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Berry E, Hostetter J, Bachtold J, Zamarripa S, Argenbright KE. Evaluating colonoscopy quality by performing provider type. J Natl Cancer Inst 2024; 116:1264-1269. [PMID: 38588561 PMCID: PMC11308165 DOI: 10.1093/jnci/djae080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 03/20/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Colorectal cancer is the third most diagnosed cancer and the second leading cause of cancer death in the United States. Colonoscopy is an essential tool for screening, used as a primary approach and follow-up to an abnormal stool-based colorectal cancer screening result. Colonoscopy quality is often measured with 4 key indicators: bowel preparation, cecal intubation, mean withdrawal time, and adenoma detection. Colonoscopies are most often performed by gastroenterologists (GI), however, in rural and medically underserved areas, non-GI providers often perform colonoscopies. This study aims to evaluate the quality and safety of screening colonoscopies performed by non-GI practitioner, comparing their outcomes with those of GI providers. METHODS Descriptive statistics were used to characterize the study population. Results for quality indicators were stratified by provider type and compared. Statistical significance was determined using a P value of less than .05 as the threshold for all comparisons; all P values were 2-sided. RESULTS No statistical difference was found when comparing performance by provider type. Median performance for gastroenterologists, general surgeons, and family medicine providers ranged from 98% to 100% for cecal intubation; 97.4% to 100% for bowel preparation; 57.4% to 88.9% for male adenoma detection rate; 47.7% to 62.13% for female adenoma detection rate; and 0:12:10 to 0:20:16 for mean withdrawal time. All provider types met and exceeded the goal metric for each of the quality indicators (P < .001). CONCLUSIONS As a result of this analysis, we can expect non-GI practitioner to perform colonoscopies with similar quality to GI practitioner given the performance outcomes for the key quality metrics.
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Affiliation(s)
- Emily Berry
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA
| | - Jeff Hostetter
- Department of Family and Community Medicine, University of North Dakota School of Medicine & Health Sciences, Bismark, ND, USA
| | | | - Sarah Zamarripa
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA
- University of Texas Southwestern Medical Center Harold C. Simmons Comprehensive Cancer Center, Dallas, TX, USA
- University of Texas Medical Center Peter O’Donnell Jr. School of Public Health, Dallas, TX, USA
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2
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Edwardson N, Cartwright K, Sheche J, Pankratz VS, Kosich M, Kanda D, Leekity S, Mishra SI. Colorectal Cancer Screening Among Adults in Zuni Pueblo: Factors Associated with FOBT and Colonoscopy Utilization. J Community Health 2023; 48:565-575. [PMID: 36752868 PMCID: PMC9906599 DOI: 10.1007/s10900-023-01196-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2023] [Indexed: 02/09/2023]
Abstract
Although strategies to mitigate barriers to colorectal cancer (CRC) screening have proven successful in some parts of the US, few of these strategies have been studied in rural, American Indian communities that may exhibit unique culturally driven attitudes toward and knowledge of colorectal cancer and experience increased barriers to healthcare access. In this study, we describe the results of a survey among CRC screen-eligible members of Zuni Pueblo (N = 218) on an array of questions regarding CRC screening behaviors, knowledge, satisfaction with and access to healthcare services, social support for CRC screening, perceptions toward FOBT, and preference for evidence-based interventions or strategies for improving CRC screening rates. Results from the multivariable model suggest age, having a regular healthcare provider, and harboring fewer negative perceptions toward FOBT are key drivers of ever completing CRC screening. Respondents reported strong support for Community Guide-recommended interventions and strategies for increasing CRC screening for nearly all proposed interventions. Results confirm the need for multilevel, multicomponent interventions, with a particular focus on improving Zuni Pueblo community members' access to a regular source of care, improving knowledge of CRC risk factor, and addressing negative perceptions toward CRC screening. These results provide critical, community-specific insight into better understanding the drivers of low guideline-adherent screening rates and inform local healthcare providers and community leaders of context-specific strategies to improve CRC screening in Zuni Pueblo.
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Affiliation(s)
- Nicholas Edwardson
- School of Public Administration, University of New Mexico, Albuquerque, USA.
| | - Kate Cartwright
- School of Public Administration, University of New Mexico, Albuquerque, USA
| | - Judith Sheche
- University of New Mexico Health Sciences Center, Albuquerque, USA
| | - V Shane Pankratz
- Department of Internal Medicine, Health Sciences Center, University of New Mexico, University of New Mexico Comprehensive Cancer Center, Albuquerque, USA
| | - Mikaela Kosich
- Departments of Pediatrics and Family and Community Medicine, Comprehensive Cancer Center, University of New Mexico Comprehensive Cancer Center, University of New Mexico Health Sciences Center and University of New Mexico, Albuquerque, USA
| | - Deborah Kanda
- University of New Mexico Comprehensive Cancer Center, Albuquerque, USA
| | - Samantha Leekity
- University of New Mexico Comprehensive Cancer Center, Albuquerque, USA
| | - Shiraz I Mishra
- Departments of Pediatrics and Family and Community Medicine, Comprehensive Cancer Center, University of New Mexico Comprehensive Cancer Center, University of New Mexico Health Sciences Center and University of New Mexico, Albuquerque, USA
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3
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Goyal R, Wassie MM, Winter JM, Lathlean TJ, Young GP, Symonds EL. Progress in the field of noninvasive diagnostics for colorectal cancer: a systematic review for the accuracy of blood-based biomarkers for detection of advanced pre-cancerous lesions. Expert Rev Mol Diagn 2023; 23:1233-1250. [PMID: 38044883 DOI: 10.1080/14737159.2023.2290646] [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] [Received: 05/23/2023] [Accepted: 11/22/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Early detection of pre-cancerous adenomas through screening can reduce colorectal cancer (CRC) incidence. Fecal immunochemical tests are commonly used, but have limited sensitivity for pre-cancerous lesions. Blood-based screening may improve test sensitivity. This systematic review and meta-analysis was conducted to evaluate the accuracy of blood-based biomarkers for detection of advanced pre-cancerous lesions. RESEARCH DESIGN AND METHODS We present the accuracy of blood-based biomarkers for the detection of advanced pre-cancerous lesions. EMBASE, Web of Science and PubMed databases were searched, with study populations limited to adults diagnosed with advanced pre-cancerous lesions at colonoscopy, who had a blood-based biomarker test analyzed with reports of sensitivity and specificity. RESULTS 69 studies were identified, which assessed 133 unique biomarkers sets. The best performing test was a panel of 6 miRNAs, with a sensitivity of 95% and specificity of 90% for advanced pre-cancerous lesions. Only 6 biomarkers demonstrated sensitivity ≥ 50% and specificity ≥ 90% for the detection of advanced pre-cancerous lesions. CONCLUSION Many different blood-based biomarkers have been assessed for detection of advanced pre-cancerous lesions, but few have progressed beyond the discovery stage. While some biomarkers have reported high sensitivity and specificity, larger prospective studies in unbiased intended-use screening populations are required for validation.
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Affiliation(s)
- Rishabh Goyal
- Department of Medicine, College of Medicine and Public Health, Flinders University, Bedford Park, Australia
| | - Molla M Wassie
- Cancer Research, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, Australia
| | - Jean M Winter
- Cancer Research, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, Australia
| | - Timothy Jh Lathlean
- Cancer Research, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, Australia
- ROSA Research Centre, South Australian Health and Medical Research Institue, Adelaide, Australia
| | - Graeme P Young
- Cancer Research, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, Australia
| | - Erin L Symonds
- Cancer Research, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, Australia
- Gastroenterology Department, Flinders Medical Centre, Bedford Park, Australia
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4
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Scott RE, Chang P, Kluz N, Baykal-Caglar E, Agrawal D, Pignone M. Equitable Implementation of Mailed Stool Test-Based Colorectal Cancer Screening and Patient Navigation in a Safety Net Health System. J Gen Intern Med 2023; 38:1631-1637. [PMID: 36456842 PMCID: PMC10212848 DOI: 10.1007/s11606-022-07952-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Mailed stool testing programs increase colorectal cancer (CRC) screening in diverse settings, but whether uptake differs by key demographic characteristics is not well-studied and has health equity implications. OBJECTIVE To examine the uptake and equity of the first cycle of a mailed stool test program implemented over a 3-year period in a Central Texas Federally Qualified Health Center (FQHC) system. DESIGN Retrospective cohort study within a single-arm intervention. PARTICIPANTS Patients in an FQHC aged 50-75 at average CRC risk identified through electronic health records (EHR) as not being up to date with screening. INTERVENTIONS Mailed outreach in English/Spanish included an introductory letter, free-of-charge fecal immunochemical test (FIT), and lab requisition with postage-paid mailer, simple instructions, and a medical records update postcard. Patients were asked to complete the FIT or postcard reporting recent screening. One text and one letter reminded non-responders. A bilingual patient navigator guided those with positive FIT toward colonoscopy. MAIN MEASURES Proportions of patients completing mailed FIT in response to initial cycle of outreach and proportion of those with positive FIT completing colonoscopy; comparison of whether proportions varied by demographics and insurance status obtained from the EHR. KEY RESULTS Over 3 years, 33,606 patients received an initial cycle of outreach. Overall, 19.9% (n = 6672) completed at least one mailed FIT, 5.6% (n = 374) tested positive during that initial cycle, and 72.5% (n = 271 of 374) of those with positive FIT completed a colonoscopy. Hispanic/Latinx, Spanish-speaking, and uninsured patients were more likely to complete mailed FIT compared with white, English-speaking, and commercially insured patients. Spanish-speaking patients were more likely to complete colonoscopy after positive FIT compared with English-speaking patients. CONCLUSIONS Mailed FIT outreach with patient navigation implemented in an FQHC system was effective in equitably reaching patients not up to date for CRC screening.
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Affiliation(s)
- Rebekah E Scott
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Patrick Chang
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, USA
| | - Nicole Kluz
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Eda Baykal-Caglar
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, USA
- CommUnityCare Health Centers, Austin, TX, USA
| | - Deepak Agrawal
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Michael Pignone
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, USA.
- Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, USA.
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5
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McClellan SP, Canchola AJ, Potter MB, Gomez SL, Somsouk M. Neighborhood socioeconomic status and the effectiveness of colorectal cancer screening outreach with mailed fecal immunochemical tests within a safety net healthcare system in San Francisco, CA: A subgroup analysis of a randomized controlled trial. Prev Med 2023; 167:107388. [PMID: 36528113 DOI: 10.1016/j.ypmed.2022.107388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 12/07/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
Neighborhood context shapes opportunities and barriers for residents to access healthcare and cancer screening. Neighborhood socioeconomic status (nSES) is associated with disparities in colorectal cancer (CRC) screening, but the extent to which the effectiveness of specific screening interventions vary by nSES has not been studied. The original trial conducted in San Francisco, CA from 2016 to 2017 randomly assigned patients eligible for CRC screening either to a multicomponent intervention including advanced notification, mailed fecal immunochemical test (FIT) kits and reminders or to a control group receiving usual care. For the nSES analysis addresses for 9699 patients were geocoded and stratified by city-wide nSES quintile (Q1 lowest, Q5 highest) using an established index at the census tract level. Compared to usual care, the outreach intervention improved FIT test completion at one year (58.7% vs 38.4%; OR 2.32 [2.14, 2.52]) but its effectiveness did not vary substantially by nSES quintile (adjusted OR Q1 2.64 [2.30, 3.04]; Q2 2.43 [2.04, 2.90]; Q3 2.31 [1.84, 2.89]; Q4 2.47 [1.86, 3.28]; Q5 2.64 [1.83, 3.81]; Wald test for interaction p = 0.87). The implementation of mailed FIT outreach has the potential to increase CRC screening completion without leading to disparities in screening related to nSES (ClinicalTrials.gov NCT02613260).
