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Gautom P, Rosales AG, Petrik AF, Thompson JH, Slaughter MT, Mosso L, Hussain SA, Jimenez R, Coronado GD. Evaluating the Reach of a Patient Navigation Program for Follow-up Colonoscopy in a Large Federally Qualified Health Center. Cancer Prev Res (Phila) 2024:743153. [PMID: 38641422 DOI: 10.1158/1940-6207.capr-23-0498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/28/2024] [Accepted: 04/05/2024] [Indexed: 04/21/2024]
Abstract
Patient navigation (PN) has been shown to improve participation in cancer screening, including colorectal cancer screening, and the Community Preventive Services Task Force now recommends the practice. Despite the effectiveness of PN programs, little is known about the number of contacts needed to successfully reach patients or about the demographic and healthcare utilization factors associated with reach. PRECISE was an individual randomized study of PN vs. usual care conducted as a partnership between two large health systems in the Pacific Northwest. The navigation program was a six topic-area telephonic program designed to support patients with an abnormal fecal test result to obtain a follow-up colonoscopy. We report the number of contact attempts needed to successfully reach navigated patients. We used logistic regression to report the demographic and healthcare utilization characteristics associated with patients allocated to PN who were successfully reached. We identified 1200 patients with an abnormal FIT result, among whom 970 were randomized into the study (45.7% were female, 17.5% were Spanish-speaking, mean age was 60.8). Of the 479 patients allocated to the PN intervention, 382 (79.7%) were reached within 18 call attempts and nearly all (n = 356; 93.2%) were reached within six contact attempts. Patient characteristics associated with reach were race, county of residence, and body mass index. Our findings can guide future efforts to optimize the reach of PN programs.
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Affiliation(s)
- Priyanka Gautom
- Kaiser Permanente Center for Health Research, Portland, United States
| | | | | | | | | | - Leslie Mosso
- Sea Mar Community Health Centers, Seattle, WA, United States
| | | | - Ricardo Jimenez
- Sea Mar Community Health Centers, Seattle, WA, United States
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Coronado GD, Nyongesa DB, Petrik AF, Thompson JH, Escaron AL, Pham T, Leo MC. The Reach of Calls and Text Messages for Mailed FIT Outreach in the PROMPT Stepped-Wedge Colorectal Cancer Screening Trial. Cancer Epidemiol Biomarkers Prev 2024; 33:525-533. [PMID: 38319289 DOI: 10.1158/1055-9965.epi-23-0940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/27/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening participation. We assessed the reach and effectiveness of adding notifications to mailed FIT programs. METHODS We conducted secondary analyses of a stepped-wedge evaluation of an enhanced mailed FIT program (n = 15 clinics). Patients were stratified by prior FIT completion. Those with prior FIT were sent a text message (Group 1); those without were randomized 1:1 to receive a text message (Group 2) or live phone call (Group 3). All groups were sent automated phone call reminders. In stratified analysis, we measured reach and effectiveness (FIT completion within 6 months) and assessed patient-level associations using generalized estimating equations. RESULTS Patients (n = 16,934; 83% Latino; 72% completed prior FIT) were reached most often by text messages (78%), followed by live phone calls (71%), then automated phone calls (56%). FIT completion was higher in patients with prior FIT completion versus without [44% (Group 1) vs. 19% (Group 2 + Group 3); P < 0.01]. For patients without prior FIT, effectiveness was higher in those allocated to a live phone call [20% (Group 3) vs. 18% (Group 2) for text message; P = 0.04] and in those who personally answered the live call (28% vs. 9% no call completed; P < 0.01). CONCLUSIONS Text messages reached the most patients, yet effectiveness was highest in those who personally answered the live phone call. IMPACT Despite the broad reach and low cost of text messages, personalized approaches may more successfully boost FIT completion.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Center for Health Research, Portland, Oregon
- University of Arizona Cancer Center, Tucson, Arizona
| | | | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Anne L Escaron
- AltaMed Health Services Corporation, Los Angeles, California
| | - Tuan Pham
- AltaMed Health Services Corporation, Los Angeles, California
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon
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Coronado GD, Jenkins CL, Shuster E, Johnson C, Amy D, Cook J, Sahnow S, Zepp JM, Mummadi R. Blood-based colorectal cancer screening in an integrated health system: a randomised trial of patient adherence. Gut 2024; 73:622-628. [PMID: 38176899 DOI: 10.1136/gutjnl-2023-330980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE We evaluated whether people who had not completed a faecal immunochemical test (FIT) for colorectal cancer (CRC) screening would complete a blood-based testing option if offered one during health encounters. Blood-based screening tests for CRC could add to the total number of people screened for CRC by providing another testing alternative. DESIGN Study participants were patients aged 45-75 years at a large, integrated health system who were offered but did not complete an FIT in the prior 3-9 months and were scheduled for a clinical encounter. Individuals were randomised (1:1) to be offered a commercially available CRC blood test (Shield, Guardant Health) versus usual care. We compared 3-month CRC screening proportions in the two groups. RESULTS We randomised 2026 patients; 2004 remained eligible following postrandomisation exclusions (1003 to usual care and 1001 to blood draw offer; mean age: 60, 62% female, 80% non-Hispanic white). Of the 1001 allocated to the blood test group, 924 were recruited following chart-review exclusions; 548 (59.3%) were reached via phone, of which 280 (51.1%) scheduled an appointment with the research team. CRC screening proportions were 17.5 percentage points higher in the blood test group versus usual care (30.5% vs 13.0%; OR 2.94, 95% CI 2.34 to 3.70; p<0.001). CONCLUSION Among adults who had declined prior CRC screening, the offer of a blood-based screening test boosted CRC screening by 17.5 percentage points over usual care. Further research is needed on how to balance the favourable adherence with lower advanced adenoma detection compared with other available tests. TRIAL REGISTRATION NUMBER NCT05987709.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
- The University of Arizona Cancer Center - North Campus, Tucson, Arizona, USA
| | | | | | - Cheryl Johnson
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - David Amy
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Jennifer Cook
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Samantha Sahnow
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | - Jamilyn M Zepp
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
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Coronado GD, Bienen L, Burnett-Hartman A, Lee JK, Rutter CM. Maximizing scarce colonoscopy resources: the crucial role of Stool-Based tests. J Natl Cancer Inst 2024:djae022. [PMID: 38310359 DOI: 10.1093/jnci/djae022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/20/2023] [Accepted: 01/24/2024] [Indexed: 02/05/2024] Open
Abstract
During the COVID-19 pandemic, health systems, including federally qualified health centers (FQHCs), experienced disruptions in colorectal cancer (CRC) screening. National organizations called for greater use of at-home stool-based testing followed by colonoscopy for those with abnormal test results to limit (in-person) colonoscopy exams to people with acute symptoms, or who were high-risk. This 'stool-test-first' strategy may also be useful for adults with low-risk adenomas who are due for surveillance colonoscopy. We argue that colonoscopy is overused both as a first-line screening method in low and average risk adults and as a surveillance tool among adults with small adenomas. Yet, simultaneously, many people do not receive much-needed colonoscopies. Delivering the right screening tests at intervals that reduce the risk of CRC, while minimizing patient inconvenience and procedural risks, can strengthen health care systems. Risk stratification could improve efficiency of CRC screening, but because models that adequately predict risk are years away from clinical use, we need to optimize use of currently available technology- that is, low-cost fecal testing followed by colonoscopy for those with abnormal test results. The COVID-19 pandemic highlighted the urgent need to adapt to resource constraints around colonoscopies and showed that increased use of stool-based testing was possible. Learning how to adapt to such constraints without sacrificing patients' health, particularly for patients who receive care at FQHCs, should be a priority for CRC prevention research.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Ave, Portland, 97227, OR, USA
- University of Arizona Cancer Center, 1515 N. Campbell Ave, Tucson, 85724-5024, AZ, USA
| | - Leslie Bienen
- Independent Researcher, C3 Science, 4241 SE Liebe St, Portland, 97206, OR, USA
| | - Andrea Burnett-Hartman
- Kaiser Permanente Colorado, Institute for Health Research, 2550 S Parker Rd, Aurora, 80014, CO, USA
| | - Jeffrey K Lee
- Division of Research, Kaiser Permanente Northern California, Oakland, PO Box 12923, CA, USA, 94604-2923
| | - Carolyn M Rutter
- Fred Hutchinson Cancer Center, Hutchinson Institute for Cancer Outcomes Research, 1700 Fairview Ave. N, Seattle, 98109, WA, USA
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Coronado GD, Anyane-Yeboa A, Byhoff E, Escaron AL, Sonik R, Talamantes E, Neslund-Dudas C. Greater Investments in Safety Net Health Systems Can Help Diversify Participation in Clinical Trials and Research. J Gen Intern Med 2024; 39:312-315. [PMID: 37884838 PMCID: PMC10853098 DOI: 10.1007/s11606-023-08489-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023]
Affiliation(s)
| | - Adjoa Anyane-Yeboa
- Division of Gastroenterology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elena Byhoff
- University of Massachusetts Medical School, Worcester, MA, USA
| | - Anne L Escaron
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, CA, USA
| | - Rajan Sonik
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, CA, USA
- Institute on Healthcare Systems, the Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA
| | - Efrain Talamantes
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, CA, USA
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Green T, Bosworth HB, Coronado GD, DeBar L, Green BB, Huang SS, Jarvik JG, Mor V, Zatzick D, Weinfurt KP, Check DK. Factors Affecting Post-trial Sustainment or De-implementation of Study Interventions: A Narrative Review. J Gen Intern Med 2024:10.1007/s11606-023-08593-7. [PMID: 38216853 DOI: 10.1007/s11606-023-08593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 12/28/2023] [Indexed: 01/14/2024]
Abstract
In contrast to traditional randomized controlled trials, embedded pragmatic clinical trials (ePCTs) are conducted within healthcare settings with real-world patient populations. ePCTs are intentionally designed to align with health system priorities leveraging existing healthcare system infrastructure and resources to ease intervention implementation and increase the likelihood that effective interventions translate into routine practice following the trial. The NIH Pragmatic Trials Collaboratory, funded by the National Institutes of Health (NIH), supports the conduct of large-scale ePCT Demonstration Projects that address major public health issues within healthcare systems. The Collaboratory has a unique opportunity to draw on the Demonstration Project experiences to generate lessons learned related to ePCTs and the dissemination and implementation of interventions tested in ePCTs. In this article, we use case studies from six completed Demonstration Projects to summarize the Collaboratory's experience with post-trial interpretation of results, and implications for sustainment (or de-implementation) of tested interventions. We highlight three key lessons learned. First, ineffective interventions (i.e., ePCT is null for the primary outcome) may be sustained if they have other measured benefits (e.g., secondary outcome or subgroup) or even perceived benefits (e.g., staff like the intervention). Second, effective interventions-even those solicited by the health system and/or designed with significant health system partner buy-in-may not be sustained if they require significant resources. Third, alignment with policy incentives is essential for achieving sustainment and scale-up of effective interventions. Our experiences point to several recommendations to aid in considering post-trial sustainment or de-implementation of interventions tested in ePCTs: (1) include secondary outcome measures that are salient to health system partners; (2) collect all appropriate data to allow for post hoc analysis of subgroups; (3) collect experience data from clinicians and staff; (4) engage policy-makers before starting the trial.
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Affiliation(s)
- Terren Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B Bosworth
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
- Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | | | - Lynn DeBar
- Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Susan S Huang
- Irvine School of Medicine, University of California, Irvine, CA, USA
| | - Jeffrey G Jarvik
- Department of Radiology, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University and Providence Veterans Administration Medical Center, Providence, RI, USA
| | - Douglas Zatzick
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - Kevin P Weinfurt
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA
| | - Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, 215 Morris St., Suite 210, Durham, NC, 27708, USA.
