Consensus-based framework for evaluating data modernization initiatives: the case of cancer registration and electronic reporting

As part of its data modernization initiative (DMI), the Centers for Disease Control and Prevention, Division of Cancer Prevention and Control is testing and implementing innovative solutions to improve cancer surveillance data quality and timeliness. We describe a consensus-based effort to create a framework to guide the evaluation of cancer surveillance modernization efforts by addressing specific context, processes, and costs related to cancer registration. We drew on prior theories, consulted with experts, and sought feedback from cancer registry staff. We developed the cancer surveillance systems, context, outcomes, and process evaluation (CS-SCOPE) framework to explain the ways in which cancer registry data quality, timeliness, and efficiency are impacted by external and internal contextual factors and interrelated process and content factors. The framework includes implementation measures to understand acceptability of process changes along with outcome measures to assess DMI initiation and ongoing sustainability. The framework's components and structures can be tailored for use in other DMI evaluations.

Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska

BACKGROUND

Three current and former awardees of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program launched integrated cancer screening strategies to better coordinate multiple cancer screenings (e.g., breast, cervical, colorectal). By integrating the strategies, efficiencies of administration and provision of screenings can be increased and costs can be reduced. This paper shares findings from these strategies and describes their effects.

METHODS

The Idaho Department of Health and Welfare developed a Baseline Assessment Checklist for six health systems to assess the current state of policies regarding cancer screening. We analyzed the checklist and reported the percentage of checklist components completed. In Rhode Island, we collaborated with a nurse-patient navigator, who promoted cancer screening, to collect details on patient navigation activities and program costs. We then described the program and reported total costs and cost per activity. In Nebraska, we described the experience of the state in administering an integrated contracts payment model across colorectal, breast, and cervical cancer screening and reported cost per person screened. Across all awardees, we interviewed key stakeholders.

RESULTS

In Idaho, results from the checklist offered guidance on areas for enhancement before integrated cancer screening strategies, but identified challenges, including lack of capacity, limited staff availability, and staff turnover. In Rhode Island, 76.1% of 1023 patient navigation activities were for colorectal cancer screening only, with a much smaller proportion devoted to breast and cervical cancer screening. Although the patient navigator found the discussions around multiple cancer screening efficient, patients were not always willing to discuss all cancer screenings. Nebraska changed its payment system from fee-for-service to fixed cost subawards with its local health departments, which integrated cancer screening funding. Screening uptake improved for breast and cervical cancer but was mixed for colorectal cancer screening.

CONCLUSIONS

The results from the case studies show that there are barriers and facilitators to integrating approaches to increasing cancer screening among primary care facilities. However, more research could further elucidate the viability and practicality of integrated cancer screening programs.

Integrated approaches to delivering cancer screenings to address disparities: lessons learned from the evaluation of CDC's Colorectal Cancer Control Program

Background

The Centers for Disease Control and Prevention launched the Colorectal Cancer Control Program to increase colorectal cancer screening among groups with low screening uptake. This engagement has enabled the health systems participating in the program to enhance infrastructure, systems, and process to implement interventions for colorectal cancer screening. These improvements have enabled other health promotion innovations such as the delivery of integrated interventions and supporting activities (referred to as integrated approaches) for multiple cancers. Using implementation science frameworks, the program evaluation team has examined these integrated approaches to capture the experiences of the awardees, health systems, and clinics.

Methods and results

The findings from this comprehensive evaluation are presented in a series of 3 manuscripts. The first manuscript provides a conceptual framework for integrated approaches for cancer screening to support comprehensive evaluations and offers recommendations for future research. The second manuscript presents findings on key factors that support readiness for implementing integrated approaches based on qualitative interviews guided by implementation science constructs. The final manuscript reports on the challenges and benefits of integrated approaches to increase cancer screening in primary care facilities based on lessons learned from three real-world implementation case studies.

Conclusion

Integrated models for implementing cancer screening could offer cost-effective approaches to reduce healthcare disparities. Additional implementation science-based systematic evaluations are needed to ensure integrated approaches are optimized, and cost-efficient models are scaled up.

Integrated interventions and supporting activities to increase uptake of multiple cancer screenings: conceptual framework, determinants of implementation success, measurement challenges, and research priorities

BACKGROUND

Screening for colorectal, breast, and cervical cancer has been shown to reduce mortality; however, not all men and women are screened in the USA. Further, there are disparities in screening uptake by people from racial and ethnic minority groups, people with low income, people who lack health insurance, and those who lack access to care. The Centers for Disease Control and Prevention funds two programs-the Colorectal Cancer Control Program and the National Breast and Cervical Cancer Early Detection Program-to help increase cancer screenings among groups that have been economically and socially marginalized. The goal of this manuscript is to describe how programs and their partners integrate evidence-based interventions (e.g., patient reminders) and supporting activities (e.g., practice facilitation to optimize electronic medical records) across colorectal, breast, and cervical cancer screenings, and we suggest research areas based on implementation science.

METHODS

We conducted an exploratory assessment using qualitative and quantitative data to describe implementation of integrated interventions and supporting activities for cancer screening. We conducted 10 site visits and follow-up telephone interviews with health systems and their partners to inform the integration processes. We developed a conceptual model to describe the integration processes and reviewed screening recommendations of the United States Preventive Services Task Force to illustrate challenges in integration. To identify factors important in program implementation, we asked program implementers to rank domains and constructs of the Consolidated Framework for Implementation Research.

RESULTS

Health systems integrated interventions for all screenings across single and multiple levels. Although potentially efficient, there were challenges due to differing eligibility of screenings by age, gender, frequency, and location of services. Program implementers ranked complexity, cost, implementation climate, and engagement of appropriate staff in implementation among the most important factors to success.

CONCLUSION

Integrating interventions and supporting activities to increase uptake of cancer screenings could be an effective and efficient approach, but we currently do not have the evidence to recommend widescale adoption. Detailed multilevel measures related to process, screening, and implementation outcomes, and cost are required to evaluate integrated programs. Systematic studies can help to ascertain the benefits of integrating interventions and supporting activities for multiple cancer screenings, and we suggest research areas that might address current gaps in the literature.

Assessing the impact of multicomponent interventions on colorectal cancer screening through simulation: What would it take to reach national screening targets in North Carolina?

Healthy People 2020 and the National Colorectal Cancer Roundtable established colorectal cancer (CRC) screening targets of 70.5% and 80%, respectively. While evidence-based interventions (EBIs) have increased CRC screening, the ability to achieve these targets at the population level remains uncertain. We simulated the impact of multicomponent interventions in North Carolina over 5 years to assess the potential for meeting national screening targets. Each intervention scenario is described as a core EBI with additional components indicated by the "+" symbol: patient navigation for screening colonoscopy (PN-for-Col+), mailed fecal immunochemical testing (MailedFIT+), MailedFIT+ targeted to Medicaid enrollees (MailedFIT + forMd), and provider assessment and feedback (PAF+). Each intervention was simulated with and without Medicaid expansion and at different levels of exposure (i.e., reach) for targeted populations. Outcomes included the percent up-to-date overall and by sociodemographic subgroups and number of CRC cases and deaths averted. Each multicomponent intervention was associated with increased CRC screening and averted both CRC cases and deaths; three had the potential to reach screening targets. PN-for-Col + achieved the 70.5% target with 97% reach after 1 year, and the 80% target with 78% reach after 5 years. MailedFIT+ achieved the 70.5% target with 74% reach after 1 year and 5 years. In the Medicaid population, assuming Medicaid expansion, MailedFIT + forMd reached the 70.5% target after 5 years with 97% reach. This study clarifies the potential for states to reach national CRC screening targets using multicomponent EBIs, but decision-makers also should consider tradeoffs in cost, reach, and ability to reduce disparities when selecting interventions.