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Affiliation(s)
- Sean P McClellan
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Alison J Canchola
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Michael B Potter
- Department of Family and Community Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Scarlett L Gomez
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Ma Somsouk
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, USA; Division of Gastroenterology, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
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6
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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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7
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Clifton ABW, Mehta SJ, Wainwright JV, Ogden SN, Saia CA, Rendle KA. Exploring Why Financial Incentives Fail to Affect At-home Colorectal Cancer Screening: a Mixed Methods Study. J Gen Intern Med 2022; 37:2751-2758. [PMID: 35037172 PMCID: PMC9411475 DOI: 10.1007/s11606-021-07228-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/19/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Despite success in increasing other health behaviors, financial incentives have shown limited to no effect on colorectal cancer (CRC screening. Little is known about the factors shaping why and for whom incentives improve screening. OBJECTIVE To explore the perspective of participants enrolled in a larger, four-arm pragmatic trial at urban family medicine practices which assessed and failed to detect significant effects of financial incentives on at-home CRC screening completion. DESIGN We performed a mixed methods study with a subset of randomly selected patients, stratified by study arm, following completion of the pragmatic trial. PARTICIPANTS Sixty patients (46.9% enrollment rate) who were eligible and overdue for colorectal cancer screening at the time of trial enrollment and who continued to receive care at family medicine practices affiliated with an urban academic health system completed the interview and questionnaire. MAIN MEASURES Using Andersen's behavioral model, a semi-structured interview guide assessed motivators, barriers, and facilitators to screening completion and the impact of incentives on decision-making. Participants also completed a brief questionnaire evaluating demographics, screening beliefs, and clinical characteristics. KEY RESULTS The majority of patients (n = 49; 82%) reported that incentives would not change their decision to complete or not complete CRC screening, which was confirmed by qualitative data as largely due to high perceived health benefits. Those who stated financial incentives would impact their decision (n = 11) were significantly less likely to agree that CRC screening is beneficial (72.7% vs 95.9%; p < 0.05) or that CRC could be cured if detected early (63.6% vs 98.0%; p < 0.05). CONCLUSIONS Financial incentives are likely not an effective behavioral intervention to increase CRC screening for all but may be powerful for increasing short-term benefit and therefore completion for some. Targeting financial incentive interventions according to patient screening beliefs may prove a cost-effective strategy in primary care outreach programs to increase CRC screening.
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Affiliation(s)
- Alicia B W Clifton
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jocelyn V Wainwright
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA
| | - Shannon N Ogden
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Chelsea A Saia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA
| | - Katharine A Rendle
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA.
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8
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Thompson JC, Ren Y, Romero K, Lew M, Bush AT, Messina JA, Jung SH, Siamakpour-Reihani S, Miller J, Jenq RR, Peled JU, van den Brink MRM, Chao NJ, Shrime MG, Sung AD. Financial incentives to increase stool collection rates for microbiome studies in adult bone marrow transplant patients. PLoS One 2022; 17:e0267974. [PMID: 35507633 PMCID: PMC9067695 DOI: 10.1371/journal.pone.0267974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/19/2022] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION In order to study the role of the microbiome in hematopoietic stem cell transplantation (HCT), researchers collect stool samples from patients at various time points throughout HCT. However, stool collection requires active subject participation and may be limited by patient reluctance to handling stool. METHODS We performed a prospective study on the impact of financial incentives on stool collection rates. The intervention group consisted of allogeneic HCT patients from 05/2017-05/2018 who were compensated with a $10 gas gift card for each stool sample. The intervention group was compared to a historical control group of allogeneic HCT patients from 11/2016-05/2017 who provided stool samples before the incentive was implemented. To control for possible changes in collections over time, we also compared a contemporaneous control group of autologous HCT patients from 05/2017-05/2018 with a historical control group of autologous HCT patients from 11/2016-05/2017; neither autologous HCT group was compensated. The collection rate was defined as the number of samples provided divided by the number of time points we attempted to obtain stool. RESULTS There were 35 allogeneic HCT patients in the intervention group, 19 allogeneic HCT patients in the historical control group, 142 autologous HCT patients in the contemporaneous control group (that did not receive a financial incentive), and 75 autologous HCT patients in the historical control group. Allogeneic HCT patients in the intervention group had significantly higher average overall collection rates when compared to the historical control group allogeneic HCT patients (80% vs 37%, p<0.0001). There were no significant differences in overall average collection rates between the autologous HCT patients in the contemporaneous control and historical control groups (36% vs 32%, p = 0.2760). CONCLUSION Our results demonstrate that a modest incentive can significantly increase collection rates. These results may help to inform the design of future studies involving stool collection.
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Affiliation(s)
- Jillian C. Thompson
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Yi Ren
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kristi Romero
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Meagan Lew
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Amy T. Bush
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julia A. Messina
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sharareh Siamakpour-Reihani
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julie Miller
- Center for Advanced Hindsight, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Robert R. Jenq
- Departments of Genomic Medicine and Stem Cell Transplantation Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas, United States of America
| | - Jonathan U. Peled
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Marcel R. M. van den Brink
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Nelson J. Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Mark G. Shrime
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anthony D. Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
- * E-mail:
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9
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Taylor LC, Kerrison RS, Herrmann B, Stoffel ST. Effectiveness of behavioural economics-based interventions to improve colorectal cancer screening participation: A rapid systematic review of randomised controlled trials. Prev Med Rep 2022; 26:101747. [PMID: 35284211 PMCID: PMC8914541 DOI: 10.1016/j.pmedr.2022.101747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/18/2022] [Accepted: 02/26/2022] [Indexed: 12/22/2022] Open
Abstract
We searched PubMed, PsycInfo and EconLit for RCTs that evaluated BE interventions in CRC screening. We identified 1027 papers for title and abstract review. 30 studies were eligible for the review. The most frequently tested BE intervention was incentives, followed by default principle and salience. Default-based interventions were most likely to be effective. Incentives had mixed evidence. BE remains a promising field of interest in relation to influencing CRC screening behaviours.
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Affiliation(s)
- Lily C. Taylor
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Robert S. Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
- School of Health Sciences, University of Surrey, Surrey, UK
| | | | - Sandro T. Stoffel
- Research Department of Behavioural Science and Health, University College London, London, UK
- European Commission, Joint Research Centre (JRC), Ispra, Italy
- Institute for Pharmaceutical Medicine, University of Basel, Basel, Switzerland
- Corresponding author at: Research Department of Behavioural Science and Health, University College London, London, UK.
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Bartholomew T, Colleoni M, Schmidt H. Financial incentives for breast cancer screening undermine informed choice. BMJ 2022; 376:e065726. [PMID: 35012959 DOI: 10.1136/bmj-2021-065726] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
| | | | - Harald Schmidt
- Department of Medical Ethics and Health Policy, University of Pennsylvania, USA
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11
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Li N, Lu B, Luo C, Cai J, Lu M, Zhang Y, Chen H, Dai M. Incidence, mortality, survival, risk factor and screening of colorectal cancer: A comparison among China, Europe, and northern America. Cancer Lett 2021; 522:255-268. [PMID: 34563640 DOI: 10.1016/j.canlet.2021.09.034] [Citation(s) in RCA: 143] [Impact Index Per Article: 47.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/26/2021] [Accepted: 09/21/2021] [Indexed: 12/18/2022]
Abstract
Colorectal cancer (CRC) is one of the most common malignancies worldwide. China, Europe and northern America account for more than half of the new CRC cases and associated deaths globally. This review summarizes the current status and temporal trends of CRC in China, Europe, and northern America. The potential primary preventive strategies and latest advances in CRC screening techniques and programs are discussed. Recently, the incidence and mortality of CRC in some European and northern American countries have decreased; conversely, CRC incidence and mortality continue to increase in China. The overall 5-year relative survival rate for CRC is similar between these regions, but there is considerable heterogeneity among European countries. Implementing population-based CRC screening programs can effectively address the growing disease burden. The effectiveness of nationwide CRC screening programs in these regions has been limited by relatively low coverage and participation rate. The deployment of state-of-the-art techniques and precise risk-adapted screening strategies incorporating effective risk prediction models and screening techniques may boost screening effectiveness. Our review provides novel foundations for the development and optimization of CRC preventive strategies.
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Affiliation(s)
- Na Li
- Department of Cancer Prevention, Hunan Cancer Hospital, Changsha, 410006, China
| | - Bin Lu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Chenyu Luo
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Jie Cai
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Ming Lu
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Yuhan Zhang
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Hongda Chen
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
| | - Min Dai
- Office of Cancer Screening, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China.
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12
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Wilding S, O'Connor DB, Conner M. Financial incentives for bowel cancer screening: Results from a mixed methods study in the United Kingdom. Br J Health Psychol 2021; 27:741-755. [PMID: 34747113 DOI: 10.1111/bjhp.12570] [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: 07/08/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purpose of bowel cancer screening is to test for signs of cancer before symptoms develop. Financial incentives are one potential method to increase participation rates. Few studies have tested incentives in relation to bowel screening in the United Kingdom (UK). The current research explored reactions to different financial incentives to participate in population-level bowel cancer screening in a UK sample. DESIGN An online mixed methods study. Recruitment was via a study recruitment website (https://prolific.ac/). METHODS 499 participants (aged 60-74 years) completed a survey on invitations for population-level bowel cancer screening using different levels of financial incentives. RESULT Respondents were generally positive about the use of financial incentives. A £10 voucher was most frequently selected as the appropriate amount to incentivise screening participation. The current invitation method with no voucher was judged to be most acceptable but suggested to produce the lowest likelihood of others participating. Offering a £10 voucher that the NHS would not be charged for if not used was the second most acceptable invitation method. There were few differences between invitation methods on own perceived likelihood of participation in bowel screening. Offering a £10 voucher was seen as leading to the greatest likelihood of others participating in bowel screening. Findings were largely unaffected by participant demographics. CONCLUSION The use of small financial incentives to increase bowel cancer screening uptake was generally well received. Impacts of incentives on actual bowel screening rates in UK samples need to be established in the light of the current findings.
