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Arena L, Soloe C, Schlueter D, Ferriola-Bruckenstein K, DeGroff A, Tangka F, Hoover S, Melillo S, Subramanian S. Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic. J Community Health 2023; 48:113-126. [PMID: 36308666 PMCID: PMC9617236 DOI: 10.1007/s10900-022-01154-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2022] [Indexed: 11/28/2022]
Abstract
COVID-19 caused significant declines in colorectal cancer (CRC) screening. Health systems and clinics, faced with a new rapidly spreading infectious disease, adapted to maintain patient safety and address the effects of the pandemic on healthcare delivery. This study aimed to understand how CDC-funded Colorectal Cancer Control Program recipients and their partner health systems and clinics may have modified evidence-based intervention (EBI) implementation to promote CRC screening during the COVID-19 pandemic; to identify barriers and facilitators to implementing modifications; and to extract lessons that can be applied to support CRC screening, chronic disease management, and clinic resilience in the face of future public health crises. Nine recipients were selected to reflect the diversity inherent among all CRCCP recipients. Recipient and clinic partner staff answered unique sets of pre-interview questions to inform tailoring of interview guides that were developed using constructs from the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) and Consolidated Framework for Implementation Research (CFIR). The study team then interviewed recipient, health system, and clinic partner staff incorporating pre-interview responses to focus each conversation. We employed a rapid qualitative analysis approach then conducted virtual focus groups with recipient representatives to validate emergent themes. Three modifications that emerged from thematic analysis include: (1) offering mailed fecal immunochemical test (FIT) kits for CRC screening with mail or drop off return; (2) increasing the use of patient education and engagement strategies; and (3) increasing the use of or improving automated patient messaging systems. With improved tracking and automated reminder systems, mailed FIT kits paired with tailored patient education and clear instructions for completing the test could help primary care clinics catch up on the backlog of missed screenings during COVID-19. Future research can assess the effectiveness and cost-effectiveness of offering mailed FIT kits on maintaining or improving CRC screening, especially among people who are medically underserved.
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Affiliation(s)
- Laura Arena
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC, 27709, USA.
| | - Cindy Soloe
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709 USA
| | - Dara Schlueter
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | | | - Amy DeGroff
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Florence Tangka
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Sonja Hoover
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709 USA
| | - Stephanie Melillo
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Sujha Subramanian
- RTI International, 3040 E. Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709 USA
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Hicklin K, O'Leary MC, Nambiar S, Mayorga ME, Wheeler SB, Davis MM, Richardson LC, Tangka FKL, Lich KH. Assessing the impact of multicomponent interventions on colorectal cancer screening through simulation: What would it take to reach national screening targets in North Carolina? Prev Med 2022; 162:107126. [PMID: 35787844 PMCID: PMC11056941 DOI: 10.1016/j.ypmed.2022.107126] [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: 08/09/2021] [Revised: 05/10/2022] [Accepted: 06/27/2022] [Indexed: 11/28/2022]
Abstract
Healthy People 2020 and the National Colorectal Cancer Roundtable established colorectal cancer (CRC) screening targets of 70.5% and 80%, respectively. While evidence-based interventions (EBIs) have increased CRC screening, the ability to achieve these targets at the population level remains uncertain. We simulated the impact of multicomponent interventions in North Carolina over 5 years to assess the potential for meeting national screening targets. Each intervention scenario is described as a core EBI with additional components indicated by the "+" symbol: patient navigation for screening colonoscopy (PN-for-Col+), mailed fecal immunochemical testing (MailedFIT+), MailedFIT+ targeted to Medicaid enrollees (MailedFIT + forMd), and provider assessment and feedback (PAF+). Each intervention was simulated with and without Medicaid expansion and at different levels of exposure (i.e., reach) for targeted populations. Outcomes included the percent up-to-date overall and by sociodemographic subgroups and number of CRC cases and deaths averted. Each multicomponent intervention was associated with increased CRC screening and averted both CRC cases and deaths; three had the potential to reach screening targets. PN-for-Col + achieved the 70.5% target with 97% reach after 1 year, and the 80% target with 78% reach after 5 years. MailedFIT+ achieved the 70.5% target with 74% reach after 1 year and 5 years. In the Medicaid population, assuming Medicaid expansion, MailedFIT + forMd reached the 70.5% target after 5 years with 97% reach. This study clarifies the potential for states to reach national CRC screening targets using multicomponent EBIs, but decision-makers also should consider tradeoffs in cost, reach, and ability to reduce disparities when selecting interventions.