Operational Characteristics of Central Cancer Registries that Support the Generation of High-Quality Surveillance Data

Objectives

We aim to assess external and internal attributes and operations of the Centers for Disease Control and Prevention (CDC)'s National Program of Cancer Registries (NPCR) central cancer registries by their consistency in meeting national data quality standards.

Methods

The NPCR 2017 Program Evaluation Instrument (PEI) data were used to assess registry operational attributes, including adoption of electronic reporting, compliance with reporting, staffing, and software used among 46 NPCR registries. These factors were stratified by (1) registries that met the NPCR 12-month standards for all years 2014-2017; (2) registries that met the NPCR 12-month standards at least once in 2014-2017 and met the NPCR 24-month standards for all years 2014-2017; and (3) registries that did not meet the NPCR 24-month standards for all years 2014-2017. Statistical tests helped identify significant differences among registries that consistently, sometimes, or seldom/never achieved data standards.

Results

Registries that always met the standards had a higher level of electronic reporting and a higher compliance with reporting among hospitals than registries that sometimes or seldom/never met the standards. Although not a statistically significant finding, the same registries also had a higher proportion of staffing positions filled, a higher proportion of certified tumor registrars, and more quality assurance and information technology staff.

Conclusions

This information may be used to understand the importance of various factors and characteristics, including the adoption of electronic reporting, that may be associated with a registry's ability to consistently meet NPCR standards. The findings may be helpful in identifying best practices for processing high-quality cancer data.

Annual Report to the Nation on the Status of Cancer, Part 1: National Cancer Statistics

BACKGROUND

The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries collaborate to provide annual updates on cancer incidence and mortality and trends by cancer type, sex, age group, and racial/ethnic group in the United States. In this report, we also examine trends in stage-specific survival for melanoma of the skin (melanoma).

METHODS

Incidence data for all cancers from 2001 through 2017 and survival data for melanoma cases diagnosed during 2001-2014 and followed-up through 2016 were obtained from the Centers for Disease Control and Prevention- and National Cancer Institute-funded population-based cancer registry programs compiled by the North American Association of Central Cancer Registries. Data on cancer deaths from 2001 to 2018 were obtained from the National Center for Health Statistics' National Vital Statistics System. Trends in age-standardized incidence and death rates and 2-year relative survival were estimated by joinpoint analysis, and trends in incidence and mortality were expressed as average annual percent change (AAPC) during the most recent 5 years (2013-2017 for incidence and 2014-2018 for mortality).

RESULTS

Overall cancer incidence rates (per 100 000 population) for all ages during 2013-2017 were 487.4 among males and 422.4 among females. During this period, incidence rates remained stable among males but slightly increased in females (AAPC = 0.2%, 95% confidence interval [CI] = 0.1% to 0.2%). Overall cancer death rates (per 100 000 population) during 2014-2018 were 185.5 among males and 133.5 among females. During this period, overall death rates decreased in both males (AAPC = -2.2%, 95% CI = -2.5% to -1.9%) and females (AAPC = -1.7%, 95% CI = -2.1% to -1.4%); death rates decreased for 11 of the 19 most common cancers among males and for 14 of the 20 most common cancers among females, but increased for 5 cancers in each sex. During 2014-2018, the declines in death rates accelerated for lung cancer and melanoma, slowed down for colorectal and female breast cancers, and leveled off for prostate cancer. Among children younger than age 15 years and adolescents and young adults aged 15-39 years, cancer death rates continued to decrease in contrast to the increasing incidence rates. Two-year relative survival for distant-stage skin melanoma was stable for those diagnosed during 2001-2009 but increased by 3.1% (95% CI = 2.8% to 3.5%) per year for those diagnosed during 2009-2014, with comparable trends among males and females.

CONCLUSIONS

Cancer death rates in the United States continue to decline overall and for many cancer types, with the decline accelerated for lung cancer and melanoma. For several other major cancers, however, death rates continue to increase or previous declines in rates have slowed or ceased. Moreover, overall incidence rates continue to increase among females, children, and adolescents and young adults. These findings inform efforts related to prevention, early detection, and treatment and for broad and equitable implementation of effective interventions, especially among under resourced populations.

Utility of linking survey and registry data to evaluate interventions and policies to address disparities in breast cancer survivorship among young women

PURPOSE

There is limited research linking data sources to evaluate the multifactorial impacts on the quality of treatment received and financial burden among young women with breast cancer. To address this gap and support future evaluation efforts, we examined the utility of combining patient survey and cancer registry data.

PATIENT AND METHODS

We administered a survey to women, aged 18-39 years, with breast cancer from four U.S. states. We conducted a systematic response-rate analysis and evaluated differences between racial groups. Survey responses were linked with cancer registry data to assess whether surveys could reliably supplement registry data.

RESULTS

A total of 830 women completed the survey for a response rate of 28.4 %. Blacks and Asian/Pacific Islanders were half as likely to respond as white women. Concordance between survey and registry data was high for demographic variables (Cohen's kappa [k]: 0.879 to 0.949), moderate to high for treatments received (k: 0.467 to 0.854), and low for hormone receptor status (k: 0.167 to 0.553). Survey items related to insurance status, employment, and symptoms revealed racial differences.

CONCLUSION

Cancer registry data, supplemented by patient surveys, can provide a broader understanding of the quality of care and financial impacts of breast cancer among young women.

Factors Affecting the Adoption of Electronic Data Reporting and Outcomes Among Selected Central Cancer Registries of the National Program of Cancer Registries

PURPOSE

The CDC's National Program of Cancer Registries has expanded the use of electronic reporting to collect more timely information on newly diagnosed cancers. The adoption, implementation, and use of electronic reporting vary significantly among central cancer registries. We identify factors affecting the adoption of electronic reporting among these registries.

METHODS

Directors and data managers of nine National Program of Cancer Registries took part in separate 1-hour telephone interviews in early 2019. Directors were asked about their registry's key data quality goals; staffing, resources, and tools used to aid processes; their definition and self-perception of electronic reporting adoption; key helpers and challenges; and cost and sustainability implications for adoption of electronic reporting. Data managers were asked about specific data collection processes, software applications, electronic reporting adoption and self-perception, information technology infrastructure, and helpers and challenges to data collection and processing, data quality, and sustainability of approach.

RESULTS

Larger registries identified organizational capacity and technical expertise as key aides. Other help for implementing electronic reporting processes came from partnerships, funding availability, management support, legislation, and access to an interstate data exchange. Common challenges among lower adopters included lack of capacity at both registry and data source levels, insufficient staffing, and a lack of information technology or technical support. Other challenges consisted of automation and interoperability of software, volume of cases received, state political environment, and quality of data received.

CONCLUSION

Feedback from the formative evaluation yielded several useful solutions that can guide implementation of electronic reporting and help refine the technical assistance provided to registries. Our findings may help guide future process and economic evaluations of electronic reporting and identify best practices to strengthen registry operations.