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Affiliation(s)
| | | | - Mark Conner
- School of Psychology, University of Leeds, UK
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13
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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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14
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Lieberman A, Gneezy A, Berry E, Miller S, Koch M, Argenbright KE, Gupta S. The effect of deadlines on cancer screening completion: a randomized controlled trial. Sci Rep 2021; 11:13876. [PMID: 34230556 PMCID: PMC8260724 DOI: 10.1038/s41598-021-93334-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/23/2021] [Indexed: 01/08/2023] Open
Abstract
Cancer is the second leading cause of death in the United States. Although screening facilitates prevention and early detection and is one of the most effective approaches to reducing cancer mortality, participation is low—particularly among underserved populations. In a large, preregistered field experiment (n = 7711), we tested whether deadlines—both with and without monetary incentives tied to them—increase colorectal cancer (CRC) screening. We found that all screening invitations with an imposed deadline increased completion, ranging from 2.5% to 7.3% relative to control (ps < .004). Most importantly, individuals who received a short deadline with no incentive were as likely to complete screening (9.7%) as those whose invitation included a deadline coupled with either a small (9.1%) or large declining financial incentive (12.0%; ps = .57 and .04, respectively). These results suggest that merely imposing deadlines—especially short ones—can significantly increase CRC screening completion, and may also have implications for other forms of cancer screening.
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Affiliation(s)
- Alicea Lieberman
- Anderson School of Management, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Ayelet Gneezy
- Rady School of Management, University of California, San Diego, La Jolla, CA, USA
| | - Emily Berry
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA
| | - Stacie Miller
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA
| | - Mark Koch
- Department of Family Medicine, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA.,University of Texas Southwestern Medical Center Harold C. Simmons Cancer Center, Dallas, TX, USA.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Samir Gupta
- San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Department of Internal Medicine, Division of Gastroenterology, and the Moores Cancer Center, University of California San Diego, San Diego, CA, USA
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15
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Mizota Y, Yamamoto S. Rainbow of KIBOU project: Effectiveness of invitation materials for improving cancer screening rate using social marketing and behavioral economics approaches. Soc Sci Med 2021; 279:113961. [PMID: 34000582 DOI: 10.1016/j.socscimed.2021.113961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 01/27/2023]
Abstract
Studies to date have shown that individual invitation (call) and re-invitation (recall) are effective in improving cancer screening rate. Also, by dividing subjects into segments and sending unique messages to each segment, the cancer screening rate is further improved. However, this approach is not realistic in the local governments due to limited resources, so we used social marketing and nudge techniques to develop cancer screening recommendation materials that do not need to send separately. This study therefore aimed to verify the effect of these materials in the real world. We compared the cancer screening rates in municipalities within Japan that used the invitation materials we developed (colorectal, breast, lung, cervical and stomach cancer), with those from the previous year. In addition, the usefulness of the materials in the real world was examined multilaterally using RE-AIM framework (Reach, Effectiveness, Adaption, Implementation, Maintenance). From 2015 to 2018, 4.3 million residents (Reach) from 787 municipalities (Adaption) were sent invitation materials for cancer screening. Of 167 municipalities that were compared, 141 (83%) showed an increase in screening rate when our materials were used. Overall, the screening rate improved by 2.6% or 1.44 fold (p < 0.001) (Effectiveness). However, the screening rate varied greatly depending on how screening is provided. Of the four years studied, 75 municipalities used the same materials for two or more years (Implementation). The material developed in this study improved the cancer screening rate in the real world, and it may be possible to further improve the screening rate if the number of opportunities for screening and its capacity is increased at the timing of sending materials. The materials can be found on the website (http://rokproject.jp/kenshin/) and free electronic files are available to municipalities wishing to use them.
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Affiliation(s)
- Yuri Mizota
- Center for Cancer Information and Control Services, National Cancer Center, 5-1-1, Tsukij, Chuo-ku, Tokyo, 104-0045, Japan; Health Service Division, Health Service Bureau, Ministry of Health, Labour, and Welfare, 1-2-2, Kasumigaseki, Chiyoda-ku, Tokyo, 100-8916, Japan; Shizuoka Graduate University of Public Health, 4-27-2, Kitaando, Aoiku, Shizuoka, 420-0881, Japan.
| | - Seiichiro Yamamoto
- Center for Cancer Information and Control Services, National Cancer Center, 5-1-1, Tsukij, Chuo-ku, Tokyo, 104-0045, Japan; Shizuoka Graduate University of Public Health, 4-27-2, Kitaando, Aoiku, Shizuoka, 420-0881, Japan; Centre for the Fourth Industrial Revolution Japan, World Economic Forum, ARK Mori Building, 37th Floor 1-12-32, Akasaka, Minato-ku, Tokyo, 107-6037, Japan.
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16
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Stecher C, Mukasa B, Linnemayr S. Uncovering a behavioral strategy for establishing new habits: Evidence from incentives for medication adherence in Uganda. JOURNAL OF HEALTH ECONOMICS 2021; 77:102443. [PMID: 33831632 PMCID: PMC8122069 DOI: 10.1016/j.jhealeco.2021.102443] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 01/06/2021] [Accepted: 02/24/2021] [Indexed: 05/14/2023]
Abstract
Incentives are used to improve many health-related behaviors, but evidence is mixed for their effectiveness both during the incentivization period and, even more so, on the persistence of the behavior after incentives are withdrawn. In this paper, we present the results of a randomized controlled trial that successfully uses incentives to improve medication adherence among HIV-infected patients in Uganda over 20 months, and follows the sample for another 6 months to measure the persistence of these behavioral improvements. Our study contributes to the literature on habit formation by identifying a behavioral strategy that is associated with persistently high medication adherence after controlling for observable individual-level characteristics and the receipt of incentives. We find evidence supporting a psychological theory of habits as reflexive context-behavior associations, which suggests new ways of designing incentive-based interventions for better promoting persistent, healthier behaviors.
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Affiliation(s)
- Chad Stecher
- Arizona State University, 500 N 3rd Street, Phoenix, AZ 85004, United States.
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17
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Inadomi JM, Issaka RB, Green BB. What Multilevel Interventions Do We Need to Increase the Colorectal Cancer Screening Rate to 80%? Clin Gastroenterol Hepatol 2021; 19:633-645. [PMID: 31887438 PMCID: PMC8288035 DOI: 10.1016/j.cgh.2019.12.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/05/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023]
Abstract
Screening reduces colorectal cancer mortality; however, this remains the second leading cause of cancer deaths in the United States and adherence to colorectal cancer screening falls far short of the National Colorectal Cancer Roundtable goal of 80%. Numerous studies have examined the effectiveness of interventions to increase colorectal cancer screening uptake. Outreach is the active dissemination of screening outside of the primary care setting, such as mailing fecal blood tests to individuals' homes. Navigation uses trained personnel to assist individuals through the screening process. Patient education may take the form of brochures, videos, or websites. Provider education can include feedback about screening rates of patient panels. Reminders to healthcare providers can be provided by dashboards of patients due for screening. Financial incentives provide monetary compensation to individuals when they complete screening tests, either as fixed payments or via a lottery. Individual preference for specific screening strategies has also been examined in several trials, with a choice of screening strategies yielding higher adherence than recommendation of a single strategy.
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Affiliation(s)
- John M. Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA,Divisions of Clinical Research and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA,Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Rachel B. Issaka
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA,Divisions of Clinical Research and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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18
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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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19
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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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20
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Shay LA, Kimbel KJ, Dorsey CN, Jauregui LC, Vernon SW, Kullgren JT, Green BB. Patients' Reactions to Being Offered Financial Incentives to Increase Colorectal Screening: A Qualitative Analysis. Am J Health Promot 2021; 35:421-429. [PMID: 33504161 DOI: 10.1177/0890117120987836] [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: 12/13/2022]
Abstract
PURPOSE To explore financial incentives as an intervention to improve colorectal cancer screening (CRCS) adherence among traditionally disadvantaged patients who have never been screened or are overdue for screening. APPROACH We used qualitative methods to describe patients' attitudes toward the offer of incentives, plans for future screening, and additional barriers and facilitators to CRCS. SETTING Kaiser Permanente Washington (KPWA). PARTICIPANTS KPWA patients who were due or overdue for CRCS. METHOD We conducted semi-structured qualitative interviews with 37 patients who were randomized to 1 of 2 incentives (guaranteed $10 or a lottery for $50) to complete CRCS. Interview transcripts were analyzed using a qualitative content approach. RESULTS Patients generally had positive attitudes toward both types of incentives, however, half did not recall the incentive offer at the time of the interview. Among those who recalled the offer, 95% were screened compared to only 25% among those who did not remember the offer. Most screeners stated that staying healthy was their primary motivator for screening, but many suggested that the incentive helped them prioritize and complete screening. CONCLUSIONS Incentives to complete CRCS may help motivate patients who would like to screen but have previously procrastinated. Future studies should ensure that the incentive offer is noticeable and shorten the deadline for completion of FIT screening.
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Affiliation(s)
- L Aubree Shay
- 12340University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | | | - Sally W Vernon
- 12340University of Texas Health Science Center at Houston, Houston, TX, USA
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21
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Myers L, Goodwin B, Ralph N, Castro O, March S. Implementation Strategies for Interventions Aiming to Increase Participation in Mail-Out Bowel Cancer Screening Programs: A Realist Review. Front Oncol 2020; 10:543732. [PMID: 33117681 PMCID: PMC7550731 DOI: 10.3389/fonc.2020.543732] [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] [Received: 03/18/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Bowel cancer is the third most commonly diagnosed cancer and the third most common cause of cancer-related death, with 1,849,518 new cases of bowel diagnosed and 880,792 deaths reported globally in 2018 alone. Survival can be improved through early detection via national mail-out bowel cancer screening programs; however, participation remains low in many countries. Behavior change is therefore required to increase participation. This realist review aims to (a) identify the behavior change techniques (BCTs) used in each intervention, (b) understand the mechanisms of action (MoAs) responsible for the BCT effectiveness, and (c) apply a behavior change model to inform how MoAs can be combined to increase screening participation. Methods: We systematically reviewed the literature for interventions aiming to increase participation in mail-out bowel cancer screening. We used a four-stage realist synthesis approach whereby (1) interventions were extracted from each study; (2) BCTs applied in each intervention were identified and coded using the BCT Taxonomy-v1; (3) the Theory and Techniques Tool was used to link BCTs to their MoA; and (4) BCTs and MoAs were categorized according to their effectiveness and what Health Action Process Approach (HAPA) stage of change they would affect. Results: We identified 68 intervention trials using 26 unique BCTs and 13 MoAs to increase participation. Sixteen BCTs and 10 MoAs were identified within the interventions that successfully increased participation rates. Interventions targeting both stages of the HAPA model had a higher success rate (80%) than those targeting one stage of change (51%). When targeting only one stage, interventions targeting the volitional stage had a higher success rate (71%) than interventions targeting only the motivational stage of change (26%). Conclusion: Importantly, this review identified a suite of BCTs and MoAs effective for increasing participation in mail-out bowel cancer screening programs. With increased participation in bowel cancer screening leading to improved survival, our findings are key to informing the improvement of policy and interventions that aim to increase screening using specific strategies at key stages of health decision-making.
