone, letter, or survey-only control. Those not completing screening after Step 1 were randomized to one of three Step 2 groups: automated motivational interviewing (MI) call, counselor-delivered MI call, or Step 2 control. Intention-to-treat (ITT) analyses assessed CRCS on follow-up surveys mailed after each step. RESULTS After Step 1 (n = 1784), CRCS was higher in the letter, telephone, and automated telephone groups (by 1%, 5%, 7%) than in survey-only controls (43%), although differences were not statistically significant. After Step 2 (n = 516), there were nonsignificant increases in CRCS in the two intervention groups compared with the controls. CRCS following any combination of stepped interventions overall was 7% higher (P = 0.024) than in survey-only controls (55.6%). CONCLUSIONS In a nationwide study of Veterans, CRCS after each of two stepped interventions of varying modes of delivery did not differ significantly from that in controls. However, combined overall, the sequence of stepped interventions significantly increased CRCS.
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Affiliation(s)
- Sally W Vernon
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, United States.
| | - Deborah J Del Junco
- Department of Surgery, Center for Translational Injury Research, The University of Texas McGovern Medical School, Houston, TX, United States
| | - Sharon P Coan
- Department of Health Promotion and Behavioral Sciences, UTHealth School of Public Health, Houston, TX, United States
| | - Caitlin C Murphy
- Department of Population & Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Scott T Walters
- Health Behavior and Health Systems, University of North Texas Health Science Center, Ft. Worth, TX, United States
| | - Robert H Friedman
- Medical Information Systems Unit, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
| | - Lori A Bastian
- General Internal Medicine, VA Connecticut, West Haven, CT 06516 and Department of Medicine, Yale University School of Medicine, New Haven, CT 06510, United States
| | | | - David R Lairson
- Department of Management Policy and Community Health, UTHealth School of Public Health, Houston, TX, United States
| | - Ronald E Myers
- Division of Population Science, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States
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13
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Gruner LF, Amitay EL, Heisser T, Guo F, Niedermaier T, Gies A, Hoffmeister M, Brenner H. The Effects of Different Invitation Schemes on the Use of Fecal Occult Blood Tests for Colorectal Cancer Screening: Systematic Review of Randomized Controlled Trials. Cancers (Basel) 2021; 13:cancers13071520. [PMID: 33806234 PMCID: PMC8037417 DOI: 10.3390/cancers13071520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary There is large heterogeneity in invitation schemes and participation rates in colorectal cancer screening programs offering fecal occult blood tests (nowadays mostly fecal immunochemical tests). It is unclear what the most effective invitation strategies are for fecal occult blood tests. In this systematic review, advance notification, mailed fecal occult blood test, and reminders had major, consistent, and complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening. Our findings show that the effectiveness of invitations for fecal occult blood test-based colorectal cancer screening can be substantially increased across several settings by the implementation of comprehensive invitation strategies. Abstract Personal invitations for fecal occult blood tests (nowadays mostly fecal immunochemical tests) are increasingly used to raise their usage for colorectal cancer screening. However, there is a large heterogeneity in applied invitation schemes. We aimed to review evidence for the effectiveness of various invitation schemes. The main outcome was the fecal occult blood test usage rate. A systematic search was performed in Medline and Web of Science (up to 9 July 2020). Randomized controlled trials or cluster-randomized controlled trials were eligible, which reported on general invitations for fecal occult blood test-based colorectal cancer screening sent to the general population at average colorectal cancer risk. (PROSPERO 2020 CRD42020169409). Overall, 34 studies were included. Invitations with an attached, i.e., mailed fecal occult blood test consistently increased test usage by 4–19.7% points, compared to other methods of test provision. Likewise, the introduction of advance notification consistently led to a higher usage rate, with an increase of 3.3–10.8% points. Reminders showed positive but varying effects by method. With an increase of 8.5–15.8% points, letter or email reminders were more effective than reminders by phone call or text message (0.6–6.5% points). Inconsistent results were found for financial incentives ((−8.4)–20% points) and for added or changed invitation material ((−3.5)–11.8% points). With 3.5–24.7% points, the strongest increases in use were achieved by multifaceted invitation, implementing multiple components. Any invitation scheme was superior over no invitation. Advance notification, mailing of fecal occult blood test, and reminders were consistently shown to have major, complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening settings.
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Affiliation(s)
- Laura F. Gruner
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Medical Faculty Heidelberg, Heidelberg University, 69120 Heidelberg, Germany
| | - Efrat L. Amitay
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Thomas Heisser
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Medical Faculty Heidelberg, Heidelberg University, 69120 Heidelberg, Germany
| | - Feng Guo
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Tobias Niedermaier
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Anton Gies
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
| | - Michael Hoffmeister
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Hermann Brenner
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-421300; Fax: +49-6221-4213002
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