Geographic Disparities in Late-Stage Breast Cancer Diagnosis Rates and Their Persistence Over Time

Background: Other than skin cancer, breast cancer is the most common cancer in the United States. Lower uptake of mammography screening is associated with higher rates of late-stage breast cancers. This study aims to show geographic patterns in the United States, where rates of late-stage breast cancer are high and persistent over time, and examines factors associated with these patterns. Materials and Methods: We examined all primary breast cancers diagnosed among all counties in 43 U.S. states with available data. We used spatial cluster analysis to identify hot spots (i.e., spatial clusters with above average late-stage diagnosis rates among counties). Demographic and socioeconomic characteristics were compared between persistent hot spots and those counties that were never hot spots. Results: Of the 2,599 counties examined in 43 states, 219 were identified as persistent hot spots. Counties with persistent hot spots (compared with counties that were never hot spots) were located in more deprived areas with worse housing characteristics, lower socioeconomic status, lower levels of health insurance, worse access to mammography, more isolated American Indian/Alaska Native, Black, or Hispanic neighborhoods, and larger income disparity. In addition, persistent hot spots were significantly more likely to be observed among poor, rural, African American, or Hispanic communities, but not among poor, rural, White communities. This analysis includes a broader range of socioeconomic conditions than those included in previous literature. Conclusion: We found geographic disparities in late-stage breast cancer diagnosis rates, with some communities experiencing persistent disparities over time. Our findings can guide public health efforts aimed at reducing disparities in stage of diagnosis for breast cancer.

Late-Stage Diagnosis and Cost of Colorectal Cancer Treatment in Two State Medicaid Programs

INTRODUCTION

To assess timing of Medicaid enrollment with late-stage colorectal cancer (CRC) diagnosis and estimate treatment costs by stage at diagnosis.

METHODS

We analyzed 2000-2009 California and Texas Medicaid data linked with cancer registry data. We assessed the association of Medicaid enrollment timing with late-stage colorectal cancer and estimated total and incremental 6-month treatment costs to Medicaid by stage using a noncancer comparison group matched on age group and sex.

RESULTS

Compared with Medicaid enrollment before diagnosis, enrolling after diagnosis was associated with late-stage diagnosis. Incremental per-person treatment costs were $31,063, $39,834, and $47,161 for localized, regional, and distant stage in California, respectively; and $28,701, $38,212, and $49,634 in Texas, respectively.

DISCUSSION

In California and Texas, Medicaid enrollment after CRC diagnosis was associated with later-stage disease and higher treatment costs. Facilitating timely and continuous Medicaid enrollment may lead to earlier stage at diagnosis, reduced costs, and improved outcomes.

The Effectiveness and Cost to Improve Colorectal Cancer Screening in a Federally Qualified Homeless Clinic in Eastern Kentucky

The objective of this study was to analyze the effectiveness and cost of patient incentives, together with patient navigation and patient reminders, to increase fecal immunochemical test (FIT) kit return rates and colorectal cancer screening uptake in one federally qualified health center (FQHC) in Appalachia. This FQHC is a designated homeless clinic, as 79.7% of its patient population are homeless. We collected process, outcome, and cost data from the FQHC for two time periods: usual care (September 2016-August 2017) and implementation (September 2017-September 2018). We reported the FIT kit return rate, the increase in return rate, and the additional number of individual screens. We also calculated the incremental cost per additional screen. The patient incentive program, with patient navigation and patient reminders, increased the number of FIT kits returned from the usual care period to the implementation period. The return rate increased by 25.9 percentage points (from 21.7% to 47.6%) with an additional 91 people screened at an incremental cost of $134.61 per screen. A patient incentive program, together with the assistance of patient navigators and supplemented with patient reminders, can help improve CRC screening uptake among vulnerable and homeless populations.

Effectiveness and Cost of Implementing Evidence-Based Interventions to Increase Colorectal Cancer Screening Among an Underserved Population in Chicago

With funding from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, The University of Chicago Center for Asian Health Equity partnered with a federally qualified health center (FQHC) to implement multiple evidence-based interventions (EBIs) in order to improve colorectal cancer (CRC) screening uptake. The purpose of this study is to determine the effectiveness and cost of implementing a provider reminder system entered manually and supplemented with patient reminders and provider assessment and feedback. The FQHC collected demographic characteristics of the FQHC and outcome data from January 2015 through December 2015 (preimplementation period) and cost from January 2016 through September 2017 (implementation period). Cost data were collected for the implementation period. We report on the demographics of the eligible population, CRC screening order, completion rates by sociodemographic characteristics, and, overall, the effectiveness and cost of implementation. From the preimplementation phase to the implementation phase, there was a 21.2 percentage point increase in CRC screens completed. The total cost of implementing EBIs was $40908.97. We estimated that an additional 283 screens were completed because of the interventions, and the implementation cost of the interventions was $144.65 per additional screen. With the interventions, CRC screening uptake in Chicago increased for all race/ethnicity and demographic backgrounds at the FQHC, particularly for patients aged 50 to 64 years and for Asian, Hispanic, and uninsured patients.

Cost and Effectiveness of Reminders to Promote Colorectal Cancer Screening Uptake in Rural Federally Qualified Health Centers in West Virginia

The purpose of this study is to evaluate the effectiveness of the West Virginia Program to Increase Colorectal Cancer Screening in implementing patient reminders to increase fecal immunochemical test (FIT) kit return rates in nine federally qualified health centers (FQHCs). Using process measures and cost data collected, the authors examined the differences in the intensity of the phone calls across FQHCs and compared them with the return rates achieved. They also reported the cost per kit successfully returned as a result of the intervention. Across all FQHCs, 5,041 FIT kits were ordered, and the initial return rate (without a reminder) was 41.1%. A total of 2,201 patients received reminder phone calls; on average, patients received 1.61 reminder calls each. The reminder interventions increased the average FIT kit return rate to 60.7%. The average total cost per FIT kit returned across all FQHCs was $60.18, and the average cost of only the reminders was $11.20 per FIT kit returned. FQHCs achieved an average increase of 19.6 percentage points in FIT kit return rates, and costs across clinics varied. Clinics with high-quality health information systems that enabled tracking of patients with minimal effort were able to implement lower cost reminder interventions.

Examining the Effectiveness of Provider Incentives to Increase CRC Screening Uptake in Neighborhood Healthcare: A California Federally Qualified Health Center

As an awardee of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, the California Department of Public Health partnered with Neighborhood Healthcare to implement evidence-based interventions and provider incentives (incentives offered to support staff, e.g., medical assistants, phlebotomists, front office staff, lab technicians) to improve colorectal cancer screening uptake. The objective of this study was to evaluate the effectiveness and cost of the provider incentive intervention implemented by Neighborhood Healthcare to increase colorectal cancer screening uptake. We collected and analyzed process and cost data to assess fecal immunochemical test (FIT) kit return rates to the health centers and the number of completed FIT kits. We estimated the costs of the preexisting interventions and the new interventions. Analyses were conducted for two time periods: preimplementation and implementation. Most Neighborhood Healthcare health centers experienced an increase in the percentage of FIT kit returns (average of 3.6 percentage points) and individuals screened (an average increase of 111 FIT kits per month) from the baseline period through the implementation period. The cost of the incentive intervention for each additional screen was $66.79. In conclusion, the results indicate that incentive programs can have an overall positive impact on both the percentage of FIT kits returned and the number of individuals screened.