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Affiliation(s)
- Larry Myers
- Centre for Health, Informatics, and Economic Research, University of Southern Queensland, Springfield Central, QLD, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Belinda Goodwin
- School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia.,Cancer Research Centre, Cancer Council Queensland, Brisbane, QLD, Australia
| | - Nicholas Ralph
- Cancer Research Centre, Cancer Council Queensland, Brisbane, QLD, Australia.,School of Nursing & Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia.,Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Oscar Castro
- Physically Active Lifestyles Research Group, Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Sonja March
- Centre for Health, Informatics, and Economic Research, University of Southern Queensland, Springfield Central, QLD, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
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22
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Kew GS, Koh CJ. Strategies to Improve Persistent Adherence in Colorectal Cancer Screening. Gut Liver 2020; 14:546-552. [PMID: 31822055 PMCID: PMC7492491 DOI: 10.5009/gnl19306] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/22/2019] [Accepted: 10/31/2019] [Indexed: 01/08/2023] Open
Abstract
Colorectal cancer is a major cause of morbidity and mortality, and screening has been shown to reduce morbidity and mortality. This review highlights pertinent aspects of adherence to screening including the various options available and key concepts to consider in any systematic program. Persistent adherence, which is key to an efficacious screening program, is the compliance with repeated screening tests over a period of time. A “chain of survival” mindset emphasizes the stepwise, sequential and persistent approach to screening and is a helpful concept to drive the message of persistent adherence. A framework for the patient and physician interactions that support screening intervention is examined, and various factors that impact both patient and physician adoption and screening modality recommendations are reviewed. While systems-based approaches to screening have great utility in automation and monitoring in a surveillance program, some emerging data suggests that the human touch is still an essential driver for active participation in these programs. Finally, the proportion of time concept is discussed as a useful index for monitoring persistent adherence in both individuals and populations.
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Affiliation(s)
- Guan Sen Kew
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Calvin Jianyi Koh
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Mehta SJ, Oyalowo A, Reitz C, Dean O, McAuliffe T, Asch DA, Doubeni CA. Text messaging and lottery incentive to improve colorectal cancer screening outreach at a community health center: A randomized controlled trial. Prev Med Rep 2020; 19:101114. [PMID: 32477853 PMCID: PMC7251946 DOI: 10.1016/j.pmedr.2020.101114] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 04/28/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
Efforts to boost colorectal cancer (CRC) screening rates in underserved populations have been limited by effectiveness and scalability. We evaluate the impact of adding a lottery-based financial incentive to a text messaging program that asks patients to opt-in to receive mailed fecal immunochemical testing (FIT). This is a two-arm pragmatic randomized controlled trial at a community health center in Southwest Philadelphia from April to July 2017. We included CRC screening-eligible patients between ages 50-74 years who had a mobile phone, active health insurance, and at least one visit to the clinic in the past 12 months. Patients received a text message about CRC screening with the opportunity to opt-in to receive mailed FIT. They were randomized 1:1 to the following: (1) text messaging outreach alone (text), or (2) text messaging with lottery for a 1-in-5 chance of winning $100 after FIT completion (text + lottery). The primary outcome was the percentage of patients completing the mailed FIT within 3 months of initial outreach. 281 patients were included in the intent-to-treat analysis. The FIT completion rate was 12.1% (95% CI, 6.7%-17.5%) in the text message arm and 12.1% (95% CI, 6.7%-17.5%) in the lottery arm, with no statistical difference between arms. The majority of post-intervention interview respondents found text messaging to be acceptable and convenient. Opt-in text messaging is a feasible option to promote the uptake of mailed FIT screening, but the addition of a lottery-based incentive did not improve completion rates. Trial Registration: clinicaltrials.gov (NCT03072095).
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
| | - Akinbowale Oyalowo
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Owen Dean
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, United States
| | - Chyke A. Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, United States
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24
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Fujita M, Fujisawa T, Hata A. Additional outreach effort of providing an opportunity to obtain a kit for fecal immunochemical test during the general health check-up to improve colorectal cancer screening rate in Japan: A longitudinal study. PLoS One 2020; 15:e0238474. [PMID: 32866208 PMCID: PMC7458287 DOI: 10.1371/journal.pone.0238474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/16/2020] [Indexed: 11/22/2022] Open
Abstract
Objectives A sufficient screening rate is indispensable to optimize the positive impact of colorectal cancer (CRC) screening. This study aimed to evaluate the effect of an additional outreach of providing an opportunity to obtain a kit for fecal immunochemical test (FIT) during the general health check-up to increase CRC screening rate. Methods This was a longitudinal study using pre-existing data in Kujukuri Town, Japan. The town provided CRC screening in the fiscal year (FY) 2017 using an existing procedure for all beneficiaries of the National Health Insurance, whereas in FY 2018, an additional outreach effort was made to only those with an even number of age (exposed group), who were offered an opportunity to obtain a kit for FIT at the time of general health check-ups but not to those with an odd number of age (control group). To estimate the effectiveness, generalized estimating equation (GEE) with individuals as clusters was performed. Results In total, 3,530 individuals were included (1,708 in the control group and 1,822 in the exposed group). GEE showed significant interaction between the groups (control and exposed) and FYs (2017 and 2018) (p<0.001), indicating that the change in CRC screening rate from 2017 to 2018 was significantly different between the two groups. Although an achieved actual rate of 17.1% in the exposed group in FY 2018 was low, the additional outreach increased the rate by 5.8 percentage point (95% confidence interval, 3.5–8.1) compared with an existing rate. Conclusions Additional outreach of providing an opportunity to obtain a kit for FIT at the time of the general health check-up improved the CRC screening rate. However, screening rate achieved by this strategy remained low, indicating further efforts is required.
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Affiliation(s)
- Misuzu Fujita
- Department of Health Research, Chiba Foundation for Heath Promotion and Disease Prevention, Chiba City, Chiba, Japan
- * E-mail:
| | - Takehiko Fujisawa
- Department of Health Research, Chiba Foundation for Heath Promotion and Disease Prevention, Chiba City, Chiba, Japan
| | - Akira Hata
- Department of Health Research, Chiba Foundation for Heath Promotion and Disease Prevention, Chiba City, Chiba, Japan
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25
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Jia P, Furuya-Kanamori L, Qin ZS, Jia PY, Xu C. Association between response rates and monetary incentives in sample study: a systematic review and meta-analysis. Postgrad Med J 2020; 97:501-510. [PMID: 32848082 DOI: 10.1136/postgradmedj-2020-137868] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/12/2020] [Accepted: 06/18/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate the effect of monetary incentive and the dose-response relationship of participants' response rates in surveys. METHODS Three databases were searched for randomised controlled trials (RCTs) that investigated the effect of monetary incentives on participants' first and final response rates. First response is defined as the responses after the participant was initially contacted and final response is defined as the responses after several reminders were sent. The potential dose-response relationship of the amount of monetary incentive on the relative response rate (RRR) was established by fitting a restricted cubic spline function based on the robust-error meta-regression model. RESULTS 105 RCTs were identified. The first RRR increased by 49% (RRR=1.49; 95% CI 1.29 to 1.72) when monetary incentives were provided. Dose-response analysis revealed that an amount between US$6.25 and US$8 had the maximum effect on increasing the first response rate. On average, the final RRR increased almost by 20% (RRR=1.18; 95% CI 1.11 to 1.25) with monetary incentive compared to no-monetary incentive. An amount between US$10 and US$15 had the maximum effect on the final response rate, with an increase in the final RRR of 34% (RRR=1.34; 95% CI 1.19 to 1.51). There was a significant increase in the response rate when two or more reminders were sent. CONCLUSION Monetary incentives and reminders improve the response rates. Future studies need to consider providing monetary incentives and sending at least two reminders to increase the response rate and reduce the chances of non-response bias.
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Affiliation(s)
- Pengli Jia
- School of Management, Shanxi Medical University, Taiyuan, China
| | - Luis Furuya-Kanamori
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Zong-Shi Qin
- School of Chinese Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Peng-Yan Jia
- State Key Laboratory of Grassland Agro-ecosystems, College of Pastoral Agricultural Science and Technology, Lanzhou University, Lanzhou, China
| | - Chang Xu
- Department of Population Medicine, College of Medicine, Qatar University, Doha, Qatar
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26
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Kutyla MJ, Gray MA, von Hippel C, Hourigan LF, Kendall BJ, Whaley AJ, O'Connor S, Holtmann GJ. Improving the Quality of Bowel Preparation: Rewarding Patients for Success or Intensive Patient Education? Dig Dis 2020; 39:113-118. [PMID: 32720916 DOI: 10.1159/000510461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 07/22/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND OBJECTIVES The quality of the bowel preparation is a critical parameter for the outcome of colonoscopies. It is well established that the bowel preparation modality (e.g., split or larger volume preparation) significantly improves the quality of the bowel preparation. Patient compliance is another important factor impacting on the quality of bowel preparations that receives relatively little research attention. We aimed to explore if intensified education or a lottery ticket as reward for good bowel preparation could improve outcomes. METHODS After informed consent, all patients received a standardized printed information booklet. In a randomized fashion, patients were offered (a) a lottery scratchy ticket with an opportunity to win $25,000 as "reward" for good bowel preparation, (b) an education session delivered over the phone by a trained nurse, or (c) no additional measure. RESULTS Overall, the quality of the bowel preparation was rated good or very good in 69.1% (95% CI 61.7-75.7%) of patients. Reward intervention did not influence the quality of bowel preparation (OR 0.42, 95% CI 0.09-1.91, p = 0.260); however, bowel preparation quality decreased in patients randomized to receive the additional education (OR 0.28, 95% CI 0.08-0.96, p = 0.042). Neither intervention significantly impacted on polyp detection rates. CONCLUSIONS Contrasting general beliefs, additional interventions (e.g., incentives or phone consultation) did not improve the quality of the bowel preparation. The unexpected result shows that utilizing extra resources must be balanced against real-world outcomes and may not always provide the expected result.
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Affiliation(s)
- Marguerite J Kutyla
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,School of Pharmacy, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Marcus A Gray
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,School of Psychology, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia.,Translational Research Institute, Brisbane, Queensland, Australia
| | - Courtney von Hippel
- School of Psychology, Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Bradley J Kendall
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Amanda J Whaley
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Sam O'Connor
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Gerald J Holtmann
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia, .,Translational Research Institute, Brisbane, Queensland, Australia, .,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia, .,Faculty of Health and Behavioural Sciences, University of Queensland, Brisbane, Queensland, Australia,
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27
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Lee J, Kim Y, Suh M, Hong S, Choi KS. Examining the effect of underlying individual preferences for present over future on lung cancer screening participation: a cross-sectional analysis of a Korean National Cancer Screening Survey. BMJ Open 2020; 10:e035495. [PMID: 32709642 PMCID: PMC7380730 DOI: 10.1136/bmjopen-2019-035495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES This study aimed to examine the effect of underlying individual preferences for the present over that for the future on lung cancer screening participation. SETTING We analysed the data from the Korean National Cancer Screening Survey in 2018. PARTICIPANTS 4500 adults aged 20-74 years old participated in the study. DESIGN In this cross-sectional survey, multivariate logistic regression analysis was carried out to examine the association between subjects' intention to participate in lung cancer screening and individual preferences. The underlying individual preferences were measured on the basis of the self-reported general willingness to spend money now in order to save money in the future and general preferences with regard to financial planning. PRIMARY OUTCOME MEASURE Intention to participate in lung cancer screening. RESULTS Individuals eligible for lung cancer screening who place less value on their future were around four times less likely to report an intention to participate in lung cancer screening than were those who valued their future (OR 3.86, 95% CI 1.89 to 7.90). A present-biassed individual (one with a tendency for immediate gratification) was also about four times less likely to report an intention to participate in screening than an individual with no present bias (OR 0.26, 95% CI 0.12 to 0.57). CONCLUSIONS Underlying individual preferences regarding the present and future significantly affect individuals' intention to participate in lung cancer screening. Hence, provision of incentives may be necessary to encourage the targeted heavy smokers who may have a strong preferences for the present over future.