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Affiliation(s)
- Karen Hicklin
- Department of Industrial and Systems Engineering, Herbert Wertheim College of Engineering, University of Florida, Gainesville, FL, USA.
| | - Meghan C O'Leary
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Maria E Mayorga
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, USA
| | - Stephanie B Wheeler
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melinda M Davis
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, OR, USA; Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA; School of Public Health, Oregon Health & Science University, Portland State University, Portland, OR, USA
| | | | | | - Kristen Hassmiller Lich
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Subramanian S, Tangka FKL, Hoover S. Role of an Implementation Economics Analysis in Providing the Evidence Base for Increasing Colorectal Cancer Screening. Prev Chronic Dis 2020; 17:E46. [PMID: 32584756 PMCID: PMC7316416 DOI: 10.5888/pcd17.190407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Purpose and Objectives Since 2005 the Centers for Disease Control and Prevention (CDC) has funded organizations across the United States to promote screening for colorectal cancer (CRC) to detect early CRC or precancerous polyps that can be treated to avoid disease progression and death. The objective of this study was to describe how findings from economic evaluation approaches of a subset of these awardees and their implementation sites (n = 9) can drive decision making and improve program implementation and diffusion. Intervention Approach We described the framework for the implementation economics evaluation used since 2016 for the Colorectal Cancer Control Program (CRCCP) Learning Collaborative. Evaluation Methods We compared CRC interventions implemented across health systems, changes in screening uptake, and the incremental cost per person of implementing an intervention. We also analyzed data on how implementation costs changed over time for a CRC program that conducted interventions in a series of rounds. Results Implementation of the interventions, which included provider and patient reminders, provider assessment and feedback, and incentives, resulted in increases in screening uptake ranging from 4.9 to 26.7 percentage points. Across the health systems, the incremental cost per person screened ranged from $18.76 to $144.55. One awardee’s costs decreased because of a reduction in intervention development and start-up costs. Implications for Public Health Health systems, CRCCP awardees, and CDC can use these findings for quality improvement activities, incorporation of information into trainings and support activities, and future program design.
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Affiliation(s)
- Sujha Subramanian
- RTI International, 307 Waverley Oaks Rd, Ste 101, Waltham, MA 02452.
| | - Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Chido-Amajuoyi OG, Sharma A, Talluri R, Tami-Maury I, Shete S. Physician-office vs home uptake of colorectal cancer screening using FOBT/FIT among screening-eligible US adults. Cancer Med 2019; 8:7408-7418. [PMID: 31637870 PMCID: PMC6885889 DOI: 10.1002/cam4.2604] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 09/23/2019] [Accepted: 09/30/2019] [Indexed: 12/16/2022] Open
Abstract
Background Guidelines of the American Cancer Society and US Preventive Services Task Force specify that colorectal cancer (CRC) screening using guaiac‐based fecal occult blood test (FOBT)/fecal immunochemical test (FIT) should be done at home. We therefore examined the prevalence and correlates of CRC screening using FOBT/FIT in physicians' office vs at home. Methods Analysis of 9493 respondents 50‐75 years old from the Cancer Control Supplement of the 2015 National Health Interview Survey was conducted. Weighted multivariable logistic regression was used to identify the determinants of in‐office vs home use of FOBT/FIT for CRC screening. Results Of the overall sample of screening‐eligible adults (n = 9403), only 937 (10.4%) respondents underwent CRC screening using FOBT/FIT within the past year; among this screening population, 279 (28.3%) respondents were screened in‐office. We found that sociodemographic factors alone, not CRC risk factors, determined whether FOBT/FIT would be used in‐office or at home. Hispanics had greater odds of being screened in‐office using FOBT/FIT (aOR: 2.04; 95% CI: 1.05‐3.99). Compared with those 50‐59 years old, respondents 70‐75 years old were less likely to be screened in‐office using FOBT/FIT (aOR: 0.44, 95% CI: 0.25‐0.79). Similarly, individuals residing in the Western region of the country had lower odds of in‐office FOBT/FIT (aOR: 0.26; 95% CI: 0.11‐0.58). Conclusion Amid low overall uptake rates of FOBT/FIT in the United States, in‐physician office testing is high, indicative of a missed opportunity for effective screening and poor adherence of physicians to national guidelines. Sociodemographic factors are determinants of uptake of FOBT/FIT at home or in‐office and should be considered in designing interventions aimed at providers and the general population. Amid low overall uptake rates of FOBT/FIT in the United States, in‐physician office testing is high, indicative of a missed opportunity for effective screening and poor adherence of physicians to national guidelines.