Economic Evaluation of Interventions to Increase Colorectal Cancer Screening at Federally Qualified Health Centers

The Centers for Disease Control and Prevention (CDC) has a long-standing commitment to increase colorectal cancer (CRC) screening for vulnerable populations. In 2005, the CDC began a demonstration in five states and, with lessons learned, launched a national program, the Colorectal Cancer Control Program (CRCCP), in 2009. The CRCCP continues today and its current emphasis is the implementation of evidence-based interventions to promote CRC screening. The purpose of this article is to provide an overview of four CRCCP awardees and their federally qualified health center partners as an introduction to the accompanying series of research briefs where we present individual findings on impacts of evidence-based interventions on CRC screening uptake for each awardee. We also include in this article the conceptual framework used to guide our research. Our findings contribute to the evidence base and guide future program implementation to improve sustainability, increase CRC screening, and address disparities in screening uptake.

Role of an Implementation Economics Analysis in Providing the Evidence Base for Increasing Colorectal Cancer Screening

Purpose and Objectives

Since 2005 the Centers for Disease Control and Prevention (CDC) has funded organizations across the United States to promote screening for colorectal cancer (CRC) to detect early CRC or precancerous polyps that can be treated to avoid disease progression and death. The objective of this study was to describe how findings from economic evaluation approaches of a subset of these awardees and their implementation sites (n = 9) can drive decision making and improve program implementation and diffusion.

Intervention Approach

We described the framework for the implementation economics evaluation used since 2016 for the Colorectal Cancer Control Program (CRCCP) Learning Collaborative.

Evaluation Methods

We compared CRC interventions implemented across health systems, changes in screening uptake, and the incremental cost per person of implementing an intervention. We also analyzed data on how implementation costs changed over time for a CRC program that conducted interventions in a series of rounds.

Results

Implementation of the interventions, which included provider and patient reminders, provider assessment and feedback, and incentives, resulted in increases in screening uptake ranging from 4.9 to 26.7 percentage points. Across the health systems, the incremental cost per person screened ranged from $18.76 to $144.55. One awardee’s costs decreased because of a reduction in intervention development and start-up costs.

Implications for Public Health

Health systems, CRCCP awardees, and CDC can use these findings for quality improvement activities, incorporation of information into trainings and support activities, and future program design.

Insurance Coverage, Employment Status, and Financial Well-Being of Young Women Diagnosed with Breast Cancer

BACKGROUND

The economic cost of breast cancer is a major personal and public health problem in the United States. This study aims to evaluate the insurance, employment, and financial experiences of young female breast cancer survivors and to assess factors associated with financial decline.

METHODS

We recruited 830 women under 40 years of age diagnosed with breast cancer between January 2013 and December 2014. The study population was identified through California, Florida, Georgia, and North Carolina population-based cancer registries. The cross-sectional survey was fielded in 2017 and included questions on demographics, insurance, employment, out-of-pocket costs, and financial well-being. We present descriptive statistics and multivariate analysis to assess factors associated with financial decline.

RESULTS

Although 92.5% of the respondents were continuously insured over the past 12 months, 9.5% paid a "higher price than expected" for coverage. Common concerns among the 73.4% of respondents who were employed at diagnosis included increased paid (55.1%) or unpaid (47.3%) time off, suffering job performance (23.2%), and staying at (30.2%) or avoiding changing (23.5%) jobs for health insurance purposes. Overall, 47.0% experienced financial decline due to treatment-related costs. Patients with some college education, multiple comorbidities, late stage diagnoses, and self-funded insurance were most vulnerable.

CONCLUSIONS

The breast cancer diagnosis created financial hardship for half the respondents and led to myriad challenges in maintaining employment. Employment decisions were heavily influenced by the need to maintain health insurance coverage.

IMPACT

This study finds that a breast cancer diagnosis in young women can result in employment disruption and financial decline.

Expenditures on Screening Promotion Activities in CDC's Colorectal Cancer Control Program, 2009-2014

Introduction

The Centers for Disease Control and Prevention (CDC) established the Colorectal Cancer Control Program (CRCCP) in 2009 to reduce disparities in colorectal cancer screening and increase screening and follow-up as recommended. We estimate the cost for evidence-based intervention and non–evidence-based intervention screening promotion activities and examine expenditures on screening promotion activities. We also identify factors associated with the costs of these activities.

Methods

By using cost and resource use data collected from 25 state grantees over multiple years (July 2009 to June 2014), we analyzed the total cost for each screening promotion activity. Multivariate analysis was used to assess the factors associated with screening promotion costs reported by grantees.

Results

The promotion activities with the largest allocation of funding across the years and grantees were mass media, patient navigation, outreach and education, and small media. Across all years of the program and across grantees, the amount spent on specific promotion activities varied widely. The factor significantly associated with promotion costs was region in which the grantee was located.

Conclusion

CDC’s CRCCP grantees spent the largest amount of the screening promotion funds on mass media, which is not recommended by the Community Preventive Services Task Force. Given the large variation across grantees in the use of and expenditures on screening promotion interventions, a systematic assessment of the yield from investment in specific promotion activities could better guide optimal resource allocation.

Comparison of Program Resources Required for Colonoscopy and Fecal Screening: Findings From 5 Years of the Colorectal Cancer Control Program

Introduction

Colonoscopy and guaiac fecal occult blood tests and fecal immunochemical tests (FOBT/FIT) are the most common colorectal cancer screening methods in the United States. However, information is limited on the program resources required over time to use these tests.

Methods

We collected cost data from 29 Centers for Disease Control and Prevention Colorectal Cancer Control Program (CRCCP) grantees by using a standardized data collection instrument for 5 program years (2009–2014). We created a panel data set with 124 records and assessed differences by screening test used.

Results

Forty-four percent of all programs (N = 124) offered colonoscopy (55 of 124), 32% (39 of 124) offered FOBT/FIT, and 24% (30 of 124) offered both. Overall, total cost per person was higher in program year 1 ($3,962), the beginning of CRCCP than in subsequent program years ($1,714). The cost per person was $3,153 for programs using colonoscopy and $1,291 for those using FOBT/FIT with diagnostic colonoscopy. The average clinical cost per person was $1,369 for colonoscopy and $280 for FOBT/FIT during the program (these do not reflect cost of repeated FOBT/FIT screens). Programs serving a large number of people had lower per-person costs than those serving a small volume, probably because of fixed costs related to nonclinical expenses.

Conclusion

Colorectal cancer screening programs incur costs in addition to the clinical cost of the screening procedures to support planning and management, contracting with providers, and tracking patients. Because programs can achieve potential economies of scale, partnerships among smaller programs for screening delivery could decrease overall costs.

Identifying optimal approaches to scale up colorectal cancer screening: an overview of the centers for disease control and prevention (CDC)'s learning laboratory

Use of recommended screening tests can reduce new colorectal cancers (CRC) and deaths, but screening uptake is suboptimal in the United States (U.S.). The Centers for Disease Control and Prevention (CDC) funded a second round of the Colorectal Cancer Control Program (CRCCP) in 2015 to increase screening rates among individuals aged 50-75 years. The 30 state, university, and tribal awardees supported by the CRCCP implement a range of multicomponent interventions targeting health systems that have low CRC screening uptake, including low-income and minority populations. CDC invited a select subset of 16 CRCCP awardees to form a learning laboratory with the goal of performing targeted evaluations to identify optimal approaches to scale-up interventions to increase uptake of CRC screening among vulnerable populations. This commentary provides an overview of the CRCCP learning laboratory, presents findings from the implementation of multicomponent interventions at four FQHCs participating in the learning laboratory, and summarizes key lessons learned on intervention implementation approaches. Lessons learned can support future program implementation to ensure scalability and sustainability of the interventions as well as guide future implementation science and evaluation studies conducted by the CRCCP learning laboratory.