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Affiliation(s)
- Jaeho Lee
- National Cancer Control Institute, National Cancer Center, Goyang, Korea (the Republic of)
| | - Yeol Kim
- National Cancer Control Institute, National Cancer Center, Goyang, Korea (the Republic of)
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea (the Republic of)
| | - Mina Suh
- National Cancer Control Institute, National Cancer Center, Goyang, Korea (the Republic of)
| | - Seri Hong
- National Cancer Control Institute, National Cancer Center, Goyang, Korea (the Republic of)
| | - Kui Son Choi
- National Cancer Control Institute, National Cancer Center, Goyang, Korea (the Republic of)
- Department of Cancer Control and Population Health, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea (the Republic of)
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28
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Gupta S, Coronado GD, Argenbright K, Brenner AT, Castañeda SF, Dominitz JA, Green B, Issaka RB, Levin TR, Reuland DS, Richardson LC, Robertson DJ, Singal AG, Pignone M. Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit. CA Cancer J Clin 2020; 70:283-298. [PMID: 32583884 PMCID: PMC7523556 DOI: 10.3322/caac.21615] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023] Open
Abstract
Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.
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Affiliation(s)
- Samir Gupta
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California
- Department of Medicine, University of California at San Diego, La Jolla, California
- Moores Cancer Center, University of California at San Diego, La Jolla, California
| | | | - Keith Argenbright
- University of Texas Southwestern Medical Center, Harold C. Simmons Cancer Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas
| | - Alison T Brenner
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sheila F Castañeda
- Department of Psychology, School of Public Health, San Diego State University, San Diego, California
| | - Jason A Dominitz
- Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Beverly Green
- Kaiser Permanente Washington, Seattle, Washington
- Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
- Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Rachel B Issaka
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Theodore R Levin
- Gastroenterology Department, Kaiser Permanente Medical Center, Walnut Creek, California
- Division of Research, Kaiser Permanente, Oakland, California
| | - Daniel S Reuland
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Douglas J Robertson
- Department of Medicine, Veterans Affairs Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Pignone
- Department of Internal Medicine and LiveStrong Cancer Institutes, Dell Medical School, University of Texas Austin, Austin, Texas
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29
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Butterly LF. Proven Strategies for Increasing Adherence to Colorectal Cancer Screening. Gastrointest Endosc Clin N Am 2020; 30:377-392. [PMID: 32439077 DOI: 10.1016/j.giec.2020.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Although colorectal cancer (CRC) can be prevented or detected early through screening and surveillance, barriers that lower adherence to screening significantly limit its effectiveness. Therefore, implementation of interventions that address and overcome adherence barriers is critical to efforts to decrease morbidity and mortality from CRC. This article reviews the current available evidence about interventions to increase adherence to CRC screening.
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Affiliation(s)
- Lynn F Butterly
- Geisel School of Medicine at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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30
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Berry E, Miller S, Koch M, Balasubramanian B, Argenbright K, Gupta S. Lower Abnormal Fecal Immunochemical Test Cut-Off Values Improve Detection of Colorectal Cancer in System-Level Screens. Clin Gastroenterol Hepatol 2020; 18:647-653. [PMID: 31085338 PMCID: PMC7731666 DOI: 10.1016/j.cgh.2019.04.077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Noninvasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cut-off concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program. METHODS We performed a prospective study of 17,017 uninsured patients, age 50 to 64 years, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cut-off value for an abnormal FIT result from 20 or more to 10 or more μg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions of patients with abnormal FIT results and neoplasia yield for standard vs lower cut-off values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cut-off value on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared with the standard, higher, hemoglobin concentration cut-off value. RESULTS The proportions of patients with abnormal FIT results were 12.3% at the 10 or more μg hemoglobin/g feces and 6.6% at the standard 20 or more μg hemoglobin/g feces cut-off value (P = .0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P = .12) and 0.9% vs 1.2% for CRC (P = .718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P = .053), and 1.7% vs 2.4% for CRC (P = .659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations of 20 or more μg/g feces. In the group with 10 to 19 μg hemoglobin/g feces, there were 3 patients with CRC (3 of 11; 27.3%) and 36 with advanced adenoma (36 of 110; 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison < .001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cut-off value (44.4%) than the standard cut-off value (39.1%) (P = .1103). CONCLUSIONS In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cut-off value (to ≥10 μg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cut-off value to optimize CRC detection and prevention. (ClinicalTrials.gov no: NCT01946282.).
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Affiliation(s)
- Emily Berry
- Moncrief Cancer Institute, Fort Worth, Texas.
| | | | - Mark Koch
- Department of Family Medicine, John Peter Smith Health Network, Fort Worth, Texas
| | - Bijal Balasubramanian
- Department of Epidemiology, Genetics, and Environmental Science, University of Texas School of Public Health Dallas Regional Campus, Dallas, Texas
| | - Keith Argenbright
- Moncrief Cancer Institute, Fort Worth, Texas; Harold C. Simmons Cancer Center, Dallas, Texas; Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samir Gupta
- San Diego Veterans Affairs Healthcare System, San Diego, California; Division of Gastroenterology, Department of Internal Medicine, Moores Cancer Center, University of California San Diego, San Diego, California.
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31
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Goodwin BC, Ireland MJ, March S, Myers L, Crawford-Williams F, Chambers SK, Aitken JF, Dunn J. Strategies for increasing participation in mail-out colorectal cancer screening programs: a systematic review and meta-analysis. Syst Rev 2019; 8:257. [PMID: 31685010 PMCID: PMC6827213 DOI: 10.1186/s13643-019-1170-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 09/27/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Population mail-out bowel screening programs are a convenient, cost-effective and sensitive method of detecting colorectal cancer (CRC). Despite the increased survival rates associated with early detection of CRC, in many countries, 50% or more of eligible individuals do not participate in such programs. The current study systematically reviews interventions applied to increase fecal occult blood test (FOBT) kit return, specifically in population mail-out programs. METHODS Five electronic databases (PubMed, PsycINFO, Scopus, CINAHL, and ProQuest Dissertations and Theses) were searched for articles published before the 10th of March 2018. Studies were included if they reported the results of an intervention designed to increase the return rate of FOBT kits that had been mailed to individuals' homes. PRISMA systematic review reporting methods were applied and each study was assessed using Cochrane's Risk of Bias tool. Pooled effect sizes were calculated for each intervention type and the risk of bias was tested as a moderator for sensitivity analysis. RESULTS The review identified 53 interventions from 30 published studies from which nine distinct intervention strategy types emerged. Sensitivity analysis showed that the risk of bias marginally moderated the overall effect size. Pooled risk ratios and confidence intervals for each intervention type revealed that telephone contact RR = 1.23, 95% CI (1.08-1.40), GP endorsement RR = 1.19, 95% CI (1.10-1.29), simplified test procedures RR = 1.17, 95% CI (1.09-1.25), and advance notifications RR = 1.09, 95% CI (1.07-1.11) were effective intervention strategies with small to moderate effect sizes. Studies with a high risk of bias were removed and pooled effects remained relatively unchanged. CONCLUSIONS Interventions that combine program-level changes incorporating the issue of advance notification and alternative screening tools with the involvement of primary health professionals through endorsement letters and telephone contact should lead to increases in kit return in mail-out CRC screening programs. SYSTEMATIC REVIEW REGISTRATION This review is registered with PROSPERO; registration number CRD42017064652.
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Affiliation(s)
- Belinda C Goodwin
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, 4300, Australia.
| | - Michael J Ireland
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, 4300, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Sonja March
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, 4300, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Larry Myers
- School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Fiona Crawford-Williams
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, 4300, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Suzanne K Chambers
- Cancer Research Centre, Cancer Council Queensland, Fortitude Valley, QLD, Australia.,Faculty of Health, University of Technology Sydney, Sydney, Australia.,Prostate Cancer Foundation of Australia, St Leonards, NSW, Australia.,Menzies Health Institute, Griffith University, Southport, QLD, Australia
| | - Joanne F Aitken
- Cancer Research Centre, Cancer Council Queensland, Fortitude Valley, QLD, Australia.,School of Public Health and Social Work, Queensland University of Technology, Brisbane, QLD, Australia.,Menzies Health Institute Queensland, Griffith University, Brisbane, QLD, Australia
| | - Jeff Dunn
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, 4300, Australia.,Cancer Research Centre, Cancer Council Queensland, Fortitude Valley, QLD, Australia.,School of Social Science, University of Queensland, Brisbane, QLD, Australia.,School of Medicine, Griffith University, Brisbane, QLD, Australia
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Ramai D, Shahnazarian V, Etienne D, Ayide G, Reddy M. Assessing urban minority attitudes for colorectal cancer screening using financial incentives. MINERVA GASTROENTERO 2019; 65:241-243. [PMID: 31617697 DOI: 10.23736/s1121-421x.19.02583-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA -
| | - Vahe Shahnazarian
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA
| | - Denzil Etienne
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA
| | - Gloria Ayide
- Cancer Services Program of Brooklyn, New York, NY, USA
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA
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Jetelina KK, Yudkin JS, Miller S, Berry E, Lieberman A, Gupta S, Balasubramanian BA. Patient-Reported Barriers to Completing a Diagnostic Colonoscopy Following Abnormal Fecal Immunochemical Test Among Uninsured Patients. J Gen Intern Med 2019; 34:1730-1736. [PMID: 31228053 PMCID: PMC6712145 DOI: 10.1007/s11606-019-05117-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 01/02/2019] [Accepted: 03/13/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND For colorectal cancer (CRC) screening to improve survival, patients with an abnormal fecal immunochemical test (FIT) must follow-up with a diagnostic colonoscopy. Adherence to follow-up is low and patient-level barriers for suboptimal adherence have yet to be explored. OBJECTIVE To characterize barriers for non-completion of diagnostic colonoscopy after an abnormal FIT reported by under- and uninsured patients receiving care in a safety-net health system. DESIGN A longitudinal, cohort study of CRC screening outreach to 8565 patients using mailed FIT kits. Patients with abnormal FIT results received telephonic navigation to arrange for a no-cost diagnostic colonoscopy. PATIENTS Adults aged 50-64 years receiving care at a North Texas safety-net health system. APPROACH Descriptive analyses characterized the patient sample and reasons for lack of follow-up after abnormal FIT over the 3-year outreach program. Thematic qualitative analyses characterized reasons for lack of follow-up with a colonoscopy after the abnormal FIT. KEY RESULTS Of 689 patients with an abnormal FIT, 45% (n = 314) did not complete a follow-up colonoscopy. Among the 314 non-completers, 184 patients reported reasons for not completing a follow-up colonoscopy included health insurance-related challenges (38%), comorbid conditions (37%), social barriers such as transportation difficulties and lack of social support (29%), concerns about FIT/colonoscopy process (12%), competing life priorities (12%), adverse effects of bowel preparation (3%), and poor health literacy (3%). Among the 314 non-completers, 131 patients did not report a barrier, as 51% reported that that had completed a previous colonoscopy in the past 10 years, 10% refused with no reason, and 10% were never reached by phone. CONCLUSIONS Future studies aimed at improving FIT screening and subsequent colonoscopy rates need to address the unique needs of patients for effective and sustainable screening programs. TRIAL REGISTRATION NCT01946282.
