Measuring and improving cervical, breast, and colorectal cancer screening rates in a multi-site urban practice in Toronto, Canada

The potential benefits of "community champions" in the healthcare system

In a study to understand acceptability and uptake of Human Papilloma Virus (HPV) self-sampling, we engaged community champions to lead recruitment and other study activities. This article describes qualitative findings relevant to the role of the community champion. We found that community champions were critical to promoting awareness about and encouraging cervical screening and HPV self-sampling. They were well-connected community members who had healthcare backgrounds, which created trust in their messages. They were highly effective at encouraging screening because of their education and cultural congruency, combined with the time for thorough and clear explanations. Women had an inherent level of comfort with the community champions that often did not exist with their physician. The community champions were seen as being able to address some of the barriers that exist within the healthcare system. We encourage health leaders to consider how this role can be sustainably and meaningfully incorporated into the healthcare system.

Health and healthcare equity within the Canadian cancer care sector: a rapid scoping review

BACKGROUND

Despite a publicly-funded healthcare system, alarming cancer-related health and healthcare inequities persist in Canada. However, it remains unclear how equity is being understood and taken up within the Canadian cancer context. Our objective was to identify how health and healthcare equity are being discussed as goals or aims within the cancer care sector in Canada.

METHODS

A rapid scoping review was conducted; five biomedical databases, 30 multidisciplinary websites, and Google were searched. We included English-language documents published between 2008 and 2021 that discussed health or healthcare equity in the Canadian cancer context.

RESULTS

Of 3860 identified documents, 83 were included for full-text analysis. The prevalence of published and grey equity-oriented literature has increased over time (2008-2014 [n = 20]; 2015-2021 [n = 62]). Only 25% of documents (n = 21) included a definition of health equity. Concepts such as inequity, inequality and disparity were frequently used interchangeably, resulting in conceptual muddling. Only 43% of documents (n = 36) included an explicit health equity goal. Although a suite of actions were described across the cancer control continuum to address equity goals, most were framed as recommendations rather than direct interventions.

CONCLUSION

Health and healthcare equity is a growing priority in the cancer care sector; however, conceptual clarity is needed to guide the development of robust equity goals, and the development of sustainable, measurable actions that redress inequities across the cancer control continuum. If we are to advance health and healthcare equity in the cancer care sector, a coordinated and integrated approach will be required to enact transformative and meaningful change.

Snakes and ladders: A qualitative study understanding the active ingredients of social interaction around the use of audit and feedback

Explore characteristics of the facilitator, group, and interaction that influence whether a group discussion about data leads to the identification of a clearly specified action plan. Peer-facilitated group discussions among primary care physicians were carried out and recorded. A follow-up focus group was conducted with peer facilitators to explore which aspects of the discussion promoted action planning. Qualitative data was analyzed using an inductive-deductive thematic analysis approach using the conceptual model developed by Cooke et al. Group discussions were coded case-specifically and then analyzed to identify which themes influenced action planning as it relates to performance improvement. Physicians were more likely to interact with practice-level data and explore actions for performance improvement when the group facilitator focused the discussion on action planning. Only one of the three sites (Site C) converged on an action plan following the peer-facilitated group discussion. At Site A, physicians shared skepticism of the data, were defensive about performance, and explained performance as a product of factors beyond their control. Site B identified several potential actions but had trouble focusing on a single indicator or deciding between physician- and group-level actions. None of the groups discussed variation in physician-level performance indicators, or how physician actions might contribute to the reported outcomes. Peer facilitators can support data interpretation and practice change; however their success depends on their personal beliefs about the data and their ability to identify and leverage change cues that arise in conversation. Further research is needed to understand how to create a psychologically safe environment that welcomes open discussion of physician variation.

Multi-component interventions and change in screening rates in primary care clinics in the Colorectal Cancer Control Program

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Evidence-based interventions (EBIs) in clinics increase colorectal cancer screening.