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Coury J, Coronado GD, Myers E, Patzel M, Thompson J, Whidden-Rivera C, Davis MM. Engaging with Rural Communities for Colorectal Cancer Screening Outreach Using Modified Boot Camp Translation. Prog Community Health Partnersh 2024; 18:47-59. [PMID: 38661826 PMCID: PMC11047025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents and Medicaid enrollees. OBJECTIVES To address disparities, we used a modified community engagement approach, Boot Camp Translation (BCT). Research partners, an advisory board, and the rural community informed messaging about CRC outreach and a mailed fecal immunochemical test program. METHODS Eligible rural patients (English-speaking and ages 50-74) and clinic staff involved in patient outreach participated in a BCT conducted virtually over two months. We applied qualitative analysis to BCT transcripts and field notes. RESULTS Key themes included: the importance of directly communicating about the seriousness of cancer, leveraging close clinic-patient relationships, and communicating the test safety, ease, and low cost. CONCLUSIONS Using a modified version of BCT delivered in a virtual format, we were able to successfully capture community input to adapt a CRC outreach program for use in rural settings. Program materials will be tested during a pragmatic trial to address rural CRC screening disparities.
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Schneider JL, Johnson CA, Jenkins C, Mummadi R, Coronado GD. "I was screaming hallelujah": Patient and provider perceptions of blood-based testing for colorectal cancer screening. PLoS One 2023; 18:e0295685. [PMID: 38127900 PMCID: PMC10734920 DOI: 10.1371/journal.pone.0295685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/27/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Blood-based tests for colorectal cancer (CRC) screening can offer many advantages over stool-based tests such as FIT. Yet, we know little about patients' and providers' perceptions of this type of test. We report findings from a qualitative study comparing patient and provider perceptions of blood-based testing for CRC screening. METHODS Patient participants were aged 45-75 years and members of a large, integrated health system. Participants were mailed, but did not complete, a FIT through an organized FIT-screening program and were scheduled for a health-care encounter at any of nine clinical sites. Participants were consented to complete a blood draw. We used purposive sampling to select and recruit patients (who did and did not complete the blood test) and providers/specialists who would be involved in offering the blood test to patients or explaining results. We administered telephone interviews using a semi-structured interview guide and recorded and transcribed all interviews, then coded and analyzed content. RESULTS We interviewed 15 patients (11 completed and 4 did not complete the blood test) and 5 providers (3 primary care providers, one gastroenterologist (GI), and one GI medical assistant). Patients were enthusiastic about completing a blood test, citing the simplicity, ease, convenience, and high perceived accuracy of the test. Providers were also receptive to a blood-based option, if adequate test performance could be achieved and if they have information that informs patients about the pros and cons of blood-based screening versus other screening tests. CONCLUSIONS Patients and providers were willing and enthusiastic about blood-based CRC screening tests. Future research focusing on performance and communication is needed.
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Affiliation(s)
- Jennifer L. Schneider
- Center for Health Research, Kaiser Permanente, Portland, Oregon, United States of America
| | - Cheryl A. Johnson
- Center for Health Research, Kaiser Permanente, Portland, Oregon, United States of America
| | - Charisma Jenkins
- Center for Health Research, Kaiser Permanente, Portland, Oregon, United States of America
| | - Rajasekhara Mummadi
- Center for Health Research, Kaiser Permanente, Portland, Oregon, United States of America
| | - Gloria D. Coronado
- Center for Health Research, Kaiser Permanente, Portland, Oregon, United States of America
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Gupta S, Barnes A, Brenner AT, Campbell J, Davis M, English K, Hoover S, Kim K, Kobrin S, Lance P, Mishra SI, Oliveri JM, Reuland DS, Subramanian S, Coronado GD. Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science. Prev Chronic Dis 2023; 20:E112. [PMID: 38060411 PMCID: PMC10723083 DOI: 10.5888/pcd20.230083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023] Open
Abstract
Introduction Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated. Methods We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US. Results All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach. Conclusion In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.
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Affiliation(s)
- Samir Gupta
- University of California, San Diego, 3350 La Jolla Village Dr, MC 111D, PO Box 12194, San Diego, CA 92160
- Jennifer Moreno VA Healthcare System, San Diego, California
| | - Autumn Barnes
- RTI International, Research Triangle Park, North Carolina
| | - Alison T Brenner
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill
| | - Janis Campbell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City
| | | | - Kevin English
- Albuquerque Area Indian Health Board, Inc, Albuquerque, New Mexico
| | - Sonja Hoover
- RTI International, Research Triangle Park, North Carolina
| | - Karen Kim
- University of Chicago Medicine, Chicago, Illinois
| | - Sarah Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland
| | | | - Shiraz I Mishra
- University of New Mexico Comprehensive Cancer Center and Health Sciences Center, Albuquerque
| | - Jill M Oliveri
- The Ohio State University Comprehensive Cancer Center, Columbus
| | - Daniel S Reuland
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
- Division of General Medicine and Clinical Epidemiology, University of North Carolina School of Medicine, Chapel Hill
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Petrik AF, Johnson ES, Mummadi R, Slaughter M, Coronado GD, Lin SC, Savitz L, Wallace N. The use of individual and multilevel data in the development of a risk prediction model to predict patients' likelihood of completing colorectal cancer screening. Prev Med Rep 2023; 36:102366. [PMID: 37732019 PMCID: PMC10507149 DOI: 10.1016/j.pmedr.2023.102366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/22/2023] Open
Abstract
Promotion of colorectal cancer (CRC) screening can be expensive and unnecessary for many patients. The use of predictive analytics promises to help health systems target the right services to the right patients at the right time while improving population health. Multilevel data at the interpersonal, organizational, community, and policy levels, is rarely considered in clinical decision making but may be used to improve CRC screening risk prediction. We compared the effectiveness of a CRC screening risk prediction model that uses multilevel data with a more conventional model that uses only individual patient data. We used a retrospective cohort to ascertain the one-year occurrence of CRC screening. The cohort was determined from a Health Maintenance Organization, in Oregon. Eligible patients were 50-75 years old, health plan members for at least one year before their birthday in 2018 and were due for screening. We created a risk model using logistic regression first with data available in the electronic health record (EHR), and then added multilevel data. In a cohort of 59,249 patients, 36.1% completed CRC screening. The individual level model included 14 demographic, clinical and encounter based characteristics, had a bootstrap-corrected C-statistic of 0.722 and sufficient calibration. The multilevel model added 9 variables from clinical setting and community characteristics, and the bootstrap-corrected C-statistic remained the same with continued sufficient calibration. The predictive power of the CRC screening model did not improve after adding multilevel data. Our findings suggest that multilevel data added no improvement to the prediction of the likelihood of CRC screening.
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Affiliation(s)
- Amanda F. Petrik
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- Northwest Permanente, Portland, OR, USA
| | - Eric S. Johnson
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- Northwest Permanente, Portland, OR, USA
| | - Rajasekhara Mummadi
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- Northwest Permanente, Portland, OR, USA
| | | | | | - Sunny C. Lin
- Oregon Health & Science University/Portland State University School of Public Health, Portland, OR, USA
- Washington University, St. Louis, MO, USA
| | - Lucy Savitz
- Kaiser Permanente Center for Health Research, Portland, OR, USA
- University of Pittsburgh, Pittsburgh, PA, USA
| | - Neal Wallace
- Oregon Health & Science University/Portland State University School of Public Health, Portland, OR, USA
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Kenzie ES, Seater M, Wakeland W, Coronado GD, Davis MM. System dynamics modeling for cancer prevention and control: A systematic review. PLoS One 2023; 18:e0294912. [PMID: 38039316 PMCID: PMC10691687 DOI: 10.1371/journal.pone.0294912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 11/13/2023] [Indexed: 12/03/2023] Open
Abstract
Cancer prevention and control requires consideration of complex interactions between multilevel factors. System dynamics modeling, which consists of diagramming and simulation approaches for understanding and managing such complexity, is being increasingly applied to cancer prevention and control, but the breadth, characteristics, and quality of these studies is not known. We searched PubMed, Scopus, APA PsycInfo, and eight peer-reviewed journals to identify cancer-related studies that used system dynamics modeling. A dual review process was used to determine eligibility. Included studies were assessed using quality criteria adapted from prior literature and mapped onto the cancer control continuum. Characteristics of studies and models were abstracted and qualitatively synthesized. 32 studies met our inclusion criteria. A mix of simulation and diagramming approaches were used to address diverse topics, including chemotherapy treatments (16%), interventions to reduce tobacco or e-cigarettes use (16%), and cancer risk from environmental contamination (13%). Models spanned all focus areas of the cancer control continuum, with treatment (44%), prevention (34%), and detection (31%) being the most common. The quality assessment of studies was low, particularly for simulation approaches. Diagramming-only studies more often used participatory approaches. Involvement of participants, description of model development processes, and proper calibration and validation of models showed the greatest room for improvement. System dynamics modeling can illustrate complex interactions and help identify potential interventions across the cancer control continuum. Prior efforts have been hampered by a lack of rigor and transparency regarding model development and testing. Supportive infrastructure for increasing awareness, accessibility, and further development of best practices of system dynamics for multidisciplinary cancer research is needed.
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Affiliation(s)
- Erin S. Kenzie
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, Oregon, United States of America
- Systems Science Program, Portland State University, Portland, Oregon, United States of America
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Mellodie Seater
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Wayne Wakeland
- Systems Science Program, Portland State University, Portland, Oregon, United States of America
| | - Gloria D. Coronado
- Kaiser Permanente Center for Health Research, Portland, Oregon, United States of America
| | - Melinda M. Davis
- OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, Oregon, United States of America
- Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, United States of America
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Thompson JH, Rivelli JS, Escaron AL, Garcia J, Ruiz E, Torres-Ozadali E, Gautom P, Richardson DM, Thibault A, Coronado GD. Developing Patient-Refined Messaging for Follow-Up Colonoscopy After Abnormal Fecal Testing in Hispanic Communities: Key Learnings from Virtual Boot Camp Translation. Hisp Health Care Int 2023:15404153231212659. [PMID: 37936370 DOI: 10.1177/15404153231212659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
Colorectal cancer (CRC) is a leading cause of cancer death in the US. Screening by fecal immunochemical test (FIT) is a strategy to lower CRC rates. Unfortunately, only half of patients with an abnormal FIT result complete the follow-up colonoscopy, an essential component of screening. We used virtual Boot Camp Translation (BCT), to elicit input from partners to develop messaging/materials to motivate patients to complete a follow-up colonoscopy. Participants were Hispanic, ages 50 to 75 years, and Spanish-speaking. All materials were developed in English and Spanish. The first meeting included expert presentations that addressed colorectal health. The two follow-up sessions obtained feedback on messaging/materials developed based on themes from the first meeting. Ten participants attended the first meeting and eight attended the follow-up sessions. The two key barriers to follow-up colonoscopy after abnormal FIT noted by participants were (a) lack of colonoscopy awareness and (b) fear of the colonoscopy procedure. We learned that participants valued simple messaging to increase knowledge and alleviate concerns, patient-friendly outreach materials, and increased access to health information. Using virtual BCT, we included participant feedback to design culturally relevant health messages to promote follow-up colonoscopy after abnormal fecal testing among Hispanic patients served by community clinics.
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Affiliation(s)
- Jamie H Thompson
- Kaiser Permanente Center for Health Research, Portland, Oregon, USA
| | | | - Anne L Escaron
- AltaMed Health Services Institute for Health Equity, Los Angeles, CA, USA
| | - Joanna Garcia
- AltaMed Health Services Institute for Health Equity, Los Angeles, CA, USA
| | - Esmeralda Ruiz
- AltaMed Health Services Institute for Health Equity, Los Angeles, CA, USA
| | | | | | | | - Annie Thibault
- Colorectal Cancer Prevention Network, College of Arts and Sciences, University of South Carolina, Columbia, SC, USA
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Coronado GD, Nyongesa DB, Escaron AL, Petrik AF, Thompson JH, Smith D, Davis MM, Schneider JL, Rivelli JS, Laguna T, Leo MC. Effectiveness and Cost of an Enhanced Mailed Fecal Test Outreach Colorectal Cancer Screening Program: Findings from the PROMPT Stepped-Wedge Trial. Cancer Epidemiol Biomarkers Prev 2023; 32:1608-1616. [PMID: 37566431 DOI: 10.1158/1055-9965.epi-23-0597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/18/2023] [Accepted: 08/09/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening rates, yet little is known about how to optimize these programs for effectiveness and cost. METHODS PROMPT was a pragmatic, stepped-wedge, cluster-randomized effectiveness trial of mailed FIT outreach. Participants in the standard condition were mailed a FIT and received live telephone reminders to return it. Participants in the enhanced condition also received a tailored advance notification (text message or live phone call) and two automated phone call reminders. The primary outcome was 6-month FIT completion; secondary outcomes were any colorectal cancer screening completion at 6 months, implementation, and program costs. RESULTS The study included 27,585 participants (80% ages 50-64, 82% Hispanic/Latino; 68% preferred Spanish). A higher proportion of enhanced participants completed FIT at 6 months than standard participants, both in intention-to-treat [+2.8%, 95% confidence interval (CI; 0.4-5.2)] and per-protocol [limited to individuals who were reached; +16.9%, 95% CI (12.3-20.3)] analyses. Text messages and automated calls were successfully delivered to 91% to 100% of participants. The per-patient cost for standard mailed FIT was $10.84. The enhanced program's text message plus automated call reminder cost an additional $0.66; live phone calls plus an automated call reminder cost an additional $10.82 per patient. CONCLUSIONS Adding advance notifications and automated calls to a standard mailed FIT program boosted 6-month FIT completion rates at a small additional per-patient cost. IMPACT Enhancements to mailed FIT outreach can improve colorectal cancer screening participation. Future research might test the addition of educational video messaging for screening-naïve adults.