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Affiliation(s)
- Katelyn K Jetelina
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, School of Public Health, 6011 Harry Hines Blvd. V8.112, Dallas, TX, 75390, USA.
| | - Joshua S Yudkin
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, School of Public Health, 6011 Harry Hines Blvd. V8.112, Dallas, TX, 75390, USA
| | - Stacie Miller
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Moncrief Cancer Center, Fort Worth, TX, USA
| | - Emily Berry
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Moncrief Cancer Center, Fort Worth, TX, USA
| | - Alicea Lieberman
- Rady School of Management, University of California, San Diego, San Diego, CA, USA
| | - Samir Gupta
- Department of Internal Medicine, University of California, San Diego, San Diego, CA, USA
| | - Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, University of Texas Health Science Center, School of Public Health, 6011 Harry Hines Blvd. V8.112, Dallas, TX, 75390, USA.,Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, USA.,Moncrief Cancer Center, Fort Worth, TX, USA
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Lieberman A, Gneezy A, Berry E, Miller S, Koch M, Ahn C, Balasubramanian BA, Argenbright KE, Gupta S. Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial. Cancer Epidemiol Biomarkers Prev 2019; 28:1902-1908. [PMID: 31387970 DOI: 10.1158/1055-9965.epi-19-0039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/22/2019] [Accepted: 07/31/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Financial incentives may improve health behaviors. We tested the impact of offering financial incentives for mailed fecal immunochemical test (FIT) completion annually for 3 years. METHODS Patients, ages 50 to 64 years, not up-to-date with screening were randomized to receive either a mailed FIT outreach (n = 6,565), outreach plus $5 (n = 1,000), or $10 (n = 1,000) incentive for completion. Patients who completed the test were reinvited using the same incentive the following year, for 3 years. In year 4, patients who returned the kit in all preceding 3 years were reinvited without incentives. Primary outcome was FIT completion among patients offered any incentive versus outreach alone each year. Secondary outcomes were FIT completion for groups offered $5 versus outreach alone, $10 versus outreach alone, and $5 versus $10. RESULTS Year 1 FIT completion was 36.9% with incentives versus 36.2% outreach alone (P = 0.59) and was not statistically different for $10 (34.6%; P = 0.31) or $5 (39.2%; P = 0.070) versus outreach alone. Year 2 completion was 61.6% with incentives versus 60.8% outreach alone (P = 0.75) and not statistically different for $10 or $5 versus outreach alone. Year 3 completion was 79.4% with incentives versus 74.8% outreach alone (P = 0.080), and was higher for $10 (82.4%) versus outreach alone (P = 0.033), but not for $5 versus outreach alone. Completion was similar across conditions in year 4 (no incentives). CONCLUSIONS Offering small incentives did not increase FIT completion relative to standard outreach. IMPACT This was the first longitudinal study testing the impact of repeated financial incentives, and their withdrawal, on FIT completion.
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Affiliation(s)
- Alicea Lieberman
- Rady School of Management, University of California San Diego, La Jolla, California
| | - Ayelet Gneezy
- Rady School of Management, University of California San Diego, La Jolla, California
| | - Emily Berry
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas
| | - Stacie Miller
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas
| | - Mark Koch
- Department of Family Medicine, John Peter Smith Health Network, Fort Worth, Texas
| | - Chul Ahn
- University of Texas Southwestern Medical Center, Harold C. Simmons Cancer Center, Dallas, Texas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bijal A Balasubramanian
- Department of Epidemiology, Genetics, & Environmental Science, UT Health School of Public Health, Dallas, Texas
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas.,University of Texas Southwestern Medical Center, Harold C. Simmons Cancer Center, Dallas, Texas.,Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samir Gupta
- San Diego Veterans Affairs Healthcare System, San Diego, California. .,Department of Internal Medicine, Division of Gastroenterology, and the Moores Cancer Center, University of California San Diego, San Diego, California
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Green BB, Anderson ML, Cook AJ, Chubak J, Fuller S, Kimbel KJ, Kullgren JT, Meenan RT, Vernon SW. Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e196570. [PMID: 31276178 PMCID: PMC6789432 DOI: 10.1001/jamanetworkopen.2019.6570] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Importance Colorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups. Objective To examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates. Design, Setting, and Participants This parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled. Interventions Interventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion). Main Outcomes and Measures The primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures. Results A total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%-15.1%) in the mail and monetary group and 7.1% (95% CI, -0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%-64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, -0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03). Conclusions and Relevance Financial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups. Trial Registration ClinicalTrials.gov identifier: NCT00697047.
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Affiliation(s)
- Beverly B Green
- Kaiser Permanente Washington, Seattle
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | | | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Kilian J Kimbel
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jeffrey T Kullgren
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Richard T Meenan
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Sally W Vernon
- Department of Health Promotion and Behavior Sciences, University of Texas School of Public Health, Houston
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Myers L, Goodwin B, March S, Dunn J. Ways to use interventions to increase participation in mail-out bowel cancer screening: a systematic review and meta-analysis. Transl Behav Med 2019; 10:384-393. [DOI: 10.1093/tbm/ibz081] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Abstract
The impact of colorectal cancer can be reduced through nationwide fecal occult blood test (FOBT) screening. Unfortunately, participation in screening programs are low with interventions only increasing participation modestly.
This meta-analysis explores if intervention effectiveness can be increased by targeting specific subpopulations with specific interventions or by combining interventions. Six databases were searched for studies aiming to increase participation in mail-out FOBT screening. To investigate if interventions are more effective for certain subpopulations, the difference in (log) Risk Ratios (RRs) between alternate subpopulations (male vs. female; low vs. high Socioeconomic Status (SES); <65 vs. ≥65 years) was assessed. To investigate if interventions should be combined, uptake rates for single interventions were compared to uptake rates for combined interventions. Cochrane Collaboration tools were used to assess the risk of bias.
Searches found 3,436 articles, with 32 meeting the inclusion criteria. These contained 30 trials that reported uptake rates within subpopulations and 17 trials that combined interventions. Most differences in intervention effects between subpopulations were nonsignificant. Combining interventions led to greater participation, RR = 1.06, confidence interval [1.03; 1.10]. As interventions rarely affect subpopulations differently, targeting them at specific subpopulations may be an ineffective strategy. While individual interventions show modest effects, these results indicate that future programs might overcome this by combining interventions together. Care is needed when selecting interventions to combine as adding some interventions (e.g., additional print materials) can reduce the effectiveness of a combined strategy. Future research should examine methods for effectively combining interventions in nationwide programs to maximize participation.
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Affiliation(s)
- Larry Myers
- School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Belinda Goodwin
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Sonja March
- School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Jeff Dunn
- Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, Australia
- Cancer Research Centre, Cancer Council Queensland, Fortitude Valley, QLD, Australia
- School of Social Science, University of Queensland, Brisbane, QLD, Australia
- School of Medicine, Griffith University, Brisbane, QLD, Australia
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37
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Nisa CF, Bélanger JJ, Schumpe BM. Parts greater than their sum: randomized controlled trial testing partitioned incentives to increase cancer screening. Ann N Y Acad Sci 2019; 1449:46-55. [PMID: 31111509 DOI: 10.1111/nyas.14115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/31/2019] [Accepted: 04/12/2019] [Indexed: 01/03/2023]
Abstract
Promoting healthy behavior is a challenge for public health officials, especially in the context of asking patients to participate in preventive cancer screenings. Small financial incentives are sometimes used, but there is a little scientific basis to support a compelling description of the best-practice implementation of such incentives. We present a simple behavioral strategy based on mental accounting from prospect theory that maximizes the impact of incentives with no additional cost. We show how the partition of one incentive into two smaller incentives of equivalent total amount produces substantial behavioral changes, demonstrated in the context of colorectal cancer screening. In a randomized controlled trial, eligible patients aged 50-74 (n = 1652 patients) were allocated to receive either one €10 incentive (upon completion of screening) or two €5 incentives (at the beginning and at the end of screening). We show that cancer screening rates were dramatically increased by partitioning the financial incentive (61.1%), compared with a single installment at the end (41.4%). These results support the hedonic editing hypothesis from prospect theory, and underline the importance of implementing theoretically grounded healthcare interventions. Our results suggest that, when patient incentives are feasible, healthcare procedures should be framed as multistage events with smaller incentives offered at multiple points in time.