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Affiliation(s)
| | - Anushree Sharma
- Department of Behavioral Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rajesh Talluri
- Department of Data Science, The University of Mississippi Medical Center, Jackson, MS, USA
| | - Irene Tami-Maury
- Department of Behavioral Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sanjay Shete
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Division of Cancer Prevention and Population Sciences, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Veettil SK, Nathisuwan S, Ching SM, Jinatongthai P, Lim KG, Kew ST, Chaiyakunapruk N. Efficacy and safety of celecoxib on the incidence of recurrent colorectal adenomas: a systematic review and meta-analysis. Cancer Manag Res 2019; 11:561-571. [PMID: 30666154 PMCID: PMC6331068 DOI: 10.2147/cmar.s180261] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Celecoxib has previously been shown to be effective in reducing recurrent colorectal adenomas, but its long-term effects are unknown. In addition, safety issues are of major concern. Therefore, we examined the efficacy and safety of celecoxib as a chemopreventive agent along with its posttreatment effect. METHODS We performed a meta-analysis based on a systematic review of randomized controlled trials (RCTs) comparing celecoxib at various doses (400 mg once daily, 200 mg twice daily, and 400 mg twice daily) vs placebo in persons with history of colorectal adenomas. Several databases were searched from inception up to April 2018. Long-term follow-ups of RCTs were also included to evaluate posttreatment effect. Primary outcome was the incidence of recurrent colorectal adenomas. Various safety outcomes were evaluated, especially cardiovascular (CV) events. Risk-benefit integrated analyses were also performed. RESULTS A total of three RCTs (4,420 patients) and three post-trial studies (2,159 patients) were included in the analysis. Use of celecoxib at any dose for 1-3 years significantly reduced the incidence of recurrent advanced adenomas (risk ratio, 0.42 [95% CI, 0.34-0.53]) and any adenomas (0.67 [95% CI, 0.62-0.72]) compared with placebo. Subgroup analysis on different dosing suggested a greater effect with 400 mg twice daily. However, celecoxib 400 mg twice daily significantly increased the risk of serious adverse (1.2 [95% CI, 1.0-1.5]) and CV events (3.42 [95% CI, 1.56-7.46]), while celecoxib at 400 mg/day, especially with once daily dosing, did not increase CV risk (1.01 [95% CI, 0.70-1.46]). Analysis of post-trial studies indicated that the treatment effect disappeared (1.15 [95% CI, 0.88-1.49]) after discontinuing celecoxib for >2 years. CONCLUSION Celecoxib 400 mg once daily dosing could potentially be considered as a viable chemopreventive option in patients with high risk of adenomas but with low CV risk. Long-term trials on celecoxib at a dose of ≤400 mg either once or twice daily are warranted.
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Affiliation(s)
- Sajesh K Veettil
- Department of Pharmacy Practice, School of Pharmacy, International Medical University, Kuala Lumpur, Malaysia
| | - Surakit Nathisuwan
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand,
| | - Siew Mooi Ching
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
- Malaysian Research Institute on Ageing, Universiti Putra Malaysia, Serdang, Malaysia
- Department of Medical Sciences, School of Healthcare and Medical Sciences, Sunway University, Selangor, Malaysia
| | - Peerawat Jinatongthai
- Division of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia,
| | - Kean Ghee Lim
- Department of Surgery, Clinical School, International Medical University, Seremban, Malaysia
| | - Siang Tong Kew
- Department of Internal Medicine, School of Medicine, International Medical University, Kuala Lumpur, Malaysia
| | - Nathorn Chaiyakunapruk
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Selangor, Malaysia,
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Center of Pharmaceutical Outcomes Research, Naresuan University, Phitsanulok, Thailand,
- School of Pharmacy, University of Wisconsin, Madison, WI, USA,
- Asian Centre for Evidence Synthesis in Population, Implementation and Clinical Outcomes (PICO), Health and Well-being Cluster, Global Asia in the 21st Century (GA21) Platform, Monash University Malaysia, Selangor, Malaysia,
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Subramanian S, Hoover S, Tangka FKL, DeGroff A, Soloe CS, Arena LC, Schlueter DF, Joseph DA, Wong FL. A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program. Cancer 2018; 124:4154-4162. [PMID: 30359464 DOI: 10.1002/cncr.31686] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/12/2018] [Accepted: 06/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community. METHODS The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program. RESULTS Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions. CONCLUSIONS Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality.
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Affiliation(s)
| | | | - Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy DeGroff
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Dara F Schlueter
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Djenaba A Joseph
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Faye L Wong
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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What Happened to Disparities in CRC Screening Among FFS Medicare Enrollees Following Medicare Modernization? J Racial Ethn Health Disparities 2018; 6:273-291. [PMID: 30232793 DOI: 10.1007/s40615-018-0522-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/24/2018] [Accepted: 08/07/2018] [Indexed: 12/21/2022]
Abstract
The Medicare Modernization Act of 2003, implemented in 2006, increased managed care options for seniors. It introduced insurance plans for prescription drug coverage for all Medicare beneficiaries, whether they were enrolled in FFS or managed care (Medicare Advantage) plans. The availability of drug coverage beginning in 2006 served to free up budgets for FFS Medicare enrollees that could be used to make copayments for colorectal cancer (CRC) screening using endoscopy (colonoscopy or sigmoidoscopy). In 2007, Medicare eliminated the copayments required by seniors for CRC screening by endoscopy. Later in 2008, CRC screening by colonoscopy became part of the gold standard for CRC screening. This legitimized its use and offered even further encouragement to seniors, who may have been reluctant to undergo the procedure because of the non-pecuniary risks associated with it. In addition, 37 CRC screening interventions occurred during this timeframe to enhance compliance with screening standards. Using multilevel analysis of individuals' endoscopy utilization, derived from 100% FFS Medicare claims, along with county-level market and contextual factors, we compare the periods before and after the MMA (2001-2005 to 2006-2009) to determine whether disparities in the utilization of endoscopic CRC screening occurred or changed over the decade. We examined Blacks, Asians, and Hispanics relative to Whites, and Females relative to Males (with race or ethnicity combined). We examined each state separately for evidence of disparities within states, to avoid confounding by geographic disparities. We expected that the net effect of the policy changes and the targeted interventions over the decade would be to increase CRC screening by endoscopy, reducing disparities. We saw improvements over time (reduced disparities relative to Whites) for Blacks and Hispanics residing in several states, and improvements over time for Females relative to Males in many states. For the vast majority of states, however, disparities persisted with Whites and Males exhibiting greater rates of utilization than other groups. States that undertook the interventions were more likely to have had improvements in disparities or positive disparities for women and minorities. While some gains were made over this time period, the gains were unevenly distributed across the USA and more work needs to be done to reduce remaining disparities.