Colorectal Cancer Screening: Preferences, Past Behavior, and Future Intentions

BACKGROUND

Screening rates for colorectal cancer are below the Healthy People 2020 goal. There are several colorectal cancer screening tests that differ in terms of accuracy, recommended frequency, and administration. In this article, we compare how a set of personal characteristics correlates with preferences for colorectal cancer screening test attributes, past colorectal cancer screening behavior, and future colorectal cancer screening intentions.

METHODS

We conducted a discrete-choice experiment survey to assess relative preferences for attributes of colorectal cancer screening tests among adults aged 50-75 years in USA. We used a latent class logit model to identify classes of preferences and calculated willingness to pay for changes in test attributes. A set of personal characteristics were included in the latent class analysis and analyses of self-reported past screening behavior and self-assessed likelihood of future colorectal cancer screening.

RESULTS

Latent class analysis identified three types of respondents. Class 1 valued test accuracy, class 2 valued removing polyps and avoiding discomfort, and class 3 valued cost. Having had a prior colonoscopy and a higher income were predictors of the likelihood of future screening and membership in classes 1 and 2. Health insurance and a self-reported higher risk of developing colorectal cancer were associated with prior screening and higher future screening intentions, but not class membership.

CONCLUSION

We identified distinct classes of preferences focusing on different test features and personal characteristics associated with reported behavior and intentions. Healthcare providers should engage in a careful assessment of patient preferences when recommending colorectal cancer test options to encourage colorectal cancer screening uptake.

Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost-effectiveness

BACKGROUND

The objectives of the current study were to assess changes in colorectal cancer (CRC) screening uptake and the cost-effectiveness of implementing multiple evidence-based interventions (EBIs). EBIs were implemented at 2 federally qualified health centers that participated in the Colorado Department of Public Health and Environment's Clinic Quality Improvement for Population Health initiative.

METHODS

Interventions included patient and provider reminder systems (health system 1), provider assessment and feedback (health systems 1 and 2), and numerous support activities (health systems 1 and 2). The authors evaluated health system 1 from July 2013 to June 2015 and health system 2 from July 2014 to June 2017. Evaluation measures included annual CRC screening uptake, EBIs implemented, funds received and expended by each health system to implement EBIs, and intervention costs to the Colorado Department of Public Health and Environment and health systems.

RESULTS

CRC screening uptake increased by 18 percentage points in health system 1 and 10 percentage points in health system 2. The improvements in CRC screening uptake, not including the cost of the screening tests, were obtained at an added cost ranging from $24 to $29 per person screened.

CONCLUSIONS

In both health systems, the multicomponent interventions implemented likely resulted in improvements in CRC screening. The results suggest that significant increases in CRC screening uptake can be achieved in federally qualified health centers when appropriate technical support and health system commitment are present. The cost estimates of the multicomponent interventions suggest that these interventions and support activities can be implemented in a cost-effective manner.

Evaluation of patient-focused interventions to promote colorectal cancer screening among new york state medicaid managed care patients

BACKGROUND

The objective of this study was to evaluate an ongoing initiative to improve colorectal cancer (CRC) screening uptake in the New York State (NYS) Medicaid managed care population.

METHODS

Patients aged 50 to 75 years who were not up to date with CRC screening and resided in 2 NYS regions were randomly assigned to 1 of 3 cohorts: no mailed reminder, mailed reminder, and mailed reminder + incentive (in the form of a $25 cash card). Screening prevalence and the costs of the intervention were summarized.

RESULTS

In total, 7123 individuals in the Adirondack Region and 10,943 in the Central Region (including the Syracuse metropolitan area) were included. Screening prevalence in the Adirondack Region was 7.2% in the mailed reminder + incentive cohort, 7.0% in the mailed reminder cohort, and 5.8% in the no mailed reminder cohort. In the Central Region, screening prevalence was 7.2% in the mailed reminder cohort, 6.9% in the mailed reminder + incentive cohort, and 6.5% in the no mailed reminder cohort. The cost of implementing interventions in the Central Region was approximately 53% lower than in the Adirondack Region.

CONCLUSIONS

Screening uptake was low and did not differ significantly across the 2 regions or within the 3 cohorts. The incentive payment and mailed reminder did not appear to be effective in increasing CRC screening. The total cost of implementation was lower in the Central Region because of efficiencies generated from lessons learned during the first round of implementation in the Adirondack Region. More varied multicomponent interventions may be required to facilitate the completion of CRC screening among Medicaid beneficiaries.

A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program

BACKGROUND

Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community.

METHODS

The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program.

RESULTS

Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions.

CONCLUSIONS

Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality.

Effectiveness and cost of multilayered colorectal cancer screening promotion interventions at federally qualified health centers in Washington State

BACKGROUND

It has been demonstrated that fecal immunochemical test (FIT) mailing programs are effective for increasing colorectal cancer (CRC) screening. The objectives of the current study were to assess the magnitude of uptake that could be achieved with a mailed FIT program in a federally qualified health center and whether such a program can be implemented at a reasonable cost to support sustainability.

METHODS

The Washington State Department of Health's partner HealthPoint implemented a direct-mail FIT program at 9 medical clinics, along with a follow-up reminder letter and automated telephone calls to those not up-to-date with recommended screening. Supplemental outreach events at selected medical clinics and a 50th birthday card screening reminder program also were implemented. The authors collected and analyzed process, effectiveness, and cost measures and conducted a systematic assessment of the short-term cost effectiveness of the interventions.

RESULTS

Overall, 5178 FIT kits were mailed with 4009 follow-up reminder letters, and 8454 automated reminder telephone calls were made over 12 months. In total, 1607 FIT kits were returned within 3 months of the end of the implementation period: an overall return rate of 31% for the mailed FIT program. The average total intervention cost per FIT kit returned was $39.81, and the intervention implementation cost per kit returned was $18.76.

CONCLUSIONS

The mailed FIT intervention improved CRC screening uptake among HealthPoint's patient population. This intervention was implemented for less than $40 per individual successfully screened. The findings and lessons learned can assist other clinics that serve disadvantaged populations to increase their CRC screening adherence.

Economic assessment of patient navigation to colonoscopy-based colorectal cancer screening in the real-world setting at the University of Chicago Medical Center

BACKGROUND

This report details the cost effectiveness of a non-nurse patient navigation (PN) program that was implemented at the University of Chicago Medical Center to increase colonoscopy-based colorectal cancer (CRC) screening.

METHODS

The authors investigated the impact of the PN intervention by collecting process measures. Individuals who received navigation were compared with a historic cohort of non-navigated patients. In addition, a previously validated data-collection instrument was tailored and used to collect all costs related to developing, implementing, and administering the program; and the incremental cost per patient successfully navigated (the cost of the intervention divided by the change in the number who complete screening) was calculated.

RESULTS

The screening colonoscopy completion rate was 85.1% among those who were selected to receive PN compared with 74.3% when no navigation was implemented. With navigation, the proportion of no-shows was 8.2% compared with 15.4% of a historic cohort of non-navigated patients. Because the perceived risk of noncompletion was greater among those who received PN (previous no-show or cancellation, poor bowel preparation) than that in the historic cohort, a scenario analysis was performed. Assuming no-show rates between 0% and 50% and using a navigated rate of 85%, the total incremental program cost per patient successfully navigated ranged from $148 to $359, whereas the incremental intervention-only implementation cost ranged from $88 to $215.

CONCLUSIONS

The current findings indicate that non-nurse PN can increase colonoscopy completion, and this can be achieved at a minimal incremental cost for an insured population at an urban academic medical center.