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Affiliation(s)
- Claudia F Nisa
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jocelyn J Bélanger
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Birga M Schumpe
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
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Sarma EA, Silver MI, Kobrin SC, Marcus PM, Ferrer RA. Cancer screening: health impact, prevalence, correlates, and interventions. Psychol Health 2019; 34:1036-1072. [DOI: 10.1080/08870446.2019.1584673] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Elizabeth A. Sarma
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Michelle I. Silver
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Sarah C. Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Pamela M. Marcus
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Rebecca A. Ferrer
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
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39
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Mehta SJ, Pepe RS, Gabler NB, Kanneganti M, Reitz C, Saia C, Teel J, Asch DA, Volpp KG, Doubeni CA. Effect of Financial Incentives on Patient Use of Mailed Colorectal Cancer Screening Tests: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e191156. [PMID: 30901053 PMCID: PMC6583304 DOI: 10.1001/jamanetworkopen.2019.1156] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 02/03/2019] [Indexed: 12/26/2022] Open
Abstract
Importance Mailing fecal immunochemical test (FIT) kits to patients' homes has been shown to boost colorectal cancer screening rates, but response rates remain limited, and organized programs typically require repeated outreach attempts. Behavioral economics has shown that offering salient financial incentives to patients may increase participation in preventive health. Objective To compare the impact of different financial incentives for mailed FIT outreach. Design, Setting, and Participants This 4-parallel-arm randomized clinical trial included patients aged 50 to 75 years who had an established primary care clinician, at least 2 visits in the prior 2 years, and were eligible for colorectal cancer screening and not up-to-date. This study was conducted at urban primary care practices at an academic health system from December 2015 to February 2018. Data analysis was conducted from March 2018 to September 2018. Interventions Eligible patients received a letter from their primary care clinician that included a mailed FIT kit and instructions for use. They were randomized in a 1:1:1:1 ratio to receive (1) no financial incentive; (2) an unconditional $10 incentive included with the mailing; (3) a $10 incentive conditional on FIT completion; or (4) a conditional lottery with a 1-in-10 chance of winning $100 after FIT completion. Main Outcomes and Measures Fecal immunochemical test completion within 2 and 6 months of initial outreach. Results A total of 897 participants were randomized, with a median age of 57 years (interquartile range, 52-62 years); 56% were women, and 69% were black. The overall completion rate across all arms was 23.5% at 2 months. The completion rate at 2 months was 26.0% (95% CI, 20.4%-32.3%) in the no incentive arm, 27.2% (95% CI, 21.5%-33.6%) in the unconditional incentive arm, 23.2% (95% CI, 17.9%-29.3%) in the conditional incentive arm, and 17.7% (95% CI, 13.0%-23.3%) in the lottery incentive arm. None of the arms with an incentive were statistically superior to the arm without incentive. The overall FIT completion rate across all arms was 28.9% at 6 months, and there was also no difference by arm. The completion rate at 6 months was 32.7% (95% CI, 26.6%-39.3%) in the no incentive arm, 31.7% (95% CI, 25.7%-38.2%) in the unconditional incentive arm, 26.8% (95% CI, 21.1%-33.1%) in the conditional incentive arm, and 24.3% (95% CI, 18.9%-30.5%) in the lottery incentive arm. Conclusions and Relevance Mailed FIT resulted in high colorectal cancer screening response rates in this population, but different forms of financial incentives of the same expected value ($10) did not incrementally increase FIT completion rates. The incentive value may have been too small or financial incentives may not be effective in this context. Trial Registration ClinicalTrials.gov Identifier: NCT02594150.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine 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
- Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Rebecca S. Pepe
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole B. Gabler
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mounika Kanneganti
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chelsea Saia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joseph Teel
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine 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, Pennsylvania
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine 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, Pennsylvania
| | - Chyke A. Doubeni
- Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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40
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Issaka RB, Avila P, Whitaker E, Bent S, Somsouk M. Population health interventions to improve colorectal cancer screening by fecal immunochemical tests: A systematic review. Prev Med 2019; 118:113-121. [PMID: 30367972 PMCID: PMC6322951 DOI: 10.1016/j.ypmed.2018.10.021] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 09/07/2018] [Accepted: 10/20/2018] [Indexed: 12/13/2022]
Abstract
Despite clear evidence that colorectal cancer (CRC) screening reduces mortality, screening, including fecal immunochemical tests (FIT), is underutilized. We conducted a systematic review to determine the evidence of efficacy of interventions to improve FIT completion that could be scaled and utilized in population health management. We systematically searched publication databases for studies evaluating provider- or system-level interventions to improve CRC screening by FIT between 1 January 1996 and 13 December 2017 without language restrictions. Twenty articles describing 25 studies were included, 23 were randomized controlled trials with 1 quasi-experimental and 1 observational study. Ten studies discussed mailed FIT outreach, 4 pre-FIT patient reminders, 3 tailored patient messages, 2 post-FIT reminders, 2 paired FIT with influenza vaccinations, 2 provider alerts and 1 study each described the use of high-quality small media and patient financial incentives. Mailed FIT outreach was consistently effective with median improvement in CRC screening of 21.5% (interquartile range (IQR) 13.6%-29.0%). FIT paired with vaccinations led to a median 15.9% (IQR 15.6%-16.3%) improvement, while pre-FIT and post-FIT reminders demonstrated modest efficacy with median 4.1% (IQR 3.6%-6.7%) and 3.1% (IQR 2.9%-3.3%) improvement in CRC screening, respectively. More than half the studies were at high or unclear risk of bias; heterogeneous study designs and characteristics precluded meta-analysis. FIT-based CRC screening programs utilizing multilevel interventions (e.g. mailed FIT outreach, FIT paired with other preventative services, and provider alerts) have the potential to significantly increase screening participation. However, such programs must also follow-up patients with abnormal FIT results.
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Affiliation(s)
- Rachel B Issaka
- Clinical Research & Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, United States of America; Division of Gastroenterology, University of Washington School of Medicine, Seattle, WA, United States of America.
| | - Patrick Avila
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, United States of America
| | - Evans Whitaker
- University of California San Francisco Medical Library, University of California, San Francisco, San Francisco, CA, United States of America
| | - Stephen Bent
- Department of Medicine, University of California, San Francisco, San Francisco, CA, United States of America
| | - Ma Somsouk
- Division of Gastroenterology, University of California, San Francisco, San Francisco, CA, United States of America; Center for Vulnerable Populations, University of California, San Francisco, San Francisco, CA, United States of America
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Dougherty MK, Brenner AT, Crockett SD, Gupta S, Wheeler SB, Coker-Schwimmer M, Cubillos L, Malo T, Reuland DS. Evaluation of Interventions Intended to Increase Colorectal Cancer Screening Rates in the United States: A Systematic Review and Meta-analysis. JAMA Intern Med 2018; 178:1645-1658. [PMID: 30326005 PMCID: PMC6583619 DOI: 10.1001/jamainternmed.2018.4637] [Citation(s) in RCA: 212] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Colorectal cancer screening (CRC) is recommended by all major US medical organizations but remains underused. OBJECTIVE To identify interventions associated with increasing CRC screening rates and their effect sizes. DATA SOURCES PubMed, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Library, and ClinicalTrials.gov were searched from January 1, 1996, to August 31, 2017. Key search terms included colorectal cancer and screening. STUDY SELECTION Randomized clinical trials of US-based interventions in clinical settings designed to improve CRC screening test completion in average-risk adults. DATA EXTRACTION AND SYNTHESIS At least 2 investigators independently extracted data and appraised each study's risk of bias. Where sufficient data were available, random-effects meta-analysis was used to obtain either a pooled risk ratio (RR) or risk difference (RD) for screening completion for each type of intervention. MAIN OUTCOMES AND MEASURES The main outcome was completion of CRC screening. Examination included interventions to increase completion of (1) initial CRC screening by any recommended modality, (2) colonoscopy after an abnormal initial screening test result, and (3) continued rounds of annual fecal blood tests (FBTs). RESULTS The main review included 73 randomized clinical trials comprising 366 766 patients at low or medium risk of bias. Interventions that were associated with increased CRC screening completion rates compared with usual care included FBT outreach (RR, 2.26; 95% CI, 1.81-2.81; RD, 22%; 95% CI, 17%-27%), patient navigation (RR, 2.01; 95% CI, 1.64-2.46; RD, 18%; 95% CI, 13%-23%), patient education (RR, 1.20; 95% CI, 1.06-1.36; RD, 4%; 95% CI, 1%-6%), patient reminders (RR, 1.20; 95% CI, 1.02-1.41; RD, 3%; 95% CI, 0%-5%), clinician interventions of academic detailing (RD, 10%; 95% CI, 3%-17%), and clinician reminders (RD, 13%; 95% CI, 8%-19%). Combinations of interventions (clinician interventions or navigation added to FBT outreach) were associated with greater increases than single components (RR, 1.18; 95% CI, 1.09-1.29; RD, 7%; 95% CI, 3%-11%). Repeated mailed FBTs with navigation were associated with increased annual FBT completion (RR, 2.09; 95% CI, 1.91-2.29; RD, 39%; 95% CI, 29%-49%). Patient navigation was not associated with colonoscopy completion after an initial abnormal screening test result (RR, 1.21; 95% CI, 0.92-1.60; RD, 14%; 95% CI, 0%-29%). CONCLUSIONS AND RELEVANCE Fecal blood test outreach and patient navigation, particularly in the context of multicomponent interventions, were associated with increased CRC screening rates in US trials. Fecal blood test outreach should be incorporated into population-based screening programs. More research is needed on interventions to increase adherence to continued FBTs, follow-up of abnormal initial screening test results, and cost-effectiveness and other implementation barriers for more intensive interventions, such as navigation.
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Affiliation(s)
- Michael K Dougherty
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Alison T Brenner
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Seth D Crockett
- Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Shivani Gupta
- Division of Gastroenterology and Hepatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephanie B Wheeler
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill.,Department of Health Policy and Management, University of North Carolina at Chapel Hill
| | - Manny Coker-Schwimmer
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Laura Cubillos
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Teri Malo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill
| | - Daniel S Reuland
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill.,Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill
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42
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Bakhai S, Ahluwalia G, Nallapeta N, Mangat A, Reynolds JL. Faecal immunochemical testing implementation to increase colorectal cancer screening in primary care. BMJ Open Qual 2018; 7:e000400. [PMID: 30397662 PMCID: PMC6203033 DOI: 10.1136/bmjoq-2018-000400] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/14/2018] [Accepted: 09/22/2018] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is the second leading cause of cancer death in USA, and CRC screening remains suboptimal. The aim of this quality improvement was to increase CRC screening in the internal medicine clinic (IMC) patients, between the ages of 50–75 years, from a baseline rate of 50%–70% over 12 months with the introduction of faecal immunochemical test (FIT) testing. We used the Plan–Do–Study–Act (PDSA) method and performed a root cause analysis to identify barriers to acceptance of CRC screening. The quality improvement team created a driver diagram to identify and prioritise change ideas. We developed a process flow map to optimise opportunities to improve CRC screening. We performed eight PDSA cycles. The major components of interventions included: (1) leveraging health information technology; (2) optimising team work, (3) education to patient, physicians and IMC staff, (4) use of patient navigator for tracking FIT completion and (5) interactive workshops for the staff and physicians to learn motivational interview techniques. The outcome measure included CRC screening rates with either FIT or colonoscopy. The process measures included FIT order and completion rates. Data were analysed using a statistical process control and run charts. Four hundred and seven patients visiting the IMC were offered FIT, and 252 (62%) completed the test. Twenty-two (8.7%) of patients were FIT positive, 14 of those (63.6%) underwent a subsequent diagnostic colonoscopy. We achieved 75% CRC screening with FIT or colonoscopy within 12 months and exceeded our goal. Successful strategies included engaging the leadership, the front-line staff and a highly effective multidisciplinary team. For average-risk patients, FIT was the preferred method of screening. We were able to sustain a CRC screening rate of 75% during the 6-month postproject period. Sustainable annual FIT is required for successful CRC screening.