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Performance of a quantitative fecal immunochemical test for detecting advanced colorectal neoplasia: a prospective cohort study. BMC Cancer 2018; 18:509. [PMID: 29720130 PMCID: PMC5932873 DOI: 10.1186/s12885-018-4402-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The fecal immunochemical test (FIT) is easier to use and more sensitive than the guaiac fecal occult blood test, but it is unclear how to optimize FIT performance. We compared the sensitivity and specificity for detecting advanced colorectal neoplasia between single-sample (1-FIT) and two-sample (2-FIT) FIT protocols at a range of hemoglobin concentration cutoffs for a positive test. METHODS We recruited 2,761 average-risk men and women ages 49-75 referred for colonoscopy within a large nonprofit, group-model health maintenance organization (HMO), and asked them to complete two separate single-sample FITs. We generated receiver-operating characteristic (ROC) curves to compare sensitivity and specificity estimates for 1-FIT and 2-FIT protocols among those who completed both FIT kits and colonoscopy. We similarly compared sensitivity and specificity between hemoglobin concentration cutoffs for a single-sample FIT. RESULTS Differences in sensitivity and specificity between the 1-FIT and 2-FIT protocols were not statistically significant at any of the pre-specified hemoglobin concentration cutoffs (10, 15, 20, 25, and 30 μg/g). There was a significant difference in test performance of the one-sample FIT between 50 ng/ml (10 μg/g) and each of the higher pre-specified cutoffs. Disease prevalence was low. CONCLUSIONS A two-sample FIT is not superior to a one-sample FIT in detection of advanced adenomas; the one-sample FIT at a hemoglobin concentration cutoff of 50 ng/ml (10 μg/g) is significantly more sensitive for advanced adenomas than at higher cutoffs. These findings apply to a population of younger, average-risk patients in a U.S. integrated care system with high rates of prior screening.
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Pain Town, an Agent-Based Model of Opioid Use Trajectories in a Small Community. SOCIAL, CULTURAL, AND BEHAVIORAL MODELING 2018. [DOI: 10.1007/978-3-319-93372-6_31] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Majidi A, Majidi S, Salimzadeh S, Khazaee- Pool M, Sadjadi A, Salimzadeh H, Delavari A. Cancer Screening Awareness and Practice in a Middle Income Country; A Systematic Review from Iran. Asian Pac J Cancer Prev 2017; 18:3187-3194. [PMID: 29281865 PMCID: PMC5980869 DOI: 10.22034/apjcp.2017.18.12.3187] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: Ageing population and noticeable changes in lifestyle in developing countries like Iran caused an
increase in cancer incidence. This requires organized cancer prevention and screening programs in population level,
but most importantly community should be aware of these programs and willing to use them. This study explored
existing evidence on public awareness and practice, as well as, adherence to cancer screening in Iranian population.
Methods: Major English databases including Web of Science, PubMed, Scopus, and domestic Persian databases i.e.,
SID, Magiran, and Barakat search engines were searched. All publications with focus on Iranian public awareness
about cancer prevention, screening, and early detection programs which were published until August 2015, were
explored in this systematic review. For this purpose, we used sensitive Persian phrases/key terms and English keywords
which were extracted from medical subject headings (MeSH). Taking PRISMA guidelines into considerations eligible
documents, were evaluated and abstracted by two separate reviewers. Results: We found 72 articles relevant to this
topic. Screening tests were known to, or being utilized by only a limited number of Iranians. Most Iranian women relied
on physical examination particularly self-examination, instead of taking mammogram, as the most standard test to find
breast tumors. Less than half of the average-risk adult populations were familiar with colorectal cancer risk factors and
its screening tests, and only very limited number of studies reported taking at least one time colonoscopy or FOBT,
at most 5.0% and 15.0%, respectively. Around half of women were familiar with cervical cancer and Pap-smear test
with less than 45% having completed at least one lifetime test. The lack of health insurance coverage was a barrier to
participate in screening tests. Furthermore some people would not select to be screened only because they do not know
how or where they can receive these services. Conclusion: Low awareness and suboptimal use of screening tests in
Iran calls for effective programs to enhance intention and compliance to screening, improving the patient-physician
communication, identifying barriers for screening and providing tailored public awareness and screening programs.