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Affiliation(s)
| | | | - Anne L Escaron
- AltaMed Health Services, Corporation, Los Angeles, California
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Dave Smith
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | | | | | - Tanya Laguna
- AltaMed Health Services, Corporation, Los Angeles, California
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon
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Schneider JL, Rivelli JS, Vaughn KA, Thompson JH, Petrik AF, Escaron AL, Coronado GD. Implementing an enhanced mailed FIT program to improve CRC screening at a federally qualified health center: experiences of patients and staff. Transl Behav Med 2023; 13:757-767. [PMID: 37210075 PMCID: PMC10538470 DOI: 10.1093/tbm/ibad025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Abstract
Colorectal cancer (CRC) is a leading cause of cancer death in the USA. Screening programs in federally qualified health centers (FQHCs) are essential to reducing CRC-related mortality and morbidity among underserved populations. Centralized, population-based mailed fecal immunochemical test (FIT) programs can improve CRC screening rates, but barriers to implementation remain. We qualitatively explored barriers and facilitators to implementation of a mailed FIT program at a large, urban FQHC that employed advance notification "primers" (live calls and texts) and automated reminders. We interviewed 25 patients and 45 FQHC staff by telephone about their experience with the program. Interviews were transcribed, coded, and content analyzed using NVivo.12. Patients and staff found advance notifications conveyed through live phone calls or text messages to be acceptable and motivational for FIT completion. Live phone primers were helpful in addressing patients' questions and misconceptions about screening, particularly for patients new to screening. Advance notifications sent by text were considered timely and useful in preparing patients for receipt of the FIT. Barriers to implementation included lack of receipt of primers, reminders, or the mailed FIT itself due to inaccurate patient contact information within the FQHC medical record; lack of systems for documenting mailed FIT outreach to coordinate with clinical care; and lack of local caller identification for primers and reminders. Our findings demonstrate that an enhanced mailed FIT program using primers and reminders was acceptable. Our findings can help other FQHCs implement and optimize their mailed FIT programs.
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Affiliation(s)
- Jennifer L Schneider
- Science Program Department, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227, USA
| | - Jennifer S Rivelli
- Science Program Department, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227, USA
| | - Katherine A Vaughn
- Science Program Department, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227, USA
| | - Jamie H Thompson
- Science Program Department, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227, USA
| | - Amanda F Petrik
- Science Program Department, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227, USA
| | - Anne L Escaron
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, 2040 Camfield Avenue, Los Angeles, CA 90040, USA
| | - Gloria D Coronado
- Science Program Department, Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227, USA
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Coronado GD, Ferrari RM, Barnes A, Castañeda SF, Cromo M, Davis MM, Doescher MP, English K, Hatcher J, Kim KE, Kobrin S, Liebovitz D, Mishra SI, Nodora JN, Norton WE, Oliveri JM, Reuland DS, Subramanian S, Thompson JH, Paskett ED. Characteristics of patient navigation programs in the Cancer Moonshot ACCSIS colorectal cancer screening initiative. J Natl Cancer Inst 2023; 115:680-694. [PMID: 36810931 PMCID: PMC10248850 DOI: 10.1093/jnci/djad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 02/01/2023] [Accepted: 02/13/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Although patient navigation has shown promise for increasing participation in colorectal cancer screening and follow-up, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative. METHODS We developed a data collection template organized by ACCSIS framework domains. The template was populated by a representative from each of the 8 ACCSIS research projects. We report standardized descriptions of 1) the socio-ecological context in which the navigation program was being conducted, 2) navigation program characteristics, 3) activities undertaken to facilitate program implementation (eg, training), and 4) outcomes used in program evaluation. RESULTS ACCSIS patient navigation programs varied broadly in their socio-ecological context and settings, the populations they served, and how they were implemented in practice. Six research projects adapted and implemented evidence-based patient navigation programs; the remaining projects developed new programs. Five projects began navigation when patients were due for initial colorectal cancer screening; 3 projects began navigation later in the screening process, when patients were due for follow-up colonoscopy after an abnormal stool-test result. Seven projects relied on existing clinical staff to deliver the navigation; 1 hired a centralized research navigator. All project researchers plan to evaluate the effectiveness and implementation of their programs. CONCLUSIONS Our detailed program descriptions may facilitate cross-project comparisons and guide future implementation and evaluation of patient navigation programs in clinical practice.
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Affiliation(s)
| | - Renée M Ferrari
- Lineberger Comprehensive Cancer Center, Carolina Cancer Screening Initiative, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - Autumn Barnes
- Research Triangle International, Research Triangle Park, NC, USA
| | - Sheila F Castañeda
- Department of Psychology, South Bay Latino Research Center, San Diego State University, Chula Vista, CA, USA
| | - Mark Cromo
- Department of Internal Medicine, Healthy Kentucky Research Building, University of Kentucky, Lexington, KY, USA
| | - Melinda M Davis
- Department of Family Medicine and School of Public Health, Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland, OR, USA
| | - Mark P Doescher
- Department of Family and Preventive Medicine, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Kevin English
- Albuquerque Area Southwest Tribal Epidemiology Center, Albuquerque Area Indian Health Board, Inc, Albuquerque, NM, USA
| | - Jenna Hatcher
- University of Arizona Cancer Center, University of Arizona, Tucson, AZ, USA
| | | | - Sarah Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - David Liebovitz
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Shiraz I Mishra
- University of New Mexico Comprehensive Cancer Center and Departments of Pediatrics and Family and Community Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Jesse N Nodora
- Department of Family Medicine and Public Health, Moores UC San Diego Cancer Center, University of California, San Diego, La Jolla, CA, USA
| | - Wynne E Norton
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Jill M Oliveri
- Comprehensive Cancer Center, Ohio State University, Columbus, OH, USA
| | - Daniel S Reuland
- Lineberger Comprehensive Cancer Center, Carolina Cancer Screening Initiative, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | | | | | - Electra D Paskett
- Department of Internal Medicine, College of Medicine and Comprehensive Cancer Center, Ohio State University, Columbus, OH, USA
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Gautom P, Escaron AL, Garcia J, Thompson JH, Rivelli JS, Ruiz E, Torres-Ozadali E, Richardson DM, Coronado GD. Developing patient-refined colorectal cancer screening materials: application of a virtual community engagement approach. BMC Gastroenterol 2023; 23:179. [PMID: 37221503 DOI: 10.1186/s12876-023-02774-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/19/2023] [Indexed: 05/25/2023] Open
Abstract
INTRODUCTION In partnership with a federally qualified health center (FQHC), an adapted virtual version of boot camp translation (BCT) was used to elicit input from Spanish-speaking Latino patients and staff to develop messaging and patient education materials for follow-up colonoscopy after abnormal fecal testing. We describe how we adapted an existing in-person BCT process to be delivered virtually and present evaluations from participants on the virtual format. METHODS Three virtual BCT sessions were facilitated by bilingual staff and conducted via Zoom. These sessions included introductions and discussions on colorectal cancer (CRC), CRC screening, and gathered feedback from participants on draft materials. Ten adults were recruited from the FQHC. A research team member from the FQHC served as the point of contact (POC) for all participants and offered Zoom introductory sessions and/or technology support before and during the sessions. Following the third session, participants were invited to complete an evaluation form about their virtual BCT experience. Using a 5-point Likert Scale (where 5 = strongly agree), questions focused on session utility, group comfort level, session pacing, and overall sense of accomplishment. RESULTS Average scores ranged from 4.3 to 5.0 indicating strong support towards the virtual BCT sessions. Additionally, our study emphasized the importance of a POC to provide technical support to participants throughout the process. Using this approach, we successfully incorporated feedback from participants to design culturally relevant materials to promote follow-up colonoscopy. CONCLUSION We recommend ongoing public health emphasis on the use of virtual platforms for community engaged work.
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Affiliation(s)
- Priyanka Gautom
- OHSU-PSU School of Public Health, 1810 SW 5th Ave, Portland, OR, 97201, USA.
| | - Anne L Escaron
- Institute for Health Equity, AltaMed Health Services Corp, 2040 Camfield Avenue, Los Angeles, CA, 90040, USA
| | - Joanna Garcia
- Institute for Health Equity, AltaMed Health Services Corp, 2040 Camfield Avenue, Los Angeles, CA, 90040, USA
| | - Jamie H Thompson
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Jennifer S Rivelli
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Esmeralda Ruiz
- Institute for Health Equity, AltaMed Health Services Corp, 2040 Camfield Avenue, Los Angeles, CA, 90040, USA
| | - Evelyn Torres-Ozadali
- Institute for Health Equity, AltaMed Health Services Corp, 2040 Camfield Avenue, Los Angeles, CA, 90040, USA
| | - Dawn M Richardson
- OHSU-PSU School of Public Health, 1810 SW 5th Ave, Portland, OR, 97201, USA
| | - Gloria D Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
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Gustavson AM, Lewinski AA, Fitzsimmons-Craft EE, Coronado GD, Linke SE, O'Malley DM, Adams AS, Glasgow RE, Klesges LM. Strategies to Bridge Equitable Implementation of Telehealth. Interact J Med Res 2023; 12:e40358. [PMID: 37184909 PMCID: PMC10227708 DOI: 10.2196/40358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 12/08/2022] [Accepted: 03/30/2023] [Indexed: 05/16/2023] Open
Abstract
During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.
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Affiliation(s)
- Allison M Gustavson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Allison A Lewinski
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, United States
- School of Nursing, Duke University, Durham, NC, United States
| | | | - Gloria D Coronado
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Sarah E Linke
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, United States
| | - Denalee M O'Malley
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, United States
| | - Alyce S Adams
- Stanford Cancer Institute, Stanford, CA, United States
| | - Russell E Glasgow
- Department of Family Medicine and Adult & Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Lisa M Klesges
- Division of Public Health Sciences, Washington University School of Medicine, St Louis, MO, United States
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Coronado GD, Ruiz E, Torres-Ozadali E, Thompson JH, Rivelli JS, Thibault A, Escaron AL. Video text messaging is needed to deliver patient education about preventive care in the United States. PLOS Digit Health 2023; 2:e0000258. [PMID: 37253020 PMCID: PMC10228759 DOI: 10.1371/journal.pdig.0000258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Gloria D. Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | - Esmeralda Ruiz
- Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California, United States of America
| | - Evelyn Torres-Ozadali
- Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California, United States of America
| | - Jamie H. Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | - Jennifer S. Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
| | - Annie Thibault
- Colorectal Cancer Prevention Network, University of South Carolina, Columbia, South Carolina, United States of America
| | - Anne L. Escaron
- Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California, United States of America
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Okasako-Schmucker DL, Peng Y, Cobb J, Buchanan LR, Xiong KZ, Mercer SL, Sabatino SA, Melillo S, Remington PL, Kumanyika SK, Glenn B, Breslau ES, Escoffery C, Fernandez ME, Coronado GD, Glanz K, Mullen PD, Vernon SW. Community Health Workers to Increase Cancer Screening: 3 Community Guide Systematic Reviews. Am J Prev Med 2023; 64:579-594. [PMID: 36543699 PMCID: PMC10033345 DOI: 10.1016/j.amepre.2022.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/21/2022] [Accepted: 10/25/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Many in the U.S. are not up to date with cancer screening. This systematic review examined the effectiveness of interventions engaging community health workers to increase breast, cervical, and colorectal cancer screening. METHODS Authors identified relevant publications from previous Community Guide systematic reviews of interventions to increase cancer screening (1966 through 2013) and from an update search (January 2014-November 2021). Studies written in English and published in peer-reviewed journals were included if they assessed interventions implemented in high-income countries; reported screening for breast, cervical, or colorectal cancer; and engaged community health workers to implement part or all of the interventions. Community health workers needed to come from or have close knowledge of the intervention community. RESULTS The review included 76 studies. Interventions engaging community health workers increased screening use for breast (median increase=11.5 percentage points, interquartile interval=5.5‒23.5), cervical (median increase=12.8 percentage points, interquartile interval=6.4‒21.0), and colorectal cancers (median increase=10.5 percentage points, interquartile interval=4.5‒17.5). Interventions were effective whether community health workers worked alone or as part of a team. Interventions increased cancer screening independent of race or ethnicity, income, or insurance status. DISCUSSION Interventions engaging community health workers are recommended by the Community Preventive Services Task Force to increase cancer screening. These interventions are typically implemented in communities where people are underserved to improve health and can enhance health equity. Further training and financial support for community health workers should be considered to increase cancer screening uptake.