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Even more effective are multi-component interventions (MCIs) vs a single strategy.

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We examined the effectiveness of MCIs in CDC’s Colorectal Cancer Control Program.

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Combination of 3–4 EBIs or 2–3 strategies led to significant increase in screening.

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Some MCIs led up to 7.2 percentage points annual increases.

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality. Implementation of evidence-based interventions (EBIs) increases CRC screening. The purpose of this analysis is to determine which combinations of EBIs or strategies led to increases in clinic-level screening rates among clinics participating in CDC’s Colorectal Cancer Control Program (CRCCP). Data were collected from CRCCP clinics between 2015 and 2018 and the analysis was conducted in 2020. The outcome variable was the annual change in clinic level CRC screening rate in percentage points. We used first difference (FD) estimator of linear panel data regression model to estimate the associations of outcome with independent variables, which include different combinations of EBIs and intervention strategies. The study sample included 486 unique clinics with 1156 clinic years of total observations. The average baseline screening rate was 41 % with average annual increase of 4.6 percentage points. Only two out of six combinations of any two EBIs were associated with increases in screening rate (largest was 6.5 percentage points, P < 0.001). Any combinations involving three EBIs or all four EBIs were significantly associated with the outcome with largest increase of 7.2 percentage points (P < 0.001). All interventions involving 2–3 strategies led to increases in rate with largest increase associated with the combination of increasing community demand and access (6.1 percentage points, P < 0.001). Clinics implementing combinations of these EBIs, particularly those including three or more EBIs, often were more likely to have impact on screening rate change than those implementing none.

Implementing a standardized protocol to improve cervical cancer screening rates in primary care

BACKGROUND

Routine cervical cancer screening for women aged 21-65 is a recommended standard practice. Early identification and treatment of cervical cancer improves patient outcomes.

LOCAL PROBLEM

Cervical cancer screening rates at the primary care project site were 51%, well below the national benchmark of 87%. The purpose of this quality improvement project was to increase cervical cancer screening rates by implementing a standardized eligibility assessment protocol.

METHODS

This initiative took place at an outpatient family practice site over 7.5 months and included 2,018 eligible patients.

INTERVENTIONS

Evidence-based interventions included a standardized process change that shifted eligibility assessment from an opportunistic screening by providers to a proactive screening by clinical staff. Using a system reminder prompt, clinical staff began assessing all eligible patients during rooming and proactively scheduling future Pap appointments in office or placing OBGYN referrals, per patient preference.

RESULTS

A statistically significant increase in cervical cancer screening rates occurred, 33% ( p < .001). The rate of scheduled Pap appointments increased by 124% ( p < .001), the rate of OBGYN referrals increased by 300% ( p < .001), and the rate of completed Pap tests in office increased by 280% ( p < .001).

CONCLUSION

The results suggest that implementing a proactive, standardized screening process can increase cervical cancer screening rates in primary care.

Experiential QI Activity for Residents to Improve Women's Preventive Services

INTRODUCTION

The Accreditation Council for Graduate Medical Education (ACGME) requires family medicine residents to complete a quality improvement (QI) project. There is a need for more QI training activities to be shared to meet this requirement. Our objective was to describe an activity for residents to improve women's preventive health services in an underserved clinic. Specific aims were to determine: (1) how women's receipt of preventive services compared to benchmarks, (2) physician and staff knowledge of the process and barriers to receiving services, and (3) whether an intervention to increase awareness among physicians and staff improved preventive services.

METHODS

Residents (N=30) evaluated charts (N=505) to determine receipt of mammograms, pap tests, colon cancer screenings, and pneumonia vaccines. We compared estimates to existing clinic benchmarks. We presented initial (preintervention) results to physicians and staff at clinic team meetings. We collected perceptions of processes and barriers to preventive services. Preintervention methods were replicated (N=100) and results were compared (postintervention).