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Affiliation(s)
- Azam Majidi
- Digestive Oncology Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
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Peterse EFP, Meester RGS, Gini A, Doubeni CA, Anderson DS, Berger FG, Zauber AG, Lansdorp-Vogelaar I. Value Of Waiving Coinsurance For Colorectal Cancer Screening In Medicare Beneficiaries. Health Aff (Millwood) 2017; 36:2151-2159. [PMID: 29200350 PMCID: PMC6067012 DOI: 10.1377/hlthaff.2017.0228] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Financial barriers to colorectal cancer screening persist despite the Affordable Care Act (ACA). Medicare beneficiaries may face 20 percent coinsurance for a screening colonoscopy when the procedure includes the removal of polyps or follows a positive fecal screening test. Using an established microsimulation model, we estimated that waiving this coinsurance would result in 1.7 fewer colorectal cancer deaths (a decrease of 13 percent) and $17,000 higher colorectal cancer-related costs (an increase of 0.6 percent) for the Centers for Medicare and Medicaid Services per 1,000 sixty-five-year-olds, assuming a 10-percentage-point increase in the rates of first colonoscopy screening, follow-up, and surveillance. If the rates did not change, waiving coinsurance would increase total costs by $51,000 (1.9 percent) per 1,000 sixty-five-year-olds. Estimated screening benefits were comparable when fecal testing was assumed to be the primary screening method. Moreover, waiving coinsurance would be cost-effective if the screening rate increased by 0.6 percentage points, assuming a willingness-to-pay threshold of $50,000 per quality-adjusted life-year gained. Thus, the waiver is likely to have a favorable balance of health and cost impact.
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Affiliation(s)
- Elisabeth F P Peterse
- Elisabeth F. P. Peterse ( ) is a PhD candidate in the Department of Public Health, Erasmus University Medical Center, in Rotterdam, the Netherlands
| | - Reinier G S Meester
- Reinier G. S. Meester is a postdoctoral researcher in the Department of Public Health, Erasmus University Medical Center
| | - Andrea Gini
- Andrea Gini is a PhD candidate in the Department of Public Health, Erasmus University Medical Center
| | - Chyke A Doubeni
- Chyke A. Doubeni is an associate professor in the Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, in Philadelphia
| | - Daniel S Anderson
- Daniel S. Anderson is a staff gastoenterologist in the Southern California Kaiser Permanente Group, in San Diego
| | - Franklin G Berger
- Franklin G. Berger is the George H. Bunch Professor in the Department of Biological Sciences and director of Center for Colon Cancer Research, both in the Jones Physical Sciences Center, University of South Carolina, in Columbia
| | - Ann G Zauber
- Ann G. Zauber is a member, attending biostatistician in the Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, in New York City
| | - Iris Lansdorp-Vogelaar
- Iris Lansdorp-Vogelaar is an associate professor in the Department of Public Health, Erasmus University Medical Center
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Tangka FKL, Subramanian S. Importance of implementation economics for program planning-evaluation of CDC's colorectal cancer control program. EVALUATION AND PROGRAM PLANNING 2017; 62:64-66. [PMID: 28034480 PMCID: PMC5847314 DOI: 10.1016/j.evalprogplan.2016.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA.
| | - Sujha Subramanian
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452 USA.
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Tangka FKL, Subramanian S, Hoover S, Royalty J, Joseph K, DeGroff A, Joseph D, Chattopadhyay S. Costs of promoting cancer screening: Evidence from CDC's Colorectal Cancer Control Program (CRCCP). EVALUATION AND PROGRAM PLANNING 2017; 62:67-72. [PMID: 27989647 PMCID: PMC5840873 DOI: 10.1016/j.evalprogplan.2016.12.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 12/11/2016] [Indexed: 05/02/2023]
Abstract
The Colorectal Cancer Control Program (CRCCP) provided funding to 29 grantees to increase colorectal cancer screening. We describe the screening promotion costs of CRCCP grantees to evaluate the extent to which the program model resulted in the use of funding to support interventions recommended by the Guide to Community Preventive Services (Community Guide). We analyzed expenditures for screening promotion for the first three years of the CRCCP to assess cost per promotion strategy, and estimated the cost per person screened at the state level based on various projected increases in screening rates. All grantees engaged in small media activities and more than 90% used either client reminders, provider assessment and feedback, or patient navigation. Based on all expenditures, projected cost per eligible person screened for a 1%, 5%, and 10% increase in state-level screening proportions are $172, $34, and $17, respectively. CRCCP grantees expended the majority of their funding on Community Guide recommended screening promotion strategies but about a third was spent on other interventions. Based on this finding, future CRC programs should be provided with targeted education and information on evidence-based strategies, rather than broad based recommendations, to ensure that program funds are expended mainly on evidence-based interventions.