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Affiliation(s)
- Devon L Okasako-Schmucker
- Community Guide Office, Office of the Associate Director for Policy and Strategy (OADPS), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Yinan Peng
- Community Guide Office, Office of the Associate Director for Policy and Strategy (OADPS), Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Jamaicia Cobb
- Community Guide Office, Office of the Associate Director for Policy and Strategy (OADPS), Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Ka Zang Xiong
- Community Guide Office, Office of the Associate Director for Policy and Strategy (OADPS), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shawna L Mercer
- Community Guide Office, Office of the Associate Director for Policy and Strategy (OADPS), Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan A Sabatino
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta Georgia
| | - Stephanie Melillo
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention, Atlanta Georgia
| | - Patrick L Remington
- Department of Population Health Sciences, Madison School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Shiriki K Kumanyika
- Department of Community Health and Prevention, Drexel University Dornsife School of Public Health, Philadelphia, Pennsylvania
| | - Beth Glenn
- Department of Health Policy & Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Erica S Breslau
- Healthcare Delivery Research Program, Division of Cancer Control & Population Sciences, National Cancer Institute, Rockville, Maryland
| | - Cam Escoffery
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Maria E Fernandez
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | | | - Karen Glanz
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patricia D Mullen
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | - Sally W Vernon
- Department of Health Promotion and Behavioral Sciences, The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
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Staman KL, Check DK, Zatzick D, Mor V, Fritz JM, Sluka K, DeBar LL, Jarvik JG, Volandes A, Coronado GD, Chambers DA, Weinfurt KP, George SZ. Intervention delivery for embedded pragmatic clinical trials: Development of a tool to measure complexity. Contemp Clin Trials 2023; 126:107105. [PMID: 36708968 PMCID: PMC10126825 DOI: 10.1016/j.cct.2023.107105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/03/2023] [Accepted: 01/23/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. METHODS We conducted a literature review, developed a tool, and conducted two rounds of phone calls with NIH Pragmatic Trials Collaboratory Demonstration Project principal investigators to develop the Intervention Delivery Complexity Tool. After refining the tool, we piloted it with Collaboratory demonstration projects and developed an online version of the tool using the R Shiny application (https://duke-som.shinyapps.io/ICT-ePCT/). RESULTS The 6-item tool consists of internal and external factors. Internal factors pertain to the intervention itself and include workflow, training, and the number of intervention components. External factors are related to intervention delivery at the system level including differences in healthcare systems, the dependency on setting for implementation, and the number of steps between the intervention and the outcome. CONCLUSION The Intervention Delivery Complexity Tool was developed as a standard way to overcome communication challenges of intervention delivery within an embedded pragmatic trial. This version of the tool is most likely to be useful to the trial team and its health system partners during trial planning and conduct. We expect further evolution of the tool as more pragmatic trials are conducted and feedback is received on its performance outside of the NIH Pragmatic Trials Collaboratory.
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Affiliation(s)
- Karen L Staman
- Duke Clinical Research Institute, CHB Wordsmith, Inc, Raleigh, NC, USA
| | - Devon K Check
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | - Lynn L DeBar
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | | | - Kevin P Weinfurt
- Population Health Sciences and Duke Clinical Research Institute, Durham, NC, USA
| | - Steven Z George
- Department of Orthopaedic Surgery and Duke Clinical Research Institute, Durham, NC, USA.
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Coronado GD, Petrik AF, Slaughter M, Kepka D, Naleway AL. Adolescents Who Have Undergone Human Papillomavirus Vaccination Are More Likely to Get a COVID-19 Vaccine. J Adolesc Health 2023; 72:985-988. [PMID: 36781325 PMCID: PMC9918864 DOI: 10.1016/j.jadohealth.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 11/22/2022] [Accepted: 12/22/2022] [Indexed: 02/13/2023]
Abstract
PURPOSE Human papillomavirus (HPV) and COVID-19 vaccination are both recommended for adolescents of ages 12-17. In May 2021, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices allowed the two vaccines to be administered concurrently. METHODS We identified adolescents of ages 12-17 using electronic health records from a large integrated delivery system. We assessed associations between socio-demographic characteristics and uptake of HPV vaccination and COVID-19 vaccination, as well as the cumulative proportion of adolescents who obtained a COVID-19 vaccine over time by HPV vaccination status. RESULTS We identified 40,819 adolescents; 65% had received any COVID-19 vaccination, and 79% had received any HPV vaccination. Adolescents who had initiated HPV vaccination had about 4-fold greater odds of having obtained a COVID-19 vaccine than those who had not (odds ratio = 4.02, 95% confidence interval = 3.81, 4.24). DISCUSSION Patterns of vaccination uptake suggest possible advantages to co-promotion of adolescent vaccines.
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Affiliation(s)
- Gloria D. Coronado
- Kaiser Permanente Center for Health Research, Portland, Oregon,Address correspondence to: Gloria D. Coronado, Ph.D., Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227
| | | | | | - Deanna Kepka
- University of Utah School of Nursing, Salt Lake City, Utah
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Davis MM, Coury J, Larson JH, Gunn R, Towey EG, Ketelhut A, Patzel M, Ramsey K, Coronado GD. Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot. J Rural Health 2023; 39:279-290. [PMID: 35703582 PMCID: PMC9969840 DOI: 10.1111/jrh.12685] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer (CRC) screening rates. We piloted a collaborative mailed FIT program with health plans and rural clinics to evaluate preliminary effectiveness and refine implementation strategies. METHODS We conducted a single-arm study using a convergent, parallel mixed-methods design to evaluate the implementation of a collaborative mailed FIT program. Enrollees were identified using health plan claims and confirmed via clinic scrub. The intervention included a vendor-delivered automated phone call (auto-call) prompt, FIT mailing, and reminder auto-call; clinics were encouraged to make live reminder calls. Practice facilitation was the primary implementation strategy. At 12 months post mailing, we assessed the rates of: (1) mailed FIT return and (2) completion of any CRC screening. We took fieldnotes and conducted postintervention key informant interviews to assess implementation outcomes (eg, feasibility, acceptability, and adaptations). RESULTS One hundred and sixty-nine Medicaid or Medicare enrollees were mailed a FIT. Over the 12-month intervention, 62 participants (37%) completed screening of which 21% completed the mailed FIT (most were returned within 3 months), and 15% screened by other methods (FITs distributed in-clinic, colonoscopy). Enrollee demographics and the reminder call may encourage mailed FIT completion. Program feasibility and acceptability was high and supported by perceived positive benefit, alignment with existing workflows, adequate staffing, and practice facilitation. CONCLUSION Collaborative health plan-clinic mailed FIT programs are feasible and acceptable for implementation in rural clinics and support CRC screening completion. Studies that pragmatically test collaborative approaches to mailed FIT and patient navigation follow-up after abnormal FIT and support broad scale-up in rural settings are needed.
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Affiliation(s)
- Melinda M. Davis
- Oregon Rural Practice-based Research Network, Portland, Oregon, USA,Department of Family Medicine and School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Jen Coury
- Oregon Rural Practice-based Research Network, Portland, Oregon, USA
| | | | | | | | | | - Mary Patzel
- Oregon Rural Practice-based Research Network, Portland, Oregon, USA
| | - Katrina Ramsey
- Biostatistics, Epidemiology, and Research Design (BERD) Program, Oregon Health & Science University, Portland, Oregon, USA
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Thompson JH, Rivelli J, Schneider J, Petrik AF, Coronado GD. Abstract A019: Impact of COVID-19 on patient navigation services for follow-up colonoscopy after abnormal fecal testing in community health centers. Cancer Res 2022. [DOI: 10.1158/1538-7445.crc22-a019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Abstract
Introductory sentence about purpose of the study: The PRECISE study tests the effectiveness of a targeted patient navigation program for follow-up colonoscopy after abnormal fecal testing in community health centers. We present adaptations of the patient navigation program resulting from the impact of the COVID-19 pandemic. Brief description of pertinent experimental procedures: Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after an abnormal FIT result to prevent CRC or find it in early, treatable forms. Unfortunately, almost half of patients with an abnormal FIT result fail to complete this essential screening component. Patient navigation can provide needed support for patients to complete a follow-up colonoscopy. PRECISE is a collaboration with a large community health center whose patient population is 37% Latino. Eligible patients were aged 50-75, had an abnormal FIT result in the past month, and were due for a follow-up colonoscopy. Patients were randomized to patient navigation or usual care. Patient navigation was delivered by a bilingual (English and Spanish) patient navigator using a six-topic phone-based protocol, adapted from the New Hampshire Colorectal Cancer Screening Program. Summary of new, unpublished data: A total of 985 patients were enrolled in the PRECISE study, 489 randomized to the intervention arm and 496 to the control arm. Due to the COVID-19 pandemic, we made adaptations to the navigator training program and navigation delivery. We converted our in-person training program to a virtual navigation training series combining pre-recorded videos and live webinars. Additionally, we strengthened relationships with GI practices to expedite referrals, improve scheduling processes, and better understand COVID-related policy changes including the conversion of some pre-procedure consultations to a phone-based platform and COVID-19 testing requirements prior to the colonoscopy. Finally, we adapted patient navigator messages to address fear and anxiety about getting medical care during the peak COVID-19 pandemic. Preliminary patient navigation outcomes will be available in September 2022. Statement of conclusions: This innovative clinical trial highlights the importance of patient navigation to improve CRC screening in community health centers. Rapid response to COVID-19 provided the opportunity to adapt our navigator program for a virtual setting allowing for 1) the sustainability of patient navigation during the pandemic and 2) the broadening of training resources for patient navigators and community health workers.
Citation Format: Jamie H. Thompson, Jennifer Rivelli, Jennifer Schneider, Amanda F. Petrik, Gloria D. Coronado. Impact of COVID-19 on patient navigation services for follow-up colonoscopy after abnormal fecal testing in community health centers [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer; 2022 Oct 1-4; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;82(23 Suppl_1):Abstract nr A019.