RESULTS

Preintervention, mammograms (72%) and Pap tests (65%) were lower than clinic benchmarks. Most (81%) women ages 65 and older received a pneumonia vaccine; however, this was lower than the national Healthy People 2020 goal. Fear, knowledge, and scheduling were identified as top barriers. Post-intervention, there was a statistically significant increase in Pap tests (P=.0013).

CONCLUSION

This activity trained residents how to impact their practice through QI methods and can be used in other programs as a foundation for developing basic QI initiatives. Future efforts should focus on evaluating barriers to preventive services from the patient perspective.

Unpacking the intention to action gap: a qualitative study understanding how physicians engage with audit and feedback

Background

Audit and feedback (A&F) often successfully enhances health professionals’ intentions to improve quality of care but does not consistently lead to practice changes. Recipients often cite data credibility and limited resources as barriers impeding their ability to act upon A&F, suggesting the intention-to-action gap manifests while recipients are interacting with their data. While attention has been paid to the role feedback and contextual variables play in contributing to (or impeding) success, we lack a nuanced understanding of how healthcare professionals interact with and process clinical performance data.

Methods

We used qualitative, semi-structured interviews guided by Normalization Process Theory (NPT). Questions explored the role of data in quality improvement, experiences with the A&F report, perceptions of the data, and interpretations and reflections. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using a combination of inductive and deductive strategies using reflexive thematic analysis informed by a constructivist paradigm.

Results

Healthcare professional characteristics (individual quality improvement capabilities and beliefs about data) seem to influence engagement with A&F to a greater degree than feedback variables (i.e., delivered by peers) and observed contextual factors (i.e., strong quality improvement culture). Most participants lacked the capabilities to interpret practice-level data in an actionable way despite a motivation to engage meaningfully. Reasons for the intention-to-action gap included challenges interpreting longitudinal data, appreciating the nuances of common data sources, understanding how aggregate data provides insights into individualized care, and identifying practice-level actions to improve quality. These factors limited effective cognitive participation and collective action, as outlined in NPT.

Conclusions

A well-designed A&F intervention is necessary but not sufficient to inform practice changes. A&F initiatives must include co-interventions to address recipient characteristics (i.e., beliefs and capabilities) and context to optimize impact. Effective strategies to overcome the intention-to-action gap may include modelling how to use A&F to inform practice change, providing opportunities for social interaction relating to the A&F, and circulating examples of effective actions taken in response to A&F. More broadly, undergraduate medical education and post-graduate training must ensure physicians are equipped with QI capabilities, with an emphasis on the skills required to interpret and act on practice-level data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01088-1.

Correlates of non-adherence to breast, cervical, and colorectal cancer screening among screen-eligible women: a population-based cohort study in Ontario, Canada

PURPOSE

Breast, cervical, and colorectal cancers are cancers that can be detected early through screening. Despite organized cancer screening programs in Ontario, Canada participation remains low among marginalized populations. Although extensive research has been done about factors contributing to under-screening by cancer site, the predictors of under/never screened conjointly for all three types of cancer remain unknown.

METHODS

Using provincial-level linked administrative data sets, we examined Ontario women who were screen-eligible for all three types of cancer over a 36-month period (i.e., April 2014-March 2017) and determined how many were up to date on 0, 1, 2, and all three types of screenings. Multivariate logistic regression was utilized to examine individual and structural predictors of screening with the group overdue for all screening being the reference group.

RESULTS

Of the 1,204,551 screen-eligible women, 15% were overdue for all. Living in the lowest income neighborhoods (AOR 0.46 [95% CI 0.45-0.47]), being recent immigrants (AOR 0.54 [95% CI 0.53-0.55]), having no primary care provider (AOR 0.17 [95% CI 0.16-0.17]), and having no contact with health care services (AOR 0.09 [95% CI 0.09-0.09]) significantly increased the likelihood of being overdue for all versus no screening type.

CONCLUSIONS

Considering that more than 15% of screen-eligible women in Ontario were overdue for all types of cancer screening, it is imperative to address structural barriers such as lack of a primary care provider. Innovative interventions like "one-stop shopping" where screening for different cancers can be offered at the same time could promote screening uptake.