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Affiliation(s)
- Florence K L Tangka
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA.
| | - Sujha Subramanian
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452, USA
| | - Sonja Hoover
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452, USA
| | - Janet Royalty
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Kristy Joseph
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Amy DeGroff
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Djenaba Joseph
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Sajal Chattopadhyay
- Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
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Subramanian S, Tangka FKL, Hoover S, Royalty J, DeGroff A, Joseph D. Costs of colorectal cancer screening provision in CDC's Colorectal Cancer Control Program: Comparisons of colonoscopy and FOBT/FIT based screening. EVALUATION AND PROGRAM PLANNING 2017; 62:73-80. [PMID: 28190597 PMCID: PMC5863533 DOI: 10.1016/j.evalprogplan.2017.02.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 02/06/2017] [Indexed: 05/18/2023]
Abstract
We assess annual costs of screening provision activities implemented by 23 of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) grantees and report differences in costs between colonoscopy and FOBT/FIT-based screening programs. We analysed annual cost data for the first three years of the CRCCP (July 2009-June 2011) for each screening provision activity and categorized them into clinical and non-clinical screening provision activities. The largest cost components for both colonoscopy and FOBT/FIT-based programs were screening and diagnostic services, program management, and data collection and tracking. During the first 3 years of the CRCCP, the average annual clinical cost for screening and diagnostic services per person served was $1150 for colonoscopy programs, compared to $304 for FIT/FOBT-based programs. Overall, FOBT/FIT-based programs appear to have slightly higher non-clinical costs per person served (average $1018; median $838) than colonoscopy programs (average $980; median $686). Colonoscopy-based CRCCP programs have higher clinical costs than FOBT/FIT-based programs during the 3-year study timeframe (translating into fewer people screened). Non-clinical costs for both approaches are similar and substantial. Future studies of the cost-effectiveness of colorectal cancer screening initiatives should consider both clinical and non-clinical costs.
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Affiliation(s)
- Sujha Subramanian
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452, USA.
| | - Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Sonja Hoover
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452, USA
| | - Janet Royalty
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Amy DeGroff
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Djenaba Joseph
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
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15
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Hoover S, Subramanian S, Tangka FKL, Cole-Beebe M, Sun A, Kramer CL, Pacillio G. Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies. EVALUATION AND PROGRAM PLANNING 2017; 62:81-86. [PMID: 28153341 PMCID: PMC5847315 DOI: 10.1016/j.evalprogplan.2017.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/04/2017] [Indexed: 05/18/2023]
Abstract
Many studies have documented barriers to colorectal cancer screenings. However, there is lack of comprehensive information on the time and costs borne by low-income patients and the persons accompanying the patient (caregiver) for colonoscopies in the United States. We surveyed patients in three health clinics in Philadelphia retrospectively who had undergone free colonoscopies in the previous 18-month period. Participants were asked questions about time and out-of-pockets expenses for themselves and their caregivers. Even when colonoscopies were free to the patient through Colorectal Cancer Control Program funded by the Centers for Disease Control and Prevention, the patient and caregivers still incurred costs in relation to preparing for, undergoing, and recovering from a colonoscopy. These costs can be substantial and may account for some of the low colorectal cancer screening rates especially among the low-income populations. Patients' and caregivers' costs need to be considered when designing and implementing colorectal cancer control programs.
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Affiliation(s)
- Sonja Hoover
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452, USA
| | - Sujha Subramanian
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452, USA.
| | - Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Highway, NE, Mailstop K-76, Atlanta, GA 30341-3717, USA
| | - Maggie Cole-Beebe
- RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452, USA
| | - Amy Sun
- RTI International, 307 Waverley Oaks Road, Waltham, MA 02452, USA
| | - Cheryl L Kramer
- Philadelphia Department of Public Health, Health Center 4, 4400 Haverford Avenue, Philadelphia, PA 19104, USA
| | - Gina Pacillio
- Philadelphia Department of Public Health, Health Center 4, 4400 Haverford Avenue, Philadelphia, PA 19104, USA
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16
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Personalized medicine for prevention: can risk stratified screening decrease colorectal cancer mortality at an acceptable cost? Cancer Causes Control 2017; 28:299-308. [DOI: 10.1007/s10552-017-0864-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 02/01/2017] [Indexed: 12/15/2022]
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van der Steen A, Knudsen AB, van Hees F, Walter GP, Berger FG, Daguise VG, Kuntz KM, Zauber AG, van Ballegooijen M, Lansdorp-Vogelaar I. Optimal colorectal cancer screening in states' low-income, uninsured populations—the case of South Carolina. Health Serv Res 2015; 50:768-89. [PMID: 25324198 PMCID: PMC4450929 DOI: 10.1111/1475-6773.12246] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To determine whether, given a limited budget, a state's low-income uninsured population would have greater benefit from a colorectal cancer (CRC) screening program using colonoscopy or fecal immunochemical testing (FIT). DATA SOURCES/STUDY SETTING South Carolina's low-income, uninsured population. STUDY DESIGN Comparative effectiveness analysis using microsimulation modeling to estimate the number of individuals screened, CRC cases prevented, CRC deaths prevented, and life-years gained from a screening program using colonoscopy versus a program using annual FIT in South Carolina's low-income, uninsured population. This analysis assumed an annual budget of $1 million and a budget availability of 2 years as a base case. PRINCIPAL FINDINGS The annual FIT screening program resulted in nearly eight times more individuals being screened, and more important, approximately four times as many CRC deaths prevented and life-years gained than the colonoscopy screening program. Our results were robust for assumptions concerning economic perspective and the target population, and they may therefore be generalized to other states and populations. CONCLUSIONS A FIT screening program will prevent more CRC deaths than a colonoscopy-based program when a state's budget for CRC screening supports screening of only a fraction of the target population.