Patterns and Trends in Cancer Screening in the United States

Introduction

We examined the prevalence of cancer screening reported in 2015 among US adults, adjusted for important sociodemographic and access-to-care variables. By using data from the National Health Interview Survey (NHIS) for 2000 through 2015, we examined trends in prevalence of cancer screening that adhered to US Preventive Services Task Force screening recommendations in order to monitor screening progress among traditionally underserved population subgroups.

Methods

We analyzed NHIS data from surveys from 2000 through 2015 to estimate prevalence and trends in use of recommended screening tests for breast, cervical, colorectal, and prostate cancers. We used logistic regression and report predictive margins for population subgroups adjusted for various socioeconomic and demographic variables.

Results

Colorectal cancer screening was the only test that increased during the study period. We found disparities in prevalence of test use among subgroups for all tests examined. Factors that reduced the use of screening tests included no contact with a doctor in the past year, no usual source of health care, and no insurance coverage.

Conclusion

Understanding use of cancer screening tests among different population subgroups is vital for planning public health interventions with potential to increase screening uptake and reduce disparities in cancer morbidity and mortality. Overarching goals of Healthy People 2020 are to “achieve health equity, eliminate disparities, and improve the health of all groups.” Adjusted findings for 2015, compared with previous years, show persistent screening disparities, particularly among the uninsured, and progress for colorectal cancer screening only.

An Analysis of Cancer Registry Cost Data: Methodology and Results

The Centers for Disease Control and Prevention initiated an economic analysis of the National Program of Cancer Registries (NPCR) in 2005 to estimate the true economic costs of operating a cancer registry, identify costs associated with registry activities, and evaluate the factors that may affect the efficiency of registry operations. We developed a Web-based NPCR cost assessment tool (NPCR-CAT) to collect activity-based cost data from all 48 NPCR registries. We collected data on registry funding, actual expenditures, and factors that may affect the efficiency of operating a central cancer registry. Key lessons learned during data collection and analysis include the importance of working closely with registry staff and balancing the need for standardized data elements with an understanding of individual registry characteristics. Our findings and lessons can be adapted to develop costing tools for other surveillance systems and cancer control programs, both domestically and internationally.

Costs of promoting cancer screening: Evidence from CDC's Colorectal Cancer Control Program (CRCCP)

The Colorectal Cancer Control Program (CRCCP) provided funding to 29 grantees to increase colorectal cancer screening. We describe the screening promotion costs of CRCCP grantees to evaluate the extent to which the program model resulted in the use of funding to support interventions recommended by the Guide to Community Preventive Services (Community Guide). We analyzed expenditures for screening promotion for the first three years of the CRCCP to assess cost per promotion strategy, and estimated the cost per person screened at the state level based on various projected increases in screening rates. All grantees engaged in small media activities and more than 90% used either client reminders, provider assessment and feedback, or patient navigation. Based on all expenditures, projected cost per eligible person screened for a 1%, 5%, and 10% increase in state-level screening proportions are $172, $34, and $17, respectively. CRCCP grantees expended the majority of their funding on Community Guide recommended screening promotion strategies but about a third was spent on other interventions. Based on this finding, future CRC programs should be provided with targeted education and information on evidence-based strategies, rather than broad based recommendations, to ensure that program funds are expended mainly on evidence-based interventions.

Costs of colorectal cancer screening provision in CDC's Colorectal Cancer Control Program: Comparisons of colonoscopy and FOBT/FIT based screening

We assess annual costs of screening provision activities implemented by 23 of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) grantees and report differences in costs between colonoscopy and FOBT/FIT-based screening programs. We analysed annual cost data for the first three years of the CRCCP (July 2009-June 2011) for each screening provision activity and categorized them into clinical and non-clinical screening provision activities. The largest cost components for both colonoscopy and FOBT/FIT-based programs were screening and diagnostic services, program management, and data collection and tracking. During the first 3 years of the CRCCP, the average annual clinical cost for screening and diagnostic services per person served was $1150 for colonoscopy programs, compared to $304 for FIT/FOBT-based programs. Overall, FOBT/FIT-based programs appear to have slightly higher non-clinical costs per person served (average $1018; median $838) than colonoscopy programs (average $980; median $686). Colonoscopy-based CRCCP programs have higher clinical costs than FOBT/FIT-based programs during the 3-year study timeframe (translating into fewer people screened). Non-clinical costs for both approaches are similar and substantial. Future studies of the cost-effectiveness of colorectal cancer screening initiatives should consider both clinical and non-clinical costs.

Patients and caregivers costs for colonoscopy-based colorectal cancer screening: Experience of low-income individuals undergoing free colonoscopies

Many studies have documented barriers to colorectal cancer screenings. However, there is lack of comprehensive information on the time and costs borne by low-income patients and the persons accompanying the patient (caregiver) for colonoscopies in the United States. We surveyed patients in three health clinics in Philadelphia retrospectively who had undergone free colonoscopies in the previous 18-month period. Participants were asked questions about time and out-of-pockets expenses for themselves and their caregivers. Even when colonoscopies were free to the patient through Colorectal Cancer Control Program funded by the Centers for Disease Control and Prevention, the patient and caregivers still incurred costs in relation to preparing for, undergoing, and recovering from a colonoscopy. These costs can be substantial and may account for some of the low colorectal cancer screening rates especially among the low-income populations. Patients' and caregivers' costs need to be considered when designing and implementing colorectal cancer control programs.

Cost-Effectiveness Analysis of Four Simulated Colorectal Cancer Screening Interventions, North Carolina

INTRODUCTION

Colorectal cancer (CRC) screening rates are suboptimal, particularly among the uninsured and the under-insured and among rural and African American populations. Little guidance is available for state-level decision makers to use to prioritize investment in evidence-based interventions to improve their population's health. The objective of this study was to demonstrate use of a simulation model that incorporates synthetic census data and claims-based statistical models to project screening behavior in North Carolina.

METHODS

We used individual-based modeling to simulate and compare intervention costs and results under 4 evidence-based and stakeholder-informed intervention scenarios for a 10-year intervention window, from January 1, 2014, through December 31, 2023. We compared the proportion of people living in North Carolina who were aged 50 to 75 years at some point during the window (that is, age-eligible for screening) who were up to date with CRC screening recommendations across intervention scenarios, both overall and among groups with documented disparities in receipt of screening.

RESULTS

We estimated that the costs of the 4 intervention scenarios considered would range from $1.6 million to $3.75 million. Our model showed that mailed reminders for Medicaid enrollees, mass media campaigns targeting African Americans, and colonoscopy vouchers for the uninsured reduced disparities in receipt of screening by 2023, but produced only small increases in overall screening rates (0.2-0.5 percentage-point increases in the percentage of age-eligible adults who were up to date with CRC screening recommendations). Increased screenings ranged from 41,709 additional life-years up to date with screening for the voucher intervention to 145,821 for the mass media intervention. Reminders mailed to Medicaid enrollees and the mass media campaign for African Americans were the most cost-effective interventions, with costs per additional life-year up to date with screening of $25 or less. The intervention expanding the number of endoscopy facilities cost more than the other 3 interventions and was less effective in increasing CRC screening.

CONCLUSION

Cost-effective CRC screening interventions targeting observed disparities are available, but substantial investment (more than $3.75 million) and additional approaches beyond those considered here are required to realize greater increases population-wide.