What Is Organized Screening and What Is Its Value?

Most screening in the United States occurs in an opportunistic fashion, although organized screening occurs in some integrated health care systems. Organized colorectal cancer (CRC) screening consists of an explicit screening policy, defined target population, implementation team, health care team for clinical care delivery, quality assurance infrastructure, and method for identifying cancer outcomes. Implementation of an organized screening program offers opportunities to systematically assess the success of the program and develop interventions to address identified gaps in an effort to optimize CRC outcomes. There is evidence of that organized screening is associated with improvements in screening participation and CRC mortality.

A "Tea and Cookies" Approach: Co-designing Cancer Screening Interventions with Patients Living with Low Income

BACKGROUND

In our primary care organization, we have observed income gradients in cancer screening for our patients despite outreach. We hypothesized that outreach strategies could be improved upon to be more compelling for our patients living with low income.

OBJECTIVE

To use co-design to adapt our current strategies and create new strategies to improve cancer screening uptake for patients living with low income.

DESIGN

An exploratory, qualitative study in two phases: interviews and focus groups.

PARTICIPANTS

For interviews, we recruited 25 patient participants who were or had been overdue for cancer screening and had been identified by their provider as potentially living with low income. For subsequent focus groups, we recruited 14 patient participants, 11 of whom had participated in Phase I interviews.

APPROACH

To analyse written transcripts, we took an iterative, inductive approach using content analysis and drawing on best practices in Grounded Theory methodology. Emergent themes were expanded and clarified to create a derived model of possible strategies to improve the experience of cancer screening and encourage screening uptake for patients living with low income.

KEY RESULTS

Fear and competing priorities were two key barriers to cancer screening identified by patients. Patients believed that a warm and encouraging outreach approach would work best to increase cancer screening participation. Phone calls and group education were specifically suggested as potentially promising methods. However, these views were not universal; for example, women were more likely to be in favour of group education.

CONCLUSIONS

We used input from patients living with low income to co-design a new approach to cancer screening in our primary care organization, an approach that could be broadly applicable to other contexts and settings. We learned from our patients that a multi-modal strategy will likely be best to maximize screening uptake.

Education, income and occupation and their influence on the uptake of cervical cancer prevention strategies: A systematic review

AIMS

To report a systematic review of the literature exploring how education, income and occupation influence the uptake of cervical screening and HPV vaccination among eligible women in developed countries, including the United Kingdom, United States, Spain, Germany and Norway.

BACKGROUND

Cervical cancer remains a highly prevalent disease despite it being largely preventable through cervical screening and HPV vaccination. Incidence and mortality of cervical cancer are unequally distributed among socioeconomic groups, warranting research into how individual socioeconomic factors contribute to this unbalanced uptake of prevention strategies.

DESIGN

Systematic review and narrative synthesis.

METHODS

The PRISMA guidelines (PLoS Medicine, 6, 2009, e1000097) guided the selection of papers. MEDLINE, CINHAL, PsychINFO, Science Citation Index and HMIC were searched. Ten articles were suitable. Key findings were then extracted, and a narrative synthesis was completed, using suitable guidance and the AXIS tool.

RESULTS

Obtaining high school or college education is associated with uptake of both cervical screening and HPV vaccination. Total household income and income in respect of the countries' poverty line was measured less frequently than education, but associated with screening and vaccination in some studies. Occupation was infrequently measured in comparison to education and income, limiting conclusions of its association to uptake.

CONCLUSION

Education and income have an association with uptake of cervical screening and HPV vaccination among women. However, evidence is insufficient to affirm a relationship between occupation and uptake of screening and vaccination. Further research would be advised to strengthen these findings.