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Affiliation(s)
| | - Amy B Knudsen
- Center for Colon Cancer Research, University of South CarolinaColumbia, SC
| | - Frank van Hees
- Institute for Technology Assessment, Department of Radiology, Massachusetts General HospitalBoston, MA
| | - Gailya P Walter
- Bureau of Community Health and Chronic Disease Prevention, South Carolina Department of Health and Environmental ControlColumbia, SC
| | - Franklin G Berger
- Bureau of Community Health and Chronic Disease Prevention, South Carolina Department of Health and Environmental ControlColumbia, SC
| | - Virginie G Daguise
- Division of Health Policy and Management, School of Public Health, University of MinnesotaMinneapolis, MN
| | - Karen M Kuntz
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY
| | - Ann G Zauber
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer CenterNew York, NY
| | | | - Iris Lansdorp-Vogelaar
- Institute for Technology Assessment, Department of Radiology, Massachusetts General HospitalBoston, MA
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Liles EG, Schneider JL, Feldstein AC, Mosen DM, Perrin N, Rosales AG, Smith DH. Implementation challenges and successes of a population-based colorectal cancer screening program: a qualitative study of stakeholder perspectives. Implement Sci 2015; 10:41. [PMID: 25890079 PMCID: PMC4391591 DOI: 10.1186/s13012-015-0227-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 03/03/2015] [Indexed: 12/18/2022] Open
Abstract
Background Few studies describe system-level challenges or facilitators to implementing population-based colorectal cancer (CRC) screening outreach programs. Our qualitative study explored viewpoints of multilevel stakeholders before, during, and after implementation of a centralized outreach program. Program implementation was part of a broader quality-improvement initiative. Methods During 2008–2010, we conducted semi-structured, open-ended individual interviews and focus groups at Kaiser Permanente Northwest (KPNW), a not-for-profit group model health maintenance organization using the practical robust implementation and sustainability model to explore external and internal barriers to CRC screening. We interviewed 55 stakeholders: 8 health plan leaders, 20 primary care providers, 4 program managers, and 23 endoscopy specialists (15 gastroenterologists, 8 general surgeons), and analyzed interview transcripts to identify common as well as divergent opinions expressed by stakeholders. Results The majority of stakeholders at various levels consistently reported that an automated telephone-reminder system to contact patients and coordinate mailing fecal tests alleviated organizational constraints on staff’s time and resources. Changing to a single-sample fecal immunochemical test (FIT) lessened patient and provider concerns about feasibility and accuracy of fecal testing. The centralized telephonic outreach program did, however, result in some screening duplication and overuse. Higher rates of FIT completion and a higher proportion of positive results with FIT required more colonoscopies. Conclusions Addressing barriers at multiple levels of a health system by changing the delivery system design to add a centralized outreach program, switching to a more accurate and easier-to-use fecal test, and providing educational and electronic support had both benefits and problematic consequences. Other health care organizations can use our results to understand the complexities of implementing centralized screening programs.
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Affiliation(s)
- Elizabeth G Liles
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. .,Northwest Permanente, Kaiser Permanente Northwest, 500 NE Multnomah St, Suite 100, Portland, OR, 97232, USA.
| | - Jennifer L Schneider
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
| | - Adrianne C Feldstein
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA. .,Northwest Permanente, Kaiser Permanente Northwest, 500 NE Multnomah St, Suite 100, Portland, OR, 97232, USA.
| | - David M Mosen
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
| | - Nancy Perrin
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
| | - Ana Gabriela Rosales
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
| | - David H Smith
- Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
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Bian J, Bennett CL, Fisher DA, Ribeiro M, Lipscomb J. Unintended consequences of health information technology: evidence from veterans affairs colorectal cancer oncology watch intervention. J Clin Oncol 2012; 30:3947-52. [PMID: 23045582 DOI: 10.1200/jco.2011.39.7448] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE We evaluated the Colorectal Cancer (CRC) Oncology Watch intervention, a clinical reminder implemented in Veterans Integrated Service Network 7 (including eight hospitals) to improve CRC screening rates in 2008. PATIENTS AND METHODS Veterans Affairs (VA) administrative data were used to construct four cross-sectional groups of veterans at average risk, age 50 to 64 years; one group was created for each of the following years: 2006, 2007, 2009, and 2010. We applied hospital fixed effects for estimation, using a difference-in-differences model in which the eight hospitals served as the intervention sites, and the other 121 hospitals served as controls, with 2006 to 2007 as the preintervention period and 2009 to 2010 as the postintervention period. RESULTS The sample included 4,352,082 veteran-years in the 4 years. The adherence rates were 37.6%, 31.6%, 34.4%, and 33.2% in the intervention sites in 2006, 2007, 2009, and 2010, respectively, and the corresponding rates in the controls were 31.0%, 30.3%, 32.3%, and 30.9%. Regression analysis showed that among those eligible for screening, the intervention was associated with a 2.2-percentage point decrease in likelihood of adherence (P < .001). Additional analyses showed that the intervention was associated with a 5.6-percentage point decrease in likelihood of screening colonoscopy among the adherent, but with increased total colonoscopies (all indicators) of 3.6 per 100 veterans age 50 to 64 years. CONCLUSION The intervention had little impact on CRC screening rates for the studied population. This absence of favorable impact may have been caused by an unintentional shift of limited VA colonoscopy capacity from average-risk screening to higher-risk screening and to CRC surveillance, or by physician fatigue resulting from the large number of clinical reminders implemented in the VA.
