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Lorentsen MK, Sanoff HK. Social Determinants of Health and the Link to Colorectal Cancer Outcomes. Curr Treat Options Oncol 2024; 25:453-464. [PMID: 38498252 DOI: 10.1007/s11864-024-01191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/20/2024]
Abstract
OPINION STATEMENT: Colorectal cancer (CRC) remains the second most deadly cancer in the United States, behind only lung cancer. Despite improvements in incidence due to screening and mortality in part due to better treatments, there are some groups that have not seen these promising changes. American Indian/Alaska Native and non-Hispanic Black individuals, certain geographic regions, and lower socioeconomic groups have all been shown to have worse CRC outcomes. A significant body of evidence has linked these disparities in outcomes to social determinants of health (SDH). SDH are defined by the WHO as "the non-medical factors that influence health outcomes." These factors include but are not limited to income, education, social support, neighborhood of residence, and access to healthcare. Individuals who are negatively impacted by SDH have been shown to have a higher incidence of CRC. These individuals are also less likely to receive adequate CRC screening, are less likely to receive appropriate treatment, and have increased CRC mortality. Interventions that target different SDH domains have been shown to lead to increased rates of CRC screening and receipt of appropriate treatment while simultaneously improving CRC mortality. The aim of this review is to highlight the connection between SDH and CRC outcomes while also exploring interventions that target SDH and thereby improve CRC outcomes.
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Affiliation(s)
- Michael K Lorentsen
- University of North Carolina at Chapel Hill, 170 Manning Drive, CB 7305, Chapel Hill, NC, 27599, USA
- Division of Oncology, University of North Carolina at Chapel Hill, 170 Manning Drive, CB 7305, Chapel Hill, NC, 27599, USA
| | - Hanna K Sanoff
- Division of Oncology, University of North Carolina at Chapel Hill, 170 Manning Drive, CB 7305, Chapel Hill, NC, 27599, USA.
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Ahadinezhad B, Maleki A, Akhondi A, Kazemi M, Yousefy S, Rezaei F, Khosravizadeh O. Are behavioral economics interventions effective in increasing colorectal cancer screening uptake: A systematic review of evidence and meta-analysis? PLoS One 2024; 19:e0290424. [PMID: 38315699 PMCID: PMC10843112 DOI: 10.1371/journal.pone.0290424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/08/2023] [Indexed: 02/07/2024] Open
Abstract
Various interventions have been investigated to improve the uptake of colorectal cancer screening. In this paper, the authors have attempted to provide a pooled estimate of the effect size of the BE interventions running a systematic review based meta-analysis. In this study, all the published literatures between 2000 and 2022 have been reviewed. Searches were performed in PubMed, Scopus and Cochrane databases. The main outcome was the demanding the one of the colorectal cancer screening tests. The quality assessment was done by two people so that each person evaluated the studies separately and independently based on the individual participant data the modified Jadad scale. Pooled effect size (odds ratio) was estimated using random effects model at 95% confidence interval. Galbraith, Forrest and Funnel plots were used in data analysis. Publication bias was also investigated through Egger's test. All the analysis was done in STATA 15. From the initial 1966 records, 38 were included in the final analysis in which 72612 cases and 71493 controls have been studied. About 72% have been conducted in the USA. The heterogeneity of the studies was high based on the variation in OR (I2 = 94.6%, heterogeneity X2 = 670.01 (d.f. = 36), p < 0.01). The random effect pooled odds ratio (POR) of behavioral economics (BE) interventions was calculated as 1.26 (95% CI: 1.26 to 1.43). The bias coefficient is noteworthy (3.15) and statistically significant (p< 0.01). According to the results of this meta-analysis, health policy and decision makers can improve the efficiency and cost effectiveness of policies to control this type of cancer by using various behavioral economics interventions. It's noteworthy that due to the impossibility of categorizing behavioral economics interventions; we could not perform by group analysis.