RELEVANCE TO CLINICAL PRACTICE

Interventions to promote cervical cancer prevention strategies should be targeted at women and girls with lower education levels and lower income. However, differences are displayed in the relationships between the individual socioeconomic factors and uptake of preventative strategies between countries and populations and so they should be considered separately. Nurses play a considerable role in people's perceptions and experiences of cervical screening and HPV vaccination. The review findings offer new insight that can inform future policy and nursing practice on targeting interventions to promote uptake among women who are underusing cervical cancer prevention programmes.

Colonoscopy and Sigmoidoscopy Use among the Average-Risk Population for Colorectal Cancer: A Systematic Review and Trend Analysis

Monitoring population-level colonoscopy and sigmoidoscopy use is crucial to estimate the future burden of colorectal cancer and guide screening efforts. We conducted a systematic literature search on colonoscopy and sigmoidoscopy use, published between November 2016 and December 2018 in the databases PubMed and Web of Science to update previous reviews and analyze time trends for various countries. In addition, we used data from the German and European Health Interview Surveys and the National Health Interview Survey to explore recent time trends for Germany and the US, respectively. The literature search yielded 23 new articles: fourteen from the US and nine from Australia, Canada, England, Germany, Saudi Arabia, and South Korea. Colonoscopy use within 10 years was highest and, apart from the youngest age groups eligible for colorectal cancer screening, kept increasing to levels close to 60% in the US and Germany. A recent steep increase was also observed for South Korea. Limited data were available on sigmoidoscopy use; regional studies from the US suggest that sigmoidoscopy has become rarely used. Despite high uptake and ongoing increase in the US, Germany, and South Korea, use of colonoscopy and sigmoidoscopy has either remained low or essentially unknown for the majority of countries.

Cancer screening rates among transgender adults: Cross-sectional analysis of primary care data

OBJECTIVE

To compare rates of cervical, breast, and colorectal cancer screening between patients who are transgender and those who are cisgender (ie, nontransgender).

DESIGN

Cross-sectional study.

SETTING

A multisite academic family health team in Toronto, Ont, serving more than 45 000 enrolled patients.

PARTICIPANTS

All patients enrolled in the family health team who were eligible for cervical, breast, or colorectal cancer screening. Patients were identified as transgender using an automated search of the practice electronic medical record followed by manual audit.

MAIN OUTCOME MEASURES

Screening rates for cervical, breast, and colorectal cancer calculated using data from the electronic medical record and provincial cancer screening registry. Screening rates among the transgender and cisgender populations were compared using ² tests, and logistic regression modeling was used to understand differences in screening after adjustment for age, neighbourhood income quintile, and number of primary care visits.

RESULTS

A total of 120 transgender patients were identified as eligible for cancer screening. More than 85% of transgender patients eligible for breast cancer screening were assigned male at birth. Transgender patients were less likely than cisgender patients (n = 20 514) were to be screened for cervical (56% vs 72%, P = .001; adjusted odds ratio [OR] of 0.39; 95% CI 0.25 to 0.62), breast (33% vs 65%, P < .001; adjusted OR = 0.27; 95% CI 0.12 to 0.59), and colorectal cancer (55% vs 70%, P = .046; adjusted OR = 0.50; 95% CI 0.26 to 0.99).

CONCLUSION

In this setting, transgender patients were less likely to receive recommended cancer screening compared with the cisgender population. Future research and quality improvement activities should aim to understand and address potential patient, provider, and system factors.

Ten tips for advancing a culture of improvement in primary care

Embracing practice-based quality improvement (QI) represents one way for clinicians to improve the care they provide to patients while also improving their own professional satisfaction. But engaging in care redesign is challenging for clinicians. In this article, we describe our experience over the last 7 years transforming the care delivered in our large primary care practice. We reflect on our journey and offer 10 tips to healthcare leaders seeking to advance a culture of improvement. Our organisation has developed a cadre of QI leaders, tracks a range of performance measures and has demonstrated sustained improvements in important areas of patient care. Success has required deep engagement with both patients and clinicians, a long-term vision, and requisite patience.