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Affiliation(s)
- Smita Bakhai
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Gaurav Ahluwalia
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Naren Nallapeta
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Amanpreet Mangat
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Jessica L Reynolds
- Department of Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
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43
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Hofmann B, Stanak M. Nudging in screening: Literature review and ethical guidance. PATIENT EDUCATION AND COUNSELING 2018; 101:1561-1569. [PMID: 29657111 DOI: 10.1016/j.pec.2018.03.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 03/13/2018] [Accepted: 03/26/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Nudging is the purposeful alteration of choices presented to people that aims to make them choose in predicted ways. While nudging has been used to assure high uptake and good outcome of screening programs, it has been criticized for being paternalistic, undermining free choice, and shared decision making. Accordingly, the objective of this study is to explore a) nudging strategies identified in screening, b) arguments for and against nudging; and on basis of this, to c) suggest a tentative conclusion on how to handle nudging in screening. METHODS Literature searches in Ovid MEDLINE and PsycINFO for combinations of screening and nudging. Screening based on content analysis of titles, abstracts, and articles. RESULTS 239 references were identified and 109 were included. Several forms of nudging were identified: framed information, default bias, or authority bias. Uptake and public health outcome were the most important goals. Arguments for nudging were bounded rationality, unavoidability, and beneficence, while lack of transparency, crowding out of intrinsic values, and paternalism were arguments against it. The analysis indicates that nudging can be acceptable for screenings with (high quality) evidence for high benefit-harm ratio (beneficence), where nudging does not infringe other ethical principles, such as justice and non-maleficence. In particular, nudging should not only focus on attendance rates, but also on making people "better choosers." PRACTICE IMPLICATIONS Four specific recommendations follow from the review and the analysis: 1) Nudging should be addressed in an explicit and transparent manner. 2) The means of nudging have to be in proportion to the benefit-harm ratio. 3) Disagreement on the evidence for either benefits or harms warrants special care. 4) Assessing and assuring the intended outcome of nudging appears to be crucial, as it can be context dependent.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences, Norwegian University of Science and Technology, Gjovik, Norway; Centre of Medical Ethics, University of Oslo, Oslo, Norway.
| | - Michal Stanak
- Ludwig Boltzmann Institute for Health Technology Assessment, Vienna, Austria; Faculty of Philosophy and Education, University of Vienna, Vienna, Austria.
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44
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Hassan C, Kaminski MF, Repici A. How to Ensure Patient Adherence to Colorectal Cancer Screening and Surveillance in Your Practice. Gastroenterology 2018; 155:252-257. [PMID: 29964039 DOI: 10.1053/j.gastro.2018.06.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.
| | - Michal F Kaminski
- Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre, Institute of Oncology, Warsaw, Poland
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45
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Ramai D, Etienne D, Reddy M. Does mistrust still linger? A bioethical perspective on colorectal cancer screening. Int J Colorectal Dis 2018; 33:657-658. [PMID: 29556756 DOI: 10.1007/s00384-018-3029-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Daryl Ramai
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, 121 Dekalb Avenue, Brooklyn, NY, 11201, USA.
| | - Denzil Etienne
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, 121 Dekalb Avenue, Brooklyn, NY, 11201, USA
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, 121 Dekalb Avenue, Brooklyn, NY, 11201, USA
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46
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de Klerk CM, Gupta S, Dekker E, Essink-Bot ML. Socioeconomic and ethnic inequities within organised colorectal cancer screening programmes worldwide. Gut 2018; 67:679-687. [PMID: 28073892 DOI: 10.1136/gutjnl-2016-313311] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/14/2016] [Accepted: 12/18/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Colorectal cancer (CRC) screening programmes can reduce CRC mortality. However, the implementation of a screening programme may create or exacerbate socioeconomic and ethnic health inequities if participation varies by subgroup. We determined which organised programmes characterise participation inequities by socioeconomic and ethnic subgroups, and assessed the variation in subgroup participation among programmes collecting group-specific data. DESIGN Employing a literature review and survey among leaders of national or regional screening programmes, this study identified published and unpublished data on participation by socioeconomic status and ethnicity. We assessed programmes offering faecal occult blood tests (FOBT) for screening. Primary outcome was screening participation rate. RESULTS Across 24 organised FOBT-screening programmes meeting the inclusion criteria, participation rates ranged from 21% to 73%. Most programmes (13/24, 54%) did not collect data on participation by socioeconomic status and ethnicity. Among the 11 programmes with data on participation by socioeconomic status, 90% (28/31 publications) reported lower participation among lower socioeconomic groups. Differences across socioeconomic gradients were moderate (66% vs 71%) to severe (35% vs 61%). Only six programmes reported participation results by ethnicity. Ethnic differences were moderate, though only limited data were available for evaluation. CONCLUSIONS Across organised CRC screening programmes worldwide, variation in participation by socioeconomic status and ethnicity is often not assessed. However, when measured, marked disparities in participation by socioeconomic status have been observed. Limited data were available to assess inequities by ethnicity. To avoid exacerbating health inequities, screening programmes should systematically monitor participation by socioeconomic status and ethnicity, and investigate and address determinants of low participation.
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Affiliation(s)
- C M de Klerk
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - S Gupta
- Division of Gastroenterology, Department of Internal Medicine, University of California San Diego, San Diego, California, USA
| | - E Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M L Essink-Bot
- Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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47
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Jung YS, Park CH, Kim NH, Park JH, Park DI, Sohn CI. A combination of clinical risk stratification and fecal immunochemical test is useful for identifying persons with high priority of early colonoscopy. Dig Liver Dis 2018; 50:254-259. [PMID: 29198569 DOI: 10.1016/j.dld.2017.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/30/2017] [Accepted: 11/02/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND We aimed to develop a combination screening strategy for advanced colorectal neoplasia based on the Asia-Pacific Colorectal Screening score and fecal immunochemical test results. METHODS We reviewed the records of participants who had undergone a colonoscopy and fecal immunochemical test as part of a comprehensive health screening program. The prevalence of advanced colorectal neoplasia in participants 40-49 years old was analyzed according to Asia-Pacific Colorectal Screening scores and fecal immunochemical test results. RESULTS We analyzed the data of 9205 participants 40-49 years old and 3215 participants ≥50 years old. The prevalence of advanced colorectal neoplasia in participants 40-49 years old was 1.0%, 2.1%, 7.1%, and 13.4% in the "fecal immunochemical test (-) & Asia-Pacific Colorectal Screening<2," "fecal immunochemical test (-) & Asia-Pacific Colorectal Screening≥2," "fecal immunochemical test (+) & Asia-Pacific Colorectal Screening<2," and "fecal immunochemical test (+) & Asia-Pacific Colorectal Screening≥2" subgroups, respectively. The prevalence of advanced colorectal neoplasia in "fecal immunochemical test (+) & Asia-Pacific Colorectal Screening≥2" subgroup was higher than in participants ≥50 years old with Asia-Pacific Colorectal Screening≥4 (13.4% vs. 5.8%, P<0.001). CONCLUSIONS Fecal immunochemical test-positive individuals 40-49 years old with an Asia-Pacific Colorectal Screening≥2 have a higher risk of advanced colorectal neoplasia than individuals ≥50 years old with an Asia-Pacific Colorectal Screening≥4.
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Affiliation(s)
- Yoon Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Republic of Korea.
| | - Nam Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jung Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Il Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chong Il Sohn
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Goldzahl L, Hollard G, Jusot F. Increasing breast-cancer screening uptake: A randomized controlled experiment. JOURNAL OF HEALTH ECONOMICS 2018; 58:228-252. [PMID: 29571095 DOI: 10.1016/j.jhealeco.2017.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 12/05/2017] [Accepted: 12/12/2017] [Indexed: 05/27/2023]
Abstract
Early screening increases the likelihood of detecting cancer, thereby improving survival rates. National screening programs have been established in which eligible women receive a letter containing a voucher for a free screening. Even so, mammography use is often considered as remaining too low. We test four behavioral interventions in a large-scale randomized experiment involving 26,495 women. Our main assumption is that, due to biases in decision-making, women may be sensitive to the content and presentation of the invitation letter they receive. None of our treatments had any significant impact on mammography use. Sub-sample analysis suggests that this lack of a significant impact holds also for women invited for the first time and low-income women.
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Mehta SJ, Feingold J, Vandertuyn M, Niewood T, Cox C, Doubeni CA, Volpp KG, Asch DA. Active Choice and Financial Incentives to Increase Rates of Screening Colonoscopy-A Randomized Controlled Trial. Gastroenterology 2017; 153:1227-1229.e2. [PMID: 28734830 PMCID: PMC5669820 DOI: 10.1053/j.gastro.2017.07.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 07/07/2017] [Accepted: 07/11/2017] [Indexed: 12/02/2022]
Abstract
Behavioral economic approaches could increase uptake for colorectal cancer screening. We performed a randomized controlled trial of 2245 employees to determine whether an email containing a phone number for scheduling (control), an email with the active choice to opt in or opt out (active choice), or the active choice email plus a $100 incentive (financial incentive) increased colonoscopy completion within 3 months. Higher proportions of participants in the financial incentive group underwent screening (3.7%) than in the control (1.6%) or active choice groups (1.5%) (P = .01 and P < .01). We found no difference in uptake of screening between the active choice and control groups (P = .88). The $100 conditional incentive modestly but significantly increased colonoscopy use. ClinicalTrials.gov no: NCT02660671.
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Affiliation(s)
- Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jordyn Feingold
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew Vandertuyn
- Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania
| | - Tess Niewood
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine Cox
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chyke A Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Medicine Center for Health Care Innovation, Philadelphia, Pennsylvania; Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
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50
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Jung YS, Park CH, Kim NH, Park JH, Park DI, Sohn CI. Colorectal cancer screening with the fecal immunochemical test in persons aged 30 to 49 years: focusing on the age for commencing screening. Gastrointest Endosc 2017; 86:892-899. [PMID: 28385585 DOI: 10.1016/j.gie.2017.03.1531] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/26/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The fecal immunochemical test (FIT) can be an alternative screening method for colorectal cancer in individuals aged <50 years. However, debate continues concerning the age at which commencing FIT is beneficial. METHODS We reviewed the records of participants who had undergone a colonoscopy and FIT as part of a comprehensive health screening program. To determine the age for commencing screening via FIT, participants aged <50 years were classified into 4 age subgroups as follows: 30 to 34, 35 to 39, 40 to 44, and 45 to 49 years. Average-risk participants aged 50 to 59 years comprised the control group. RESULTS We analyzed the data of 19,808 participants aged 30 to 49 years and 2233 average-risk participants aged 50 to 59 years. The advanced colorectal neoplasia (ACRN) prevalence in average-risk participants aged 50 to 59 years was 3.8%. In the subgroups of FIT-positive participants, the proportion of participants with ACRN was 2.9% (95% confidence interval [CI], 1.1%-7.4%), 9.7% (95% CI, 5.8%-15.6%), 7.7% (95% CI, 4.5%-12.8%), and 14.6% (95% CI, 8.7%-23.5%) in groups 30 to 34, 35 to 39, 40 to 44, and 45 to 49 years, respectively. The proportion of FIT-positive participants with ACRN in the groups aged 35 to 39, 40 to 44, and 45 to 49 years was higher than that in average-risk participants aged 50 to 59 years (P = .001, P = .014, and P < .001, respectively), whereas that in FIT-positive participants aged 30 to 34 years was not (P = .566). CONCLUSION FIT-positive individuals aged 35 to 49 years had a higher risk of ACRN compared with average-risk individuals aged 50 to 59 years. FIT-positive individuals aged 35 to 49 years may benefit from screening colonoscopy, thus justifying the possibility of commencing FIT from age 35 years.
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Affiliation(s)
- Yoon Suk Jung
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Nam Hee Kim
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung Ho Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Il Park
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chong Il Sohn
- Division of Gastroenterology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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