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Affiliation(s)
- John Bian
- Associate Professor, Department of Clinical Pharmacy and Outcomes Sciences, South Carolina College of Pharmacy, 715 Sumter St, Columbia, SC 29208, USA.
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Zapka J, Klabunde CN, Taplin S, Yuan G, Ransohoff D, Kobrin S. Screening colonoscopy in the US: attitudes and practices of primary care physicians. J Gen Intern Med 2012; 27:1150-8. [PMID: 22539065 PMCID: PMC3514996 DOI: 10.1007/s11606-012-2051-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 02/14/2012] [Accepted: 03/09/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery. OBJECTIVE Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns. DESIGN Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007. PARTICIPANTS 1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists. MAIN MEASURES Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics. RESULTS The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering. CONCLUSIONS PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.
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Affiliation(s)
- Jane Zapka
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Bringing an organizational perspective to the optimal number of colorectal cancer screening options debate. J Gen Intern Med 2012; 27:376-80. [PMID: 21915765 PMCID: PMC3286551 DOI: 10.1007/s11606-011-1870-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 08/03/2011] [Accepted: 08/29/2011] [Indexed: 12/24/2022]
Abstract
Improving colorectal cancer (CRC) screening rates represents a challenge for primary care providers. Some have argued that offering a choice of CRC screening modes to patients will improve the currently low adherence rates. Others have raised concerns that offering numerous CRC screening options in practice could overwhelm patients and thus dampen enthusiasm for screening. In this article we assemble evidence to critically evaluate the relative merit of these opposing views. We find little evidence to support the hypothesis that the number of options offered will affect adherence (either positively or negatively), or that expanding the modalities offered beyond FOBT and colonoscopy will improve patient satisfaction. Therefore, we assert future decisions about the number of CRC screening modes to offer would more productively be focused on considerations such as what benefit the health-care organization would derive from offering additional modes, and how this change would affect other critical components of a successful screening program such as timely diagnosis. In light of these organizational level considerations, we agree with the assertion made by others that a screening program limited to FOBT and colonoscopy is likely to be ideal in most settings.
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Abstract
Health disparities, also known as health inequities, are systematic and potentially remediable differences in one or more aspects of health across population groups defined socially, economically, demographically, or geographically. This topic has been the subject of research stretching back at least decades. Reports and studies have delved into how inequities develop in different societies and, with particular regard to health services, in access to and financing of health systems. In this review, we consider empirical studies from the United States and elsewhere, and we focus on how one aspect of health systems, clinical care, contributes to maintaining systematic differences in health across population groups characterized by social disadvantage. We consider inequities in clinical care and the policies that influence them. We develop a framework for considering the structural and behavioral components of clinical care and review the existing literature for evidence that is likely to be generalizable across health systems over time. Starting with the assumption that health services, as one aspect of social services, ought to enhance equity in health care, we conclude with a discussion of threats to that role and what might be done about them.
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Affiliation(s)
- B Starfield
- Department of Health Policy and Management, Johns Hopkins University, USA
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Mobley LR, Subramanian S, Koschinsky J, Frech HE, Trantham LC, Anselin L. Managed care and the diffusion of endoscopy in fee-for-service Medicare. Health Serv Res 2011; 46:1905-27. [PMID: 22092022 PMCID: PMC3227000 DOI: 10.1111/j.1475-6773.2011.01301.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To determine whether Medicare managed care penetration impacted the diffusion of endoscopy services (sigmoidoscopy, colonoscopy) among the fee-for-service (FFS) Medicare population during 2001-2006. METHODS We model utilization rates for colonoscopy or sigmoidoscopy as impacted by both market supply and demand factors. We use spatial regression to perform ecological analysis of county-area utilization rates over two time intervals (2001-2003, 2004-2006) following Medicare benefits expansion in 2001 to cover colonoscopy for persons of average risk. We examine each technology in separate cross-sectional regressions estimated over early and later periods to assess differential effects on diffusion over time. We discuss selection factors in managed care markets and how failure to control perfectly for market selection might impact our managed care spillover estimates. RESULTS Areas with worse socioeconomic conditions have lower utilization rates, especially for colonoscopy. Holding constant statistically the socioeconomic factors, we find that managed care spillover effects onto FFS Medicare utilization rates are negative for colonoscopy and positive for sigmoidoscopy. The spatial lag estimates are conservative and interpreted as a lower bound on true effects. Our findings suggest that managed care presence fostered persistence of the older technology during a time when it was rapidly being replaced by the newer technology.
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