Resource requirements for cancer registration in areas with limited resources: Analysis of cost data from four low- and middle-income countries

BACKGROUND

The key aims of this study were to identify sources of support for cancer registry activities, to quantify resource use and estimate costs to operate registries in low- and middle-income countries (LMIC) at different stages of development across three continents.

METHODS

Using the Centers for Disease Control and Prevention's (CDC's) International Registry Costing Tool (IntRegCosting Tool), cost and resource use data were collected from eight population-based cancer registries, including one in a low-income country (Uganda [Kampala)]), two in lower to middle-income countries (Kenya [Nairobi] and India [Mumbai]), and five in an upper to middle-income country (Colombia [Pasto, Barranquilla, Bucaramanga, Manizales and Cali cancer registries]).

RESULTS

Host institution contributions accounted for 30%-70% of total investment in cancer registry activities. Cancer registration involves substantial fixed cost and labor. Labor accounts for more than 50% of all expenditures across all registries. The cost per cancer case registered in low-income and lower-middle-income countries ranged from US $3.77 to US $15.62 (United States dollars). In Colombia, an upper to middle-income country, the cost per case registered ranged from US $41.28 to US $113.39. Registries serving large populations (over 15 million inhabitants) had a lower cost per inhabitant (less than US $0.01 in Mumbai, India) than registries serving small populations (under 500,000 inhabitants) [US $0.22] in Pasto, Colombia.

CONCLUSION

This study estimates the total cost and resources used for cancer registration across several countries in the limited-resource setting, and provides cancer registration stakeholders and registries with opportunities to identify cost savings and efficiency improvements. Our results suggest that cancer registration involve substantial fixed costs and labor, and that partnership with other institutions is critical for the operation and sustainability of cancer registries in limited resource settings. Although we included registries from a variety of limited-resource areas, information from eight registries in four countries may not be large enough to capture all the potential differences among the registries in limited-resource settings.

Economic assessment of integrated cancer and cardiovascular registries: The Barbados experience

BACKGROUND

This report describes the resources required to support the integrated approach of the Barbados National Registry for Chronic Non-communicable Diseases (BNR) to non-communicable disease (NCD) case registration, and to identify differences in cost for collecting and maintaining information on cancer and cardiovascular disease (CVD) case registration.

METHODS

We used the modified Centers for Disease Control and Prevention's International Registry Costing Tool to collect data from the CVD and cancer registries. We used cancer and CVD cost data for the annual period April 2014 through March 2015 to estimate the total cost and cost per case. We used prospectively collected average annual CVD cases, and for cancer cases we assumed 2 or 3 years are needed for retrospective data collection.

RESULTS

The Ministry of Health provided 56% of the resources for the registries. Labor accounted for over 70% of both registries' budgets, while management and administration, along with data collection and analysis, incurred the highest costs per case. Total variable cost activities related to data collection and analysis were higher for the CVD component (US$131,297) than the cancer component (US$58,917). The CVD cost per case (US$489) was in between the cancer 2-year (US$382) and the cancer 3-year (US$573) cost-per-case estimates.

CONCLUSION

These findings indicate that there are substantial fixed costs related to management and administration of NCD registries. All registries need management and administration support. When registries are combined, management and administration costs can be shared. We project that registries that can share fixed-cost infrastructure are likely to incur a lower total cost per case.

Recommendations From the International Colorectal Cancer Screening Network on the Evaluation of the Cost of Screening Programs

Worldwide, colorectal cancer is the fourth leading cause of death from cancer and the incidence is projected to increase. Many countries are exploring the introduction of organized screening programs, but there is limited information on the resources required and guidance for cost-effective implementation. To facilitate the generating of the economics evidence base for program implementation, we collected and analyzed detailed program cost data from 5 European members of the International Colorectal Cancer Screening Network. The cost per person screened estimates, often used to compare across programs as an overall measure, varied significantly across the programs. In addition, there were substantial differences in the programmatic and clinical cost incurred, even when the same type of screening test was used. Based on these findings, several recommendations are provided to enhance the underlying methodology and validity of the comparative economic assessments. The recommendations include the need for detailed activity-based cost information, the use of a comprehensive set of effectiveness measures to adequately capture differences between programs, and the incorporation of data from multiple programs in cost-effectiveness models to increase generalizability. Economic evaluation of real-world colorectal cancer-screening programs is essential to derive valuable insights to improve program operations and ensure optimal use of available resources.

The cost of cancer registry operations: Impact of volume on cost per case for core and enhanced registry activities

BACKGROUND

Cancer registration data is vital for creating evidence-based policies and interventions. Quantifying the resources needed for cancer registration activities and identifying potential efficiencies are critically important to ensure sustainability of cancer registry operations.

METHODS

Using a previously validated web-based cost assessment tool, we collected activity-based cost data and report findings using 3 years of data from 40 National Program of Cancer Registry grantees. We stratified registries by volume: low-volume included fewer than 10,000 cases, medium-volume included 10,000-50,000 cases, and high-volume included >50,000 cases.

RESULTS

Low-volume cancer registries incurred an average of $93.11 to report a case (without in-kind contributions) compared with $27.70 incurred by high-volume registries. Across all registries, the highest cost per case was incurred for data collection and abstraction ($8.33), management ($6.86), and administration ($4.99). Low- and medium-volume registries have higher costs than high-volume registries for all key activities.

CONCLUSIONS

Some cost differences by volume can be explained by the large fixed costs required for administering and performing registration activities, but other reasons may include the quality of the data initially submitted to the registries from reporting sources such as hospitals and pathology laboratories. Automation or efficiency improvements in data collection can potentially reduce overall costs.

Stated Preference for Cancer Screening: A Systematic Review of the Literature, 1990-2013

Introduction

Stated-preference methods provide a systematic approach to quantitatively assess the relative preferences for features of cancer screening tests. We reviewed stated-preference studies for breast, cervical, and colorectal cancer screening to identify the types of attributes included, the use of questions to assess uptake, and whether gaps exist in these areas. The goal of our review is to inform research on the design and promotion of public health programs to increase cancer screening.

Methods

Using the PubMed and EconLit databases, we identified studies published in English from January 1990 through July 2013 that measured preferences for breast, cervical, and colorectal cancer screening test attributes using conjoint analysis or a discrete-choice experiment. We extracted data on study characteristics and results. We categorized studies by whether attributes evaluated included screening test, health care delivery characteristics, or both.

Results

Twenty-two studies met the search criteria. Colorectal cancer was the most commonly studied cancer of the 3. Fifteen studies examined only screening test attributes (efficacy, process, test characteristics, and cost). Two studies included only health care delivery attributes (information provided, staff characteristics, waiting time, and distance to facility). Five studies examined both screening test and health care delivery attributes. Overall, cancer screening test attributes had a significant effect on a patient’s selection of a cancer screening test, and health care delivery attributes had mixed effects on choice.

Conclusion

A growing number of studies examine preferences for cancer screening tests. These studies consistently find that screening test attributes, such as efficacy, process, and cost, are significant determinants of choice. Fewer studies have examined the effect of health care delivery attributes on choice, and the results from these studies are mixed. There is a need for additional studies on the barriers to cancer screening uptake, including health care delivery attributes, and the effect of education materials on preferences.

Data sources for identifying low-income, uninsured populations: application to public health-National Breast and Cervical Cancer Early Detection Program

OBJECTIVE

To provide information on the sources of data for estimating low-income, uninsured populations. To recommend uses of these data sources. To demonstrate the application of these data sources in the public health field, using the National Breast and Cervical Cancer Early Detection Program as an example.