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Affiliation(s)
- Bahman Ahadinezhad
- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Aisa Maleki
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Amirali Akhondi
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | - Sama Yousefy
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Fatemeh Rezaei
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Omid Khosravizadeh
- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
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Mehta SJ, McDonald C, Reitz C, Kastuar S, Snider CK, Okorie E, McNelis K, Shaikh H, Cook TS, Goldberg DS, Rothstein K. A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance. Hepatol Commun 2024; 8:e0349. [PMID: 38099859 PMCID: PMC10727671 DOI: 10.1097/hc9.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Shivani Kastuar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Evelyn Okorie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Kiernan McNelis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Hamzah Shaikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tessa S. Cook
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - David S. Goldberg
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kenneth Rothstein
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Keyser HHD, Brinton JT, Bothwell S, Camacho M, Kempe A, Szefler SJ. Encouraging adherence in adolescents with asthma using financial incentives: An RCT. Pediatr Pulmonol 2023; 58:2823-2831. [PMID: 37449768 PMCID: PMC10538420 DOI: 10.1002/ppul.26594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Medication adherence in adolescents remains a significant management challenge and innovative strategies are needed to improve medication adherence. Financial incentives have been used to improve outcomes for health behaviors among adults, but have not been well-studied among adolescents. The objective of this study was to test if a modest financial incentive improved medication adherence in adolescents with asthma compared with a control group. METHODS Participants were randomized to either control (electronic medication monitoring [EMM] with App reminders/feedback for 4 months) or intervention (EMM + $1 per day for perfect medication adherence for 3 months [maximum $84] followed by 1 month of EMM only). A repeated measures mixed model, with a first order autoregressive correlation structure between errors, was used to test the null hypothesis for an interaction of treatment group and week. RESULTS Fifty-two participants were enrolled, and 48 completed primary analysis. Mean adherence rates declined in both groups over time, and there was no significant difference in the change in adherence rates between the groups (F-statistic = 0.72, ndf = 15, ddf = 625, p = 0.76). Adherence rates (during the 12 weeks when incentives were given) declined from 80% to 64% in the control group, and from 90% to 58% in the incentive group. There was no significant change in the slope of decline in the incentives group in the month following payment discontinuation. CONCLUSION A modest financial incentive did not lead to significantly different medication adherence rates in adolescents with asthma who were receiving a monitoring and reminder intervention. Further study is needed to determine viable interventions to optimize medication use in this group.
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Affiliation(s)
- Heather H De Keyser
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
| | - John T Brinton
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Samantha Bothwell
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Megan Camacho
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
| | - Allison Kempe
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital Colorado, Los Angeles, California, USA
- Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus and The Childrens Hospital, Aurora, Colorado, USA
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Richardson-Parry A, Silva M, Valderas JM, Donde S, Woodruff S, van Vugt J. Video Interventions for Reducing Health Inequity in Cancer Screening Programmes: a Systematic Review. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01749-5. [PMID: 37603223 DOI: 10.1007/s40615-023-01749-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Health equity can lead to disparities in cancer screening, treatment, and mortality. This systematic review aims to identify and describe interventions that used video or DVD formats to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates compared to usual care conditions. METHODS We searched PubMed, Web of Science, Embase, and Cochrane databases for randomized control trials (RCTs) published until 18/01/2023 that compared intervention versus usual care control groups, with the percentage of cancer screening uptake during follow-up as an outcome. The risk of Bias was assessed with the Cochrane Collaboration tool. RESULTS After screening 4201 abstracts, 192 full texts were assessed for eligibility and 18 were included that focused on colorectal (n = 9), cervical (n = 5), breast (n = 5), and prostate (n = 1) cancer screening. All were based in the USA except one and most focused on ethnicity/race, while some included low-income populations. Most of the video interventions used to increase cervical cancer screening reported positive results. Studies aimed at increasing mammography uptake were mostly effective only in specific groups of participants, such as low-income or less-educated African American women. Results for colorectal cancer screening were conflicting. Videos that were culturally tailored or used emotive format were generally more effective than information-only videos. CONCLUSIONS Video interventions to increase cancer screening among populations with low screening uptake show some positive effects, though results are mixed. Interventions that use individual and cultural tailoring of the educational material should be further developed and investigated outside of the USA.
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Affiliation(s)
| | - Mitchell Silva
- Esperity, Veldkapelgaarde 30b1.30.30, 1200, Brussels, Belgium
| | - Jose Maria Valderas
- Department of Family Medicine, National University Health System and Yong Loo Lin School of Medicine, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228, Singapore
| | - Shaantanu Donde
- Viatris, Building 4, Trident Place, Mosquito Way, Hatfield, AL10 9UL, UK
| | | | - Joris van Vugt
- Viatris, Krijgsman 20, Amstelveen, 1186DM, The Netherlands
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Greene B, Bernardo L, Thompson M, Loughead J, Ashare R. Behavioral Economic Strategies to Improve Enrollment Rates in Clinical Research: Embedded Recruitment Pilot Trial. JMIR Form Res 2023; 7:e47121. [PMID: 37477975 PMCID: PMC10403799 DOI: 10.2196/47121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023] Open
Abstract
BACKGROUND Nearly 1 in 3 clinical trials end prematurely due to underenrollment. Strategies to enhance recruitment are often implemented without scientific rigor to evaluate efficacy. Evidence-based, cost-effective behavioral economic strategies designed to influence decision-making may be useful to promote clinical trial enrollment. OBJECTIVE This study evaluated 2 behavioral economic strategies to improve enrollment and retention rates across 4 clinical trials: information provision (IP) and contingency management (CM; ie, lottery). IP targets descriptive and injunctive norms about participating in research and CM provides participants incentives to reinforce a target behavior. METHODS A sample of 212 participants was enrolled across 4 clinical trials focused on tobacco use: 2 focused on HIV and 2 focused on neuroimaging. The CM condition included a lottery: for each study visit completed, participants received 5 "draws" from a bowl containing 500 "chips" valued at US $0, US $1, US $5, or US $100. In the IP condition, text messages that targeted injunctive norms about research (eg, "Many find it a rewarding way to advance science and be part of a community") were sent through the Way to Health platform before all study visits. Participants were randomized to 1 of 4 conditions: IP, CM, IP+CM, or standard recruitment (SR). We performed logistic regression, controlling for sex and study, with condition as a between-subject predictor. Outcomes were the percentage of participants who attended a final eligibility visit (primary), met intent-to-treat (ITT) criteria (secondary), and completed the study (secondary). Recruitment was evaluated by the percentage of participants who attended a final eligibility visit, enrollment by ITT status, and retention by the percentage of participants who completed the study. RESULTS Rates of attending the eligibility visit and meeting ITT status were 58.9% (33/56) and 33.9% (19/56) for IP+CM; 45.5% (25/55) and 18.2% (10/55) for IP only; 41.5% (22/53) and 18.9% (10/53) for CM only; and 37.5% (18/48) and 12.5% (6/48) for SR, respectively. In the logistic regression, females were more likely to meet ITT status than males (odds ratio [OR] 2.7, 95% CI 1.2-5.7; P=.01). The IP+CM group was twice as likely to attend the final eligibility visit than the SR group (OR 2.4, 95% CI 1.1-5.2; P=.04). The IP+CM group was also significantly more likely to reach ITT status than the SR condition (OR 3.9, 95% CI 1.3-11.1; P=.01). Those who received any active intervention (IP, CM, or IP+CM) had a higher study completion rate (33/53, 63.5%) compared to those who received SR (5/12, 41.7%), but this difference was not significant (P=.26). CONCLUSIONS Combining IP and CM strategies may motivate participants to participate in research and improve recruitment and retention rates. Evidence from this study provides preliminary support for the utility of behavioral economics strategies to improve enrollment and reduce attrition in clinical trials.
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Affiliation(s)
- Brittney Greene
- State University of New York at Buffalo, Buffalo, NY, United States
| | - Leah Bernardo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Morgan Thompson
- School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - James Loughead
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rebecca Ashare
- State University of New York at Buffalo, Buffalo, NY, United States
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Richardson-Parry A, Silva M, Valderas JM, Donde S, Woodruff S, van Vugt J. Interactive or tailored digital interventions to increase uptake in cervical, breast, and colorectal cancer screening to reduce health inequity: a systematic review. Eur J Cancer Prev 2023; 32:396-409. [PMID: 37144585 PMCID: PMC10249608 DOI: 10.1097/cej.0000000000000796] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 02/27/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Significant health inequities exist in screening uptake for certain types of cancer. The review question was to identify and describe interactive, tailored digital, computer, and web-based interventions to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates versus usual care. METHODS We searched four medical literature databases for randomized control trials (RCTs) published until 12 January 2023 that evaluated interventions aimed at increasing the percentage of breast, prostate, cervical, or colorectal cancer screening uptake. Meta-analysis was not conducted due to heterogeneity among studies. RESULTS After screening 4200 titles and abstracts, 17 studies were included. Studies focused on colorectal ( n = 10), breast ( n = 4), cervical ( n = 2), and prostate ( n = 1) cancer screening. All were based in the USA except two. Most studies focused on ethnicity/race, while some included low-income populations. Intervention types were heterogeneous and used computer programs, apps, or web-based methods to provide tailored or interactive information to participants about screening risks and options. Some studies found positive effects for increasing cancer screening uptake in the intervention groups compared to usual care, but results were heterogeneous. CONCLUSION Interventions that