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Coronado GD, Burnett-Hartman A, Lee J, McMullen C, Rutter C, McBurnie MA, Neslund-Dudas C, Carethers J. Abstract A011: Building a data resource to advance research on early-onset colorectal cancer: The consortium for research on early-onset colorectal cancer (CREO). Cancer Res 2022. [DOI: 10.1158/1538-7445.crc22-a011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Abstract
Introductory sentence indicating purpose of the study: Over the last three decades, incidence of colorectal cancer (CRC) has risen steadily among people younger than age 50 (early-onset) in many developed countries, including the United States. More information is needed about the causes of early-onset CRC and novel, pragmatic interventions are needed to ensure rapid identification of early-onset CRC cases through timely screening and symptoms detection. Brief description of pertinent experimental procedures: The Consortium for Research on Early-Onset Colorectal Cancer (CREO) is a partnership among scientists and clinicians at four data-contributing health systems: Kaiser Permanente Northwest, Kaiser Permanente Northern California, and Kaiser Permanente Colorado, and Henry Ford Health. CREO plans to assemble a novel cohort of 8 million adults (including 3,200 early-onset CRC cases diagnosed from 2010 through 2025) encompassing electronic health record, survey, and biospecimen data to conduct research that will identify and estimate the impact of approaches to rapidly detect early-onset CRC through screening and clinical practice. Using electronic health record data from our participating health systems, we identified individuals diagnosed with CRC between 2010 and 2020. Here, we describe demographic and tumor characteristics of individuals with CRC in this cohort, and compare those to national data obtained from the Surveillance, Epidemiology, and End-Results program for the years 2012 – 2016. Summary of the new, unpublished data: We identified 15,884 adults with CRC (1,932 with early-onset CRC and 13,912 with late-onset CRC) in the four participating CREO health systems. Individuals with early-onset CRC in the CREO cohort were non-Hispanic White (54%), Hispanic (18%), Asian-American (14%), and African American/Black (9%). The proportion of CREO cohort adults with early-onset CRC was 12%; this matched the proportion in the population-based SEER data. The proportion of diagnosed CRC cases located in the rectum was 29% in both the CREO cohort and in SEER data. Anatomic location for the remaining tumors varied slightly between the CREO cohort and SEER data: in CREO data, 22% were proximal colon cancers, and 31% were distal colon cancers; in SEER data, and 29% were proximal and 22% were distal. Statement of the conclusions: Our findings show that CREO’s assembled cohort of electronic health record data from multiple large health systems matches several key aspects of population-based data from SEER. Through CREO, we plan to create a comprehensive, multi-level dataset of a new, racially and ethnically diverse cohort of 8 million adults in order to elucidate factors associated with the alarming rise in early-onset CRC and identify interventions to ensure rapid identification and secondary prevention of early-onset CRC.
Citation Format: Gloria D. Coronado, Andrea Burnett-Hartman, Jeffrey Lee, Carmit McMullen, Carolyn Rutter, Mary Ann McBurnie, Christine Neslund-Dudas, John Carethers. Building a data resource to advance research on early-onset colorectal cancer: The consortium for research on early-onset colorectal cancer (CREO) [abstract]. In: Proceedings of the AACR Special Conference on Colorectal Cancer; 2022 Oct 1-4; Portland, OR. Philadelphia (PA): AACR; Cancer Res 2022;82(23 Suppl_1):Abstract nr A011.
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Affiliation(s)
| | | | - Jeffrey Lee
- 3Kaiser Permanente Northern California Division of Research, San Francisco, CA,
| | - Carmit McMullen
- 1Kaiser Permanente Center for Health Research, Portland, OR,
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Escaron AL, Garcia J, Petrik AF, Ruiz E, Nyongesa DB, Thompson JH, Coronado GD. Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center. J Prim Care Community Health 2022; 13:21501319221138423. [PMID: 36448466 PMCID: PMC9716593 DOI: 10.1177/21501319221138423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC. METHODS As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients' preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient's electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes. RESULTS We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%). CONCLUSIONS Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.
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Affiliation(s)
- Anne L. Escaron
- AltaMed Health Services Corporation, Los Angeles, CA, USA,Anne L. Escaron, AltaMed Health Services Corporation, 2040 Camfield Ave, Los Angeles, CA 90040-1589, USA.
| | - Joanna Garcia
- AltaMed Health Services Corporation, Los Angeles, CA, USA
| | | | - Esmeralda Ruiz
- AltaMed Health Services Corporation, Los Angeles, CA, USA
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Coronado GD, Dickerson JF, Burnett-Hartman AN, Carethers JM, Lee JK, McBurnie MA, Petrik A, Keast E, Hendren S, McMullen C, Mummadi R, Murphy CC, Rutter CM. Reduced Implementation and Completion of Average-Risk Annual Fecal Immunochemical Test Colorectal Cancer Screening in Black Patients Aged 45-49 Years. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00519-5. [PMID: 35644342 DOI: 10.1016/j.cgh.2022.05.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - John M Carethers
- University of Michigan Department of Internal Medicine, Ann Arbor, Michigan
| | - Jeff K Lee
- Kaiser Permanente Division of Research, Oakland, California
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Coronado GD, Leo MC, Ramsey K, Coury J, Petrik AF, Patzel M, Kenzie ES, Thompson JH, Brodt E, Mummadi R, Elder N, Davis MM. Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial. Implement Sci Commun 2022; 3:42. [PMID: 35418107 PMCID: PMC9006522 DOI: 10.1186/s43058-022-00285-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Screening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer MoonshotSM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees. Methods Phase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities. Discussion This study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. Trial registration Registered at clinicaltrial.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Katrina Ramsey
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU Biostatistics and Design Program, 3181 S.W. Sam Jackson Park Road, Mail code: CB669, Portland, OR, 97239-3098, USA
| | - Jennifer Coury
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Mary Patzel
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Erin S Kenzie
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Jamie H Thompson
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Erik Brodt
- OHSU Family Medicine, OHSU School of Medicine, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Raj Mummadi
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA
| | - Nancy Elder
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU Family Medicine, OHSU School of Medicine, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU Family Medicine, OHSU School of Medicine, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA.,OHSU-PSU School of Public Health, 3181 S.W. Sam Jackson Park Road, Mail code: L222, Portland, OR, 97239-3098, USA
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Rutter CM, May FP, Coronado GD, Pujol TA, Thomas EG, Cabreros I. Racism Is a Modifiable Risk Factor: Relationships Among Race, Ethnicity, and Colorectal Cancer Outcomes. Gastroenterology 2022; 162:1053-1055. [PMID: 34942173 DOI: 10.1053/j.gastro.2021.12.251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 01/16/2023]
Affiliation(s)
| | - Folasade P May
- David Geffen School of Medicine and UCLA Kaiser Permanente Center for Health Equity, University of California, Los Angeles, California
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Davis MM, Schneider JL, Petrik AF, Miech EJ, Younger B, Escaron AL, Rivelli JS, Thompson JH, Nyongesa D, Coronado GD. Clinic Factors Associated With Mailed Fecal Immunochemical Test (FIT) Completion: The Difference-Making Role of Support Staff. Ann Fam Med 2022; 20:123-129. [PMID: 35346927 PMCID: PMC8959740 DOI: 10.1370/afm.2772] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 07/22/2021] [Accepted: 08/17/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Mailed fecal immunochemical test (FIT) programs can facilitate colorectal cancer (CRC) screening. We sought to identify modifiable, clinic-level factors that distinguish primary care clinics with higher vs lower FIT completion rates in response to a centralized mailed FIT program. METHODS We used baseline observational data from 15 clinics within a single urban federally qualified health center participating in a pragmatic trial to optimize a mailed FIT program. Clinic-level data included interviews with leadership using a guide informed by the Consolidated Framework for Implementation Research (CFIR) and FIT completion rates. We used template analysis to identify explanatory factors and configurational comparative methods to identify specific combinations of clinic-level conditions that uniquely distinguished clinics with higher and lower FIT completion rates. RESULTS We interviewed 39 clinic leaders and identified 58 potential explanatory factors representing clinic workflows and the CFIR inner setting domain. Clinic-level FIT completion rates ranged from 30% to 56%. The configurational model for clinics with higher rates (≥37%) featured any 1 of the following 3 factors related to support staff: (1) adding back- or front-office staff in past 12 months, (2) having staff help patients resolve barriers to CRC screening, and (3) having staff hand out FITs/educate patients. The model for clinics with lower rates involved the combined absence of these same 3 factors. CONCLUSIONS Three factors related to support staff differentiated clinics with higher and lower FIT completion rates. Adding nonphysician support staff and having those staff provide enabling services might help clinics optimize mailed FIT screening programs.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-Based Research Network, Department of Family Medicine, and School of Public Health, Oregon Health & Science University, Portland, Oregon
| | | | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Edward J Miech
- Regenstrief Institute, Center for Health Services Research, Indianapolis, Indiana
| | - Brittany Younger
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California
| | - Anne L Escaron
- AltaMed Institute for Health Equity, AltaMed Health Services Corporation, Los Angeles, California
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Jamie H Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Denis Nyongesa
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Baldwin LM, Coronado GD, West II, Schwartz MR, Meenan RT, Vollmer WM, Petrik AF, Shapiro JA, Kulkarni-Sharma YR, Green BB. Health plan-based mailed fecal testing for colorectal cancer screening among dual-eligible Medicaid/Medicare enrollees: Outcomes of 2 program models. Cancer 2022; 128:410-418. [PMID: 34586630 PMCID: PMC9793727 DOI: 10.1002/cncr.33909] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Health insurance plans are increasingly offering mailed fecal immunochemical test (FIT) programs for colorectal cancer (CRC) screening, but few studies have compared the outcomes of different program models (eg, invitation strategies). METHODS This study compares the outcomes of 2 health plan-based mailed FIT program models. In the first program (2016), FIT kits were mailed to all eligible enrollees; in the second program (2018), FIT kits were mailed only to enrollees who opted in after an outreach phone call. Participants in this observational study included dual-eligible Medicaid/Medicare enrollees who were aged 50 to 75 years and were due for CRC screening (1799 in 2016 and 1906 in 2018). Six-month FIT completion rates, implementation outcomes (eg, mailed FITs sent and reminders attempted), and program-related health plan costs for each program are described. RESULTS All 1799 individuals in 2016 were sent an introductory letter and a FIT kit. In 2018, all 1906 were sent an introductory letter, and 1905 received at least 1 opt-in call attempt, with 410 (21.5%) sent a FIT. The FIT completion rate was 16.2% (292 of 1799 [95% CI, 14.5%-17.9%]) in 2016 and 14.6% (278 of 1906 [95% CI, 13.0%-16.2%]) in 2018 (P = .36). The overall implementation costs were higher in 2016 ($40,156) than 2018 ($34,899), with the cost per completed FIT slightly higher in 2016 ($138) than 2018 ($126). CONCLUSIONS An opt-in mailed FIT program achieved FIT completion rates similar to those of a program mailing to all dual-eligible Medicaid/Medicare enrollees. LAY SUMMARY Health insurance plans can use different program models to successfully mail fecal test kits for colorectal cancer screening to dual-eligible Medicaid/Medicare enrollees, with nearly 1 in 6 enrollees completing fecal testing.
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Affiliation(s)
- Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Gloria D. Coronado
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Imara I. West
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Malaika R. Schwartz
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - Richard T. Meenan
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - William M. Vollmer
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Amanda F. Petrik
- Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Jean A. Shapiro
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Beverly B. Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
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Coronado GD. Sustainable infrastructure and risk stratification are needed to appropriately deliver colorectal cancer screening globally. Cancer 2022; 128:1165-1167. [PMID: 34985770 DOI: 10.1002/cncr.34059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/22/2021] [Accepted: 11/26/2021] [Indexed: 11/06/2022]
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Karlitz JJ, Fendrick AM, Bhatt J, Coronado GD, Jeyakumar S, Smith NJ, Plescia M, Brooks D, Limburg P, Lieberman D. Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population. Popul Health Manag 2021; 25:343-351. [PMID: 34958279 PMCID: PMC9232231 DOI: 10.1089/pop.2021.0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Outreach, including patient navigation, has been shown to increase the uptake of colorectal cancer (CRC) screening in underserved populations. This analysis evaluates the cost-effectiveness of triennial multi-target stool DNA (mt-sDNA) versus outreach, with or without a mailed annual fecal immunochemical test (FIT), in a Medicaid population. A microsimulation model estimated the incremental cost-effectiveness ratio using quality-adjusted life years (QALY), direct costs, and clinical outcomes in a cohort of Medicaid beneficiaries aged 50–64 years, over a lifetime time horizon. The base case model explored scenarios of either 100% adherence or real-world reported adherence (51.3% for mt-sDNA, 21.1% for outreach with FIT and 12.3% for outreach without FIT) with or without real-world adherence for follow-up colonoscopy (66.7% for all). Costs and outcomes were discounted at 3.0%. At 100% adherence to both screening tests and follow-up colonoscopy, mt-sDNA costed more and was less effective compared with outreach with or without FIT. When real-world adherence rates were considered for screening strategies (with 100% adherence for follow-up colonoscopy), mt-sDNA resulted in the greatest reduction in incidence and mortality from CRC (41.5% and 45.8%, respectively) compared with outreach with or without FIT; mt-sDNA also was cost-effective versus outreach with and without FIT ($32,150/QALY and $22,707/QALY, respectively). mt-sDNA remained cost-effective versus FIT, with or without outreach, under real-world adherence rates for follow-up colonoscopy. Outreach or navigation interventions, with associated real-world adherence rates to screening tests, should be considered when evaluating the cost-effectiveness of CRC screening strategies in underserved populations.
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Affiliation(s)
- Jordan J Karlitz
- Division of Gastroenterology, Denver Health Medical Center and University of Colorado School of Medicine, Denver, Colorado, USA
| | - A Mark Fendrick
- Division of General Medicine and Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, Michigan, USA
| | - Jay Bhatt
- Chicago School of Public Health, University of Illinois, Chicago, Illinois, USA
| | | | | | | | - Marcus Plescia
- Associate of State and Territorial Health Officials, Atlanta, Georgia, USA
| | | | - Paul Limburg
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
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Coronado GD, Rawlings AM, Petrik AF, Slaughter M, Johnson ES, Hannon PA, Cole A, Vu T, Mummadi RR. Precision Patient Navigation to Improve Rates of Follow-up Colonoscopy, An Individual Randomized Effectiveness Trial. Cancer Epidemiol Biomarkers Prev 2021; 30:2327-2333. [PMID: 34583969 PMCID: PMC9273475 DOI: 10.1158/1055-9965.epi-20-1793] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/17/2021] [Accepted: 09/22/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Colorectal cancer screening by annual fecal immunochemical test (FIT) with follow-up on abnormal results is a cost-effective strategy to reduce colorectal cancer incidence and mortality. Unfortunately, many patients with abnormal results do not complete a follow-up colonoscopy. We tested whether navigation targeted to patients who are unlikely to complete the procedure may improve adherence and long-term outcomes. METHODS Study participants were patients at a large, integrated health system (Kaiser Permanente Northwest) who were ages 50 to 75 and were due for a follow-up colonoscopy after a recent abnormal FIT result. Probability of adherence to follow-up was estimated at baseline using a predictive risk model. Patients whose probability was 70% or lower were randomized to receive patient navigation or usual care, with randomization stratified by probability category (<50%, 50% < 60%, 60% < 65%, 65% ≤ 70%). We compared colonoscopy completion within 6 months between the navigation and usual care groups using Cox proportional hazards regression. RESULTS Participants (n = 415; 200 assigned to patient navigation, 215 to usual care) had a mean age of 62 years, 54% were female, and 87% were non-Hispanic white. By 6 months, 76% of the patient navigation group had completed a colonoscopy, compared with 65% of the usual care group (HR = 1.35; 95% confidence interval, 1.07-1.72; log-rank P value = 0.027). CONCLUSIONS In this randomized trial, patient navigation led to improvements in follow-up colonoscopy adherence. IMPACT More research is needed to assess the value of precision-directed navigation programs.
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Affiliation(s)
- Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon.
| | - Andreea M Rawlings
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Matthew Slaughter
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Eric S Johnson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
- Northwest Permanente Medicine, Portland, Oregon
| | - Peggy A Hannon
- University of Washington School of Public Health, Seattle, Washington
| | - Allison Cole
- University of Washington School of Public Health, Seattle, Washington
- University of Washington School of Medicine, Seattle, Washington
| | - Thuy Vu
- University of Washington School of Public Health, Seattle, Washington
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Coronado GD, Nyongesa DB, Petrik AF, Thompson JH, Escaron AL, Younger B, Harbison S, Leo MC. Randomized Controlled Trial of Advance Notification Phone Calls vs Text Messages Prior to Mailed Fecal Test Outreach. Clin Gastroenterol Hepatol 2021; 19:2353-2360.e2. [PMID: 32739569 PMCID: PMC9285860 DOI: 10.1016/j.cgh.2020.07.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 07/21/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Mailing fecal immunochemical test (FITs) to individuals who are due for screening (mailed FIT outreach) increases colorectal cancer (CRC) screening. Little is known about how phone-based advance notifications (primers) affect the effectiveness of mailed FIT outreach programs. METHODS We performed a prospective study of patients at a large urban health center, 50-75 years old and due for screening, with no record of a prior FIT. Participants were randomly assigned to groups that received a live phone call primer (n = 1203) or a text message primer (n = 1622), from June through December 2018. The participants were then mailed a FIT kit, followed by 2 automated calls, and live reminder calls delivered by the care team. The main outcome was completion of FIT within 3 months of assignment to the live phone call or text message group. RESULTS Participants had a FIT completion rate of 16.8%, a mean age of 58 years, and 80% were Latino. In adjusted intention to treat analyses (n = 2825), FIT completion rates were higher in the patients assigned to receive a live phone call vs text message primer (percentage point difference, 3.3%; 95% CI, 0.4%-6.2%). Between-group differences increased to 7.3% points (95% CI, 3.6%-11.0%) in the per-protocol analysis of 2144 participants reached by the text message (1320/1622, 81%), live call (438/1203, 36%), or voice message (386/1203, 32%). This rate increased to 14.9% points (95% CI; 9.6%-20.1%) in the per-protocol analysis of 1758 participants reached by the text message or reached by the live call. CONCLUSIONS In a randomized trial, advance notification live phone calls outperformed text messages in prompting health center patients who had not previously completed a FIT to complete a mailed FIT. Clinicaltrials.gov no: NCT03167125.
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Affiliation(s)
- Gloria D. Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Denis B. Nyongesa
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Amanda F. Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Jamie H. Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | | | | | - Michael C. Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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Kepka D, Christini K, McGough E, Wagner A, Del Fiol G, Gibson B, Ayres S, Brandt HM, Mann S, Petrik AF, Coronado GD. Successful Multi-Level HPV Vaccination Intervention at a Rural Healthcare Center in the Era of COVID-19. Front Digit Health 2021; 3:719138. [PMID: 34713184 PMCID: PMC8521914 DOI: 10.3389/fdgth.2021.719138] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/21/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives: To develop and test a human papillomavirus (HPV) vaccination intervention that includes healthcare team training activities and patient reminders to reduce missed opportunities and improves the rate of appointment scheduling for HPV vaccination in a rural medical clinic in the United States. Methods: The multi-level and multi-component intervention included healthcare team training activities and the distribution of patient education materials along with technology-based patient HPV vaccination reminders for parents/caregivers and young adult patients. Missed vaccination opportunities were assessed pre- and post-intervention (n = 402 and n = 99, respectively) by retrospective chart review and compared using Pearson χ2. The patient parent/caregiver and young adult patient population (n = 80) was surveyed following the reminder messages and penalized logistic regression quantified unadjusted odds of scheduling a visit. Results: Missed opportunities for HPV vaccination declined significantly from the pre-intervention to the post-intervention period (21.6 vs. 8.1%, respectively, p = 0.002). Participants who recalled receipt of a vaccination reminder had 7.0 (95% CI 2.4–22.8) times higher unadjusted odds of scheduling a visit compared with those who did not recall receiving a reminder. The unadjusted odds of confirming that they had scheduled or were intending to schedule a follow-up appointment to receive the HPV vaccine was 4.9 (95% CI 1.51–20.59) times greater among those who had not received the vaccine for themselves or for their child. Conclusions: Results from this intervention are promising and suggest that vaccination interventions consisting of provider and support staff education and parent/caregiver and patient education materials, and reminders can reduce missed opportunities for vaccinations in rural settings.
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Affiliation(s)
- Deanna Kepka
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States.,College of Nursing, University of Utah, Salt Lake City, UT, United States
| | - Kaila Christini
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States
| | - Emily McGough
- Telluride Regional Medical Center, Telluride, CO, United States
| | - Anna Wagner
- College of Nursing, University of Utah, Salt Lake City, UT, United States
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Bryan Gibson
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Shauna Ayres
- Cancer Control and Population Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, United States
| | - Heather M Brandt
- St. Jude Children's Research Hospital and Comprehensive Cancer Center, Memphis, TN, United States
| | - Sara Mann
- School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, Portland, OR, United States
| | - Gloria D Coronado
- Kaiser Permanente Center for Health Research, Portland, OR, United States
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Coronado GD, Kihn-Stang A, Slaughter MT, Petrik AF, Thompson JH, Rivelli JS, Jimenez R, Gibbs J, Yadav N, Mummadi RR. Follow-up colonoscopy after an abnormal stool-based colorectal cancer screening result: analysis of steps in the colonoscopy completion process. BMC Gastroenterol 2021; 21:356. [PMID: 34583638 PMCID: PMC8477359 DOI: 10.1186/s12876-021-01923-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/14/2021] [Indexed: 12/23/2022] Open
Abstract
Background Delays in receiving follow-up colonoscopy after an abnormal fecal immunochemical test (FIT) result are associated with increased colorectal cancer incidence and mortality. Little is known about patterns of follow-up colonoscopy completion in federally qualified health centers. Methods We abstracted the medical records of health center patients, aged 50–75 years, who had an abnormal FIT result between August 5, 2017 and August 4, 2018 (N = 711). We assessed one-year rates of colonoscopy referral, pre-procedure visit completion, colonoscopy completion, and time to colonoscopy; associations between these outcomes and patient characteristics; and reasons for non-completion found in the medical record. Results Of the 711 patients with an abnormal FIT result, 90% were referred to colonoscopy, but only 52% completed a pre-procedure visit, and 43% completed a colonoscopy within 1 year. Median time to colonoscopy was 83 days (interquartile range: 52–131 days). Pre-procedure visit and colonoscopy completion rates were relatively low in patients aged 65–75 (vs. 50–64), who were uninsured (vs. insured) or had no clinic visit in the prior year (vs. ≥ 1 clinic visit). Common reasons listed for non-completion were that the patient declined, or the provider could not reach the patient. Discussion Efforts to improve follow-up colonoscopy rates in health centers might focus on supporting the care transition from primary to specialty gastroenterology care and emphasize care for older uninsured patients and those having no recent clinic visits. Our findings can inform efforts to improve follow-up colonoscopy uptake, reduce time to colonoscopy receipt, and save lives from colorectal cancer. Trial registration: National Clinical Trial (NCT) Identifier: NCT03925883.
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Affiliation(s)
- Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227, USA.
| | - Alexandra Kihn-Stang
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227, USA.,Oregon Health Sciences University, Portland, OR, USA
| | - Matthew T Slaughter
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227, USA
| | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227, USA
| | - Jamie H Thompson
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227, USA
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR, 97227, USA
| | | | | | - Neha Yadav
- Sea Mar Community Health Centers, Seattle, WA, USA
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Coury JK, Schneider JL, Green BB, Baldwin LM, Petrik AF, Rivelli JS, Schwartz MR, Coronado GD. Two Medicaid health plans' models and motivations for improving colorectal cancer screening rates. Transl Behav Med 2021; 10:68-77. [PMID: 30445511 DOI: 10.1093/tbm/iby094] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Screening rates for colorectal cancer (CRC) remain low, especially among certain populations. Mailed fecal immunochemical testing (FIT) outreach initiated by U.S. health plans could reach underserved individuals, while solving CRC screening data and implementation challenges faced by health clinics. We report the models and motivations of two health insurance plans implementing a mailed FIT program for age-eligible U.S. Medicaid and Medicare populations. One health plan operates in a single state with ~220,000 enrollees; the other operates in multiple states with ~2 million enrollees. We conducted in-depth qualitative interviews with key stakeholders and observed leadership and clinic staff planning during program development and implementation. Interviews were transcribed and coded using a content analysis approach; coded interview reports and meeting minutes were iteratively reviewed and summarized for themes. Between June and September 2016, nine participants were identified, and all agreed to the interview. Interviews revealed that organizational context was important to both organizations and helped shape program design. Both organizations were hoping this program would address barriers to their prior CRC screening improvement efforts and saw CRC screening as a priority. Despite similar motivations to participate in a mailed FIT intervention, contextual features of the health plans led them to develop distinct implementation models: a collaborative model using some health clinic staffing versus a centralized model operationalizing outreach primarily at the health plan. Data are not yet available on the models' effectiveness. Our findings might help inform the design of programs to deliver mailed FIT outreach.
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Affiliation(s)
| | - Jennifer L Schneider
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Science Department, Seattle, WA, USA
| | - Laura-Mae Baldwin
- University of Washington, Department of Family Medicine, Seattle, WA, USA
| | - Amanda F Petrik
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
| | - Jennifer S Rivelli
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
| | - Malaika R Schwartz
- University of Washington, Department of Family Medicine, Seattle, WA, USA
| | - Gloria D Coronado
- Kaiser Permanente, Center for Health Research, Science Department, Portland, OR, USA
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Arredondo EM, Dumbauld J, Milla M, Madanat H, Coronado GD, Haughton J, Garcia-Bigley F, Ramers C, Nodora J, Bharti B, Lopez G, Diaz M, Marquez J, Gupta S. A Promotor-Led Pilot Study to Increase Colorectal Cancer Screening in Latinos: The Juntos Contra El Cáncer Program. Health Promot Pract 2021; 22:491-501. [PMID: 32202155 PMCID: PMC8364826 DOI: 10.1177/1524839920912240] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Latinos have lower colorectal cancer (CRC) screening rates compared to other racial/ethnic groups in the United States, despite an overall increase in CRC screening over the past 10 years. To address this disparity, we implemented a promotor-led intervention to increase CRC screening test adherence in community-based settings, connecting community members with a partnering federally qualified health center. Purpose. To evaluate the Juntos Contra el Cáncer/Together Against Cancer (JUNTOS) intervention, by assessing pre-post changes in (1) CRC screening test adherence and (2) CRC knowledge and perceived barriers to CRC screening. We also assessed the feasibility and acceptability of program activities. Method. JUNTOS was a group-based intervention, delivered by promotores (community health workers), to promote CRC screening test adherence among Latino adults. The intervention consisted of a culturally tailored 2½-hour interactive workshop followed by an appointment scheduling assistance from a promotor. Workshop participants were Latino adults (males and females) aged 50 to 75 years who were not up-to-date with CRC screening guidelines. We conducted interviews before and 6 to 9 months after the workshop to assess program outcomes. Results. Of the 177 participants included, 118 reported completing the CRC screening test (66.7%) by 6 to 9 months postintervention. We observed baseline to 6- to 9-month increase in CRC knowledge and lower perceived barriers to obtaining CRC screening. Furthermore, the intervention was found to be feasible and acceptable. Conclusion. Results suggest that JUNTOS can be feasibly implemented in partnership with a federally qualified health center. The current study supports group-based CRC interventions in community and clinic settings.
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Affiliation(s)
| | - Jill Dumbauld
- University of California San Diego, La Jolla, CA, USA
| | - Maria Milla
- San Diego State University, San Diego, CA, USA
| | | | | | | | | | | | - Jesse Nodora
- University of California San Diego, La Jolla, CA, USA
| | | | - Gabriel Lopez
- Family Health Centers of San Diego, San Diego, CA, USA
| | - Mirna Diaz
- Family Health Centers of San Diego, San Diego, CA, USA
| | | | - Samir Gupta
- University of California San Diego, La Jolla, CA, USA
- VA San Diego Healthcare System, San Diego, CA, USA
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Green BB, Baldwin LM, West II, Schwartz M, Coronado GD. Low Rates of Colonoscopy Follow-up After a Positive Fecal Immunochemical Test in a Medicaid Health Plan Delivered Mailed Colorectal Cancer Screening Program. J Prim Care Community Health 2021; 11:2150132720958525. [PMID: 32912056 PMCID: PMC7488888 DOI: 10.1177/2150132720958525] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Follow-up colonoscopy after a positive fecal immunochemical test (FIT) is necessary for colorectal cancer (CRC) screening to be effective. We report colonoscopy follow-up rates after a positive FIT overall and by population characteristics in the BeneFIT demonstration pilot, a Medicaid health insurance plan-delivered mailed FIT outreach program. METHODS In 2016, 2 health insurance plans in Oregon and in Washington state mailed FIT kits to Medicaid patients who, based on claims data, were overdue for CRC screening. We report follow-up colonoscopy completion rates after positive FIT, and differences in completion rates by age, sex, race, ethnicity, preferred language, and number of primary care visits in the prior year. This research was human subjects approved with a waiver of consent for data collection. RESULTS The FIT positivity rates in Health Plan Oregon and Health Plan Washington were 7.9% (39/488) and 14.6% (125/857), respectively. Colonoscopy completion rates within 12 months of the positive test were 35.9% (14/41) in Health Plan Oregon and 32.8% (41/125) in Health Plan Washington. Colonoscopy completion rates were higher among individuals who preferred a language other than English (Non-English speakers 70.0%, English speakers 31.3%, P = .04). CONCLUSION In a health plan-delivered mailed FIT outreach program, follow-up colonoscopy rates after a positive test were low. Additional interventions are needed to assure colonoscopy after a positive FIT test and to reap the benefits of screening.
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Affiliation(s)
- Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | | | | | - Gloria D Coronado
- Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
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Davis MM, Schneider JL, Gunn R, Rivelli JS, Vaughn KA, Coronado GD. A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program. Transl Behav Med 2021; 11:540-548. [PMID: 32083287 PMCID: PMC7963281 DOI: 10.1093/tbm/ibaa010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English- and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2-3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-Based Research Network, Department of Family Medicine, and School of Public Health, Oregon Health and Science University, Mail Code, Portland, OR, USA
| | | | - Rose Gunn
- Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland, OR, USA
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Katherine A Vaughn
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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Coronado GD, Nielson CM, Keast EM, Petrik AF, Suls JM. The influence of multi-morbidities on colorectal cancer screening recommendations and completion. Cancer Causes Control 2021; 32:555-565. [PMID: 33687606 DOI: 10.1007/s10552-021-01408-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/23/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Patients' chronic disease burden can influence the likelihood that providers will recommend cancer screening and that patients will participate in it. Using data from the STOP CRC pragmatic study, we examined associations between chronic disease burden and colorectal cancer screening recommendation and use. METHODS Participating STOP CRC clinics (n = 26) received either usual care or training to implement a mailed fecal immunochemical test (FIT) outreach program. Selected clinic patients (n = 60,187 patients) were aged 50-74 and overdue for colorectal cancer screening. We used logistic regression to examine the associations between FIT recommendations and completion and patients' chronic disease burden, calculated using the Charlson Comorbidity Index and the Chronic Illness and Disability Payment System. RESULTS For each index, FIT recommendation odds were 8-9% higher among individuals with minimal chronic disease burden and 13-23% lower among individuals with high chronic disease burden (inverted U-shaped association). Among adults who were ordered a FIT, FIT completion odds were 20% lower for individuals with any, versus no, chronic condition and diminished with increasing disease burden (inverse linear association). CONCLUSIONS Analysis showed an inverted U-shaped association between patients' chronic disease burden and providers' recommendation of a FIT and an inverse linear association between patients' chronic disease burden and FIT completion. ClinicalTrials.gov registration: NCT01742065.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.
| | - Carrie M Nielson
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Erin M Keast
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA
| | - Jerry M Suls
- Center for Personalized Health, Feinstein Institute for Medical Research, New York, NY, 10022, USA
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Coury J, Miech EJ, Styer P, Petrik AF, Coates KE, Green BB, Baldwin LM, Shapiro JA, Coronado GD. What's the "secret sauce"? How implementation variation affects the success of colorectal cancer screening outreach. Implement Sci Commun 2021; 2:5. [PMID: 33431063 PMCID: PMC7802298 DOI: 10.1186/s43058-020-00104-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Mailed fecal immunochemical testing (FIT) programs can improve colorectal cancer (CRC) screening rates, but health systems vary how they implement (i.e., adapt) these programs for their organizations. A health insurance plan implemented a mailed FIT program (named BeneFIT), and participating health systems could adapt the program. This multi-method study explored which program adaptations might have resulted in higher screening rates. METHODS First, we conducted a descriptive analysis of CRC screening rates by key health system characteristics and program adaptations. Second, we generated an overall model by fitting a weighted regression line to our data. Third, we applied Configurational Comparative Methods (CCMs) to determine how combinations of conditions were linked to higher screening rates. The main outcome measure was CRC screening rates. RESULTS Seventeen health systems took part in at least 1 year of BeneFIT. The overall screening completion rate was 20% (4-28%) in year 1 and 25% (12-35%) in year 2 of the program. Health systems that used two or more adaptations had higher screening rates, and no single adaptation clearly led to higher screening rates. In year 1, small systems, with just one clinic, that used phone reminders (n = 2) met the implementation success threshold (≥ 19% screening rate) while systems with > 1 clinic were successful when offering a patient incentive (n = 4), scrubbing mailing lists (n = 4), or allowing mailed FIT returns with no other adaptations (n = 1). In year 2, larger systems with 2-4 clinics were successful with a phone reminder (n = 4) or a patient incentive (n = 3). Of the 10 systems that implemented BeneFIT in both years, seven improved their CRC screening rates in year 2. CONCLUSIONS Health systems can choose among many adaptations and successfully implement a health plan's mailed FIT program. Different combinations of adaptations led to success with health system size emerging as an important contextual factor.
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Affiliation(s)
- Jennifer Coury
- Oregon Rural Practice-based Research Network, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd., Mail Code L222, Portland, OR, 97239, USA.
| | - Edward J Miech
- Center for Health Services Research, Regenstrief Institute, Indianapolis, IN, USA
| | - Patricia Styer
- Business Administration, Southern Oregon University, Ashland, OR, USA
| | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Kelly E Coates
- Quality Improvement Program Administrator, CareOregon, Inc., Portland, OR, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Jean A Shapiro
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Chamblee, GA, USA
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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Mojica CM, Lind B, Gu Y, Coronado GD, Davis MM. Predictors of Colorectal Cancer Screening Modality Among Newly Age-Eligible Medicaid Enrollees. Am J Prev Med 2021; 60:72-79. [PMID: 33223363 PMCID: PMC8493888 DOI: 10.1016/j.amepre.2020.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 07/24/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates. METHODS Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013-June 2015) to explore predictors of colonoscopy screening (versus fecal testing). RESULTS Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4-6 (OR=1.57, 95% CI=1.15, 2.15), 7-10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0-3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening. CONCLUSIONS Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality.
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Affiliation(s)
- Cynthia M Mojica
- College of Public Health and Human Sciences, Oregon State University, Corvallis, Oregon.
| | - Bonnie Lind
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | - Yifan Gu
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon
| | | | - Melinda M Davis
- Department of Family Medicine, School of Public Health, Oregon Health & Science University, Portland, Oregon; 5Oregon Rural Practice-based Research Network, Oregon Health & Science University, Portland, Oregon
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Petrik AF, Johnson ES, Slaughter M, Rawlings A, Leo M, Thompson J, Jimenez R, Coronado GD. Abstract PO-270: The validation and redevelopment of a risk prediction model identifying patients unlikely to complete a colonoscopy following an abnormal FIT test in community clinics. Cancer Epidemiol Biomarkers Prev 2020. [DOI: 10.1158/1538-7755.disp20-po-270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Abstract
Background: Fecal testing (FIT) is an effective screening tool for colorectal cancer. If a FIT is abnormal, a follow-up colonoscopy is necessary to remove polyps or find cancers. Predicting which patients may be at risk for failing to follow-up on an abnormal fecal test could help identify patients in need of early interventions aimed at completing a colonoscopy. Using predictive analytics to determine who is unlikely to follow-up will allow health systems to tailor interventions and outreach.
Understanding the application of predictive analytics across health systems is imperative to providing appropriate care to distinct patient populations. Early interventions could decrease the disease burden if colorectal cancer is found at earlier stages. Methods: We compare two models created in two different settings. The models were created from data from FQHC’s and Logistic and Cox regressions to validate and redevelop a risk prediction model among a retrospective dataset of patients with abnormal FIT results. Results: The initial FQHC risk model included eight variables including race, clinic system, prior no-shows, insurance, prior flu shots, age, indication of anti-coagulation use, and income inequality. However, the model did not validate in a large similar health system in the Pacific Northwest. Risk factors for colonoscopy varied by county, clinics, regions, and patient populations.
Inner and outer setting variables, like referral workflows and access to colonoscopy, contributed to the likelihood of a patient completing their screening. The second model retained most predictors except for anti-coagulation use, and included new predictors like language, homeless status, prior screenings, and a comorbidity index. Conclusions: Application of a risk model helps tailor interventions to help patients complete the continuum of screening for colorectal cancer. However, health systems differ, and precision medicine is best applied when risk is understood in context and interventions are tailored for specific populations predictors.
Citation Format: Amanda F. Petrik, Eric S. Johnson, Matthew Slaughter, Andreea Rawlings, Michael Leo, Jamie Thompson, Ricardo Jimenez, Gloria D. Coronado. The validation and redevelopment of a risk prediction model identifying patients unlikely to complete a colonoscopy following an abnormal FIT test in community clinics [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-270.
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Affiliation(s)
| | - Eric S. Johnson
- 1Center for Health Research, Kaiser Northwest, Portland, OR,
| | | | | | - Michael Leo
- 1Center for Health Research, Kaiser Northwest, Portland, OR,
| | - Jamie Thompson
- 1Center for Health Research, Kaiser Northwest, Portland, OR,
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Petrik AF, Keast E, Johnson ES, Smith DH, Coronado GD. Development of a multivariable prediction model to identify patients unlikely to complete a colonoscopy following an abnormal FIT test in community clinics. BMC Health Serv Res 2020; 20:1028. [PMID: 33172444 PMCID: PMC7654150 DOI: 10.1186/s12913-020-05883-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/31/2020] [Indexed: 12/23/2022] Open
Abstract
Background Colorectal cancer (CRC) is the 3rd leading cancer killer among men and women in the US. The Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) project aimed to increase CRC screening among patients in Federally Qualified Health Centers (FQHCs) through a mailed fecal immunochemical test (FIT) outreach program. However, rates of completion of the follow-up colonoscopy following an abnormal FIT remain low. We developed a multivariable prediction model using data available in the electronic health record to assess the probability of patients obtaining a colonoscopy following an abnormal FIT test. Methods To assess the probability of obtaining a colonoscopy, we used Cox regression to develop a risk prediction model among a retrospective cohort of patients with an abnormal FIT result. Results Of 1596 patients with an abnormal FIT result, 556 (34.8%) had a recorded colonoscopy within 6 months. The model shows an adequate separation of patients across risk levels for non-adherence to follow-up colonoscopy (bootstrap-corrected C-statistic > 0.63). The refined model included 8 variables: age, race, insurance, GINI income inequality, long-term anticoagulant use, receipt of a flu vaccine in the past year, frequency of missed clinic appointments, and clinic site. The probability of obtaining a follow-up colonoscopy within 6 months varied across quintiles; patients in the lowest quintile had an estimated 18% chance, whereas patients in the top quintile had a greater than 55% chance of obtaining a follow-up colonoscopy. Conclusions Knowing who is unlikely to follow-up on an abnormal FIT test could help identify patients who need an early intervention aimed at completing a follow-up colonoscopy. Trial registration This trial was registered at ClinicalTrials.gov (NCT01742065) on December 5, 2012. The protocol is available. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05883-2.
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Affiliation(s)
- Amanda F Petrik
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR, 97381, USA.
| | - Erin Keast
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR, 97381, USA
| | - Eric S Johnson
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR, 97381, USA
| | - David H Smith
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR, 97381, USA
| | - Gloria D Coronado
- The Center for Health Research, Kaiser Permanente Northwest, 3800 N. Interstate Avenue, Portland, OR, 97381, USA
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Petrik AF, Green B, Schneider J, Miech EJ, Coury J, Retecki S, Coronado GD. Factors Influencing Implementation of a Colorectal Cancer Screening Improvement Program in Community Health Centers: an Applied Use of Configurational Comparative Methods. J Gen Intern Med 2020; 35:815-822. [PMID: 33107003 PMCID: PMC7652967 DOI: 10.1007/s11606-020-06186-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence-based programs such as mailed fecal immunochemical test (FIT) outreach can only affect health outcomes if they can be successfully implemented. However, attempts to implement programs are often limited by organizational-level factors. OBJECTIVES As part of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) pragmatic trial, we evaluated how organizational factors impacted the extent to which health centers implemented a mailed FIT outreach program. DESIGN Eight health centers participated in STOP CRC. The intervention consisted of customized electronic health record tools and clinical staff training to facilitate mailing of an introduction letter, FIT kit, and reminder letter. Health centers had flexibility in how they delivered the program. MAIN MEASURES We categorized the health centers' level of implementation based on the proportion of eligible patients who were mailed a FIT kit, and applied configurational comparative methods to identify combinations of relevant organizational-level and program-level factors that distinguished among high, medium, and low implementing health centers. The factors were categorized according to the Consolidated Framework for Implementation Research model. KEY RESULTS FIT tests were mailed to 21.0-81.7% of eligible participants at each health center. We identified a two-factor solution that distinguished among levels of implementation with 100% consistency and 100% coverage. The factors were having a centralized implementation team (inner setting) and mailing the introduction letter in advance of the FIT kit (intervention characteristics). Health centers with high levels of implementation had the joint presence of both factors. In health centers with medium levels of implementation, only one factor was present. Health centers with low levels of implementation had neither factor present. CONCLUSIONS Full implementation of the STOP CRC intervention relied on a centralized implementation team with dedicated staffing time, and the advance mailing of an introduction letter. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01742065 Registered 05 December 2012-Prospectively registered.
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Affiliation(s)
- Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA.
| | - Beverly Green
- Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Jennifer Schneider
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | | | | | | | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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Coronado GD, Schneider JL, Green BB, Coury JK, Schwartz MR, Kulkarni-Sharma Y, Baldwin LM. Health plan adaptations to a mailed outreach program for colorectal cancer screening among Medicaid and Medicare enrollees: the BeneFIT study. Implement Sci 2020; 15:77. [PMID: 32933525 PMCID: PMC7493880 DOI: 10.1186/s13012-020-01037-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 08/31/2020] [Indexed: 02/22/2023] Open
Abstract
Background Promoting uptake of evidence-based innovations in healthcare systems requires attention to how innovations are adapted to enhance their fit with a given setting. Little is known about real-world variation in how programs are delivered over time and across multiple populations and contexts, and what motivates adaptations. Methods As part of the BeneFIT study of mailed fecal immunochemical tests (FIT) to increase colorectal cancer screening, we interviewed 9 leaders from two participating Medicaid/Medicare health insurance plans to examine adaptations to their health plan-initiated mailed FIT outreach programs in the second year of implementation. We applied an adaptation and modification model developed by Stirman and colleagues to document content and context modifications made to the two programs. Results Both health plans made substantial changes to their programs in the second year; adaptations differed substantially across health plans. In Health Plan Oregon, adaptations generally targeted health centers and member populations, most content adaptations involved tailoring program components, and the program was expanded to four additional health centers. In contrast, Health Plan Washington’s second-year content adaptations were primarily at the level of members, and generally involved adding program components. Moreover, Health Plan Washington undertook large-scale context adaptations to the setting where the program was led (local vs. national), the personnel who administered the program (vendor and staffing), and the population selected for outreach (limiting outreach to dual-eligible members). Conclusions Both programs implemented a variety of adaptations that reflected the values and incentives of the broader health plan contexts. Financial incentives for screening allowed Health Plan Oregon to expand but led Health Plan Washington to offer more targeted outreach to a subset of eligible enrollees. The breadth of changes made by each health system reflects the necessity of evaluating programs in context and adjusting to specific challenges as they are identified. Further research is needed to understand the effects of these types of adaptations on program efficiency and enrollee and health system outcomes.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA.
| | - Jennifer L Schneider
- Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave., Portland, OR, 97227, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Malaika R Schwartz
- University of Washington Department of Family Medicine, Seattle, WA, USA
| | | | - Laura Mae Baldwin
- University of Washington Department of Family Medicine, Seattle, WA, USA
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Schneider JL, Rivelli JS, Gruss I, Petrik AF, Nielson CM, Green BB, Coronado GD. Barriers and Facilitators to Timely Colonoscopy Completion for Safety Net Clinic Patients. Am J Health Behav 2020; 44:460-472. [PMID: 32553027 DOI: 10.5993/ajhb.44.4.8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objectives: In this study, we conducted telephone interviews with patients in community clinics who had abnormal fecal immunochemical test (FIT) results to identify follow-up colonoscopy challenges. The FIT is an effective colorectal cancer screening method, but its value is contingent on follow-up diagnostic colonoscopy. Methods: We explored barriers at 3 timepoints: (1) abnormal FIT-result communication, (2) scheduling/completion of colonoscopy, and (3) receipt of results. We sought to understand variation in experience by both Spanish and English language patients. Results: We interviewed 32 patients (16 English; 16 Spanish), 66% of whom were women. There were 13 early completers (≤ 2 months after FIT result), 14 later completers (> 2 months after FIT result), and 5 non-completers of the colonoscopy. The greatest challenge was fear of the procedure, expressed more often by Spanish language (SL) participants and later completers. SL participants also cited cost and lack of clear communication about the need for a colonoscopy. English language (EL) participants experienced lack of reliable transportation. Conclusions: Barriers to timely colonoscopy completion following an abnormal FIT can occur at different transitions in care and vary by patient characteristics. Our findings may inform the design of programs to improve colonoscopy completion in safety net clinics.
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Affiliation(s)
- Jennifer L. Schneider
- Jennifer L. Schneider, Senior Research Associate, Center for Health Research, Kaiser Permanente Northwest, Portland, OR;,
| | - Jennifer S. Rivelli
- Jennifer S. Rivelli, Research Associate and Manager, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Inga Gruss
- Inga Gruss, Senior Research Associate, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Amanda F. Petrik
- Amanda F. Petrik, Senior Research Associate, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Carrie M. Nielson
- Carrie M. Nielson, Epidemiologist, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Beverly B. Green
- Beverly B. Green, Investigator, Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Gloria D. Coronado
- Gloria D. Coronado, Distinguished Investigator, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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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: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Meenan RT, Baldwin LM, Coronado GD, Schwartz M, Coury J, Petrik AF, West II, Green BB. Costs of Two Health Insurance Plan Programs to Mail Fecal Immunochemical Tests to Medicare and Medicaid Plan Members. Popul Health Manag 2020; 24:255-265. [PMID: 32609077 DOI: 10.1089/pop.2020.0041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BeneFIT is a 4-year observational study of a mailed fecal immunochemical test (FIT) program in 2 Medicaid/Medicare health plans in Oregon and Washington. In Health Plan Oregon's (HPO) collaborative model, HPO mails FITs that enrollees return to their clinics for processing. In Health Plan Washington's (HPW) centralized model, FITs are mailed directly to enrollees who return them to a centralized laboratory. This paper examines model-specific Year 1 development and implementation costs and estimates costs per screened enrollee. Staff completed activity-based costing spreadsheets. Non-labor costs were from study and external data. Data matched each plan's 2016 development and implementation dates. HPO development costs were $23.0K, primarily administration (eg, clinic recruitment). HPW development costs were $37.3K, 38.8% for FIT selection and mailing/tracking protocols. Year 1 implementation costs were $51.6K for HPO and $139.7K for HPW, reflecting HPW's greater outreach. Labor was 50.4% ($26.0K) of HPO's implementation costs, primarily enrollee eligibility and processing returned FITs, and was shared by HPO ($17.0K) and 6 participating clinics ($9.0K). Labor was 10.5% of HPW's implementation costs, primarily administration and enrollee eligibility. HPO's implementation costs per enrollee were 12.3% higher ($18.36) than for HPW ($16.34). Similar proportions of completed FITs among screening-eligibles produced a 15% lower cost per completed FIT in HPW ($89.75) vs. HPO ($105.79). Implementation costs for HPO only (without clinic costs) were $15.16/mailed introductory letter, $16.09/mailed FIT, and $87.35/completed FIT, comparable to HPW. Results highlight cost implications of different approaches to implementing a mailed FIT program in 2 Medicaid/Medicare health plans.
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Affiliation(s)
- Richard T Meenan
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Malaika Schwartz
- Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Jennifer Coury
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University, Portland, Oregon, USA
| | - Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Imara I West
- Department of Psychiatry, University of Washington, Seattle, Washington, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA.,Family Medicine, Washington Permanente Medical Group, Seattle, Washington, USA
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