METHODS

We describe U.S. Census Bureau data sources for identifying low-income, uninsured populations using two population surveys: the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC) and the American Community Survey (ACS), and using one model-based estimation program, the Small Area Health Insurance Estimates (SAHIE). We provide recommendations for use of these data sources, and we use CPS ASEC and SAHIE to estimate the percent of U.S. women eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

RESULTS

CPS ASEC, ACS, and SAHIE are produced by the U.S. Census Bureau, and they are reliable sources for estimates of the low-income, uninsured populations in the USA. Key characteristics of these three data sources were presented to highlight the strengths of each to meet the needs of various programs at national and local levels. Recommendations are made on the use of the data sources. Based on these three data sources, estimates of NBCCEDP eligibility showed substantial variation over time at the national and state levels, and across states and counties.

CONCLUSIONS

Publicly funded programs that are directed toward low-income, uninsured individuals require information on their eligible populations to make decisions about program policy and resource allocation, and to monitor and evaluate the effectiveness of the programs. The U.S. Census Bureau produces three data sources (CPS ASEC, ACS, and SAHIE) for these estimates. The percent of U.S. women eligible for NBCCEDP varies over time and across states and counties. The data sources for these estimates are changing in order to measure key dimensions of the Affordable Care Act (ACA) and can provide helpful information for assessing the legislation's impact.

Breast cancer screening of underserved women in the USA: results from the National Breast and Cervical Cancer Early Detection Program, 1998-2012

OBJECTIVE

To describe the number and proportion of eligible women receiving mammograms funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

Low-income, uninsured, and underinsured women aged 40-64 are eligible for mammography screening through the NBCCEDP. We used data from the NBCCEDP, the Current Population Survey, and Medical Expenditure Panel Survey to describe the number and proportion of women screened by the NBCCEDP and overall.

RESULTS

In 2011 and 2012, the NBCCEDP screened 549,043 women aged 40-64, an estimated 10.6 % (90 % confidence interval [CI] 10.4-10.9 %) of the eligible population. We estimate that 30.6 % (90 % CI 26.4-34.8 %) of eligible women aged 40-64 were screened outside the NBCCEDP, and 58.8 % (90 % CI 54.6-63.0 %) were not screened. The proportion of eligible women screened by the NBCCEDP varied across states, with an estimated range of 3.2 % (90 % CI 2.9-3.5 %) to 52.8 % (90 % CI 36.1-69.6 %) and a median of 13.7 % (90 % CI 11.0-16.4 %). The estimated proportion of eligible women aged 40-64 who received mammograms through the NBCCEDP was relatively constant over time, 11.1 % (90 % CI 10.2-11.9 %) in 1998-1999 and 10.6 % (90 % CI 10.4-11.9 %) in 2011-2012 (p = 0.23), even as the number of women screened increased from 343,692 to 549,043.

CONCLUSIONS

Although the NBCCEDP provided screening services to over a half million low-income uninsured women for mammography, it served a small percentage of those eligible. The majority of low-income, uninsured women were not screened.

Cervical cancer screening of underserved women in the United States: results from the National Breast and Cervical Cancer Early Detection Program, 1997-2012

OBJECTIVE

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screens to low-income, uninsured, and underinsured women. We describe the number and proportion of women eligible for cervical cancer screening services and the proportion of eligible women screened over the period 1997-2012.

METHODS

Low-income, uninsured, and underinsured women aged 18-64 years who have not had a hysterectomy are eligible for cervical cancer screening through the NBCCEDP. We estimated the number of low-income, uninsured women using data from the US Census Bureau. We adjusted our estimates for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used data from the NBCCEDP to describe the number of women receiving NBCCEDP-funded screening and calculated the proportion of eligible women who received screening through the NBCCEDP at the national level (by age group, race/ethnicity) and at the state level by age group. We used the Medical Expenditure Panel Survey to estimate the proportion of NBCCEDP-eligible women who were screened outside the NBCCEDP and the proportion that are not screened.

RESULTS

We estimate that in 2010-2012, 705,970 women aged 18-64 years, 6.5 % (705,970 of 9.8 million) of the eligible population, received NBCCEDP-funded Pap tests. We estimate that 60.2 % of eligible women aged 18-64 years were screened outside the NBCCEDP and 33.3 % were not screened. The NBCCEDP provided 623,603 screens to women aged 40-64 years, an estimated 16.5 % of the eligible population, and 83,660 screens to women aged 18-39 years, representing an estimated 1.2 % of the eligible population. The estimated proportions of eligible women screened in each state ranged from 1.5 to 32.7 % and 5 % to 73.2 % among the 18-64 and 40-64 years age groups, respectively. Changes in the proportion of eligible women screened over the study period were nonsignificant.

CONCLUSIONS

Although the program provided cervical screening to over 700,000 women between 2010 and 2012, it served a small percent of those eligible. The proportion of women screened varied substantially across age groups, racial/ethnic groups, and states. Many low-income, uninsured women are not being screened.

Explaining variation across grantees in breast and cervical cancer screening proportions in the NBCCEDP

PURPOSE

There is substantial variation across the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) grantees in terms of the proportion of the eligible population served by the grantees each year (hereafter referred to as the screening proportion). In this paper, we assess program- and state-level factors to better understand the reason for this variation in breast and cervical cancer screening proportions across the NBCCEDP grantees.

METHODS

We constructed a longitudinal data set, consisting of data from NBCCEDP grantees for each of the three study years (program-years 2006-2007, 2008-2009, and 2009-2010). We performed multivariate analysis to explain the variation in breast and cervical cancer screening proportions across the grantees. The program-level factors studied were the total federal funds received, average cost of screening women by grantee, and the overall organizational structure. The state-level variables included were urban versus rural mix, access to care, and the size of the eligible population.

RESULTS

Of the 48 grantees included in the study, those that serve larger populations, as measured by the size of the population and the percentage of women eligible for services, had lower screening proportions. Higher average cost of service delivery was also associated with lower screening proportions. In addition, grantees whose populations were more concentrated in urban areas had lower screening proportions.

CONCLUSIONS

Overall, the average cost of screening, the overall size of the population eligible, and the concentration of population in urban areas all had a negative relationship to the proportion of eligible women screened by NBCCEDP grantees.

End-of-Life Medical Costs of Medicaid Cancer Patients

OBJECTIVES

To quantify end-of-life (EOL) medical costs for adult Medicaid beneficiaries diagnosed with cancer.

DATA SOURCES

We linked Medicaid administrative data with 2000-2003 cancer registry data to identify 3,512 adult Medicaid beneficiaries who died after a cancer diagnosis and matched them to a cohort of beneficiaries without cancer who died during the same period.

STUDY DESIGN

We used multivariable regression analysis to estimate incremental per-person EOL cost after controlling for beneficiaries' age, race/ethnicity, sex, cancer site, and state of residence.

PRINCIPAL FINDINGS

End-of-life costs during the final 4 months of life were about $10,000 higher for Medicaid cancer patients than for those without cancer. Medicaid cancer patients are more intensive users of inpatient and ambulatory services than are Medicaid patients without cancer. Medicaid cancer patients who die soon after diagnosis have higher costs of care and use inpatient services more intensely than do Medicaid patients without cancer.

CONCLUSIONS

Medicaid cancer patients incur substantially higher EOL costs than noncancer patients. This increased cost may reflect the cost of palliative care. Future studies should assess the types and timing of services provided to Medicaid cancer patients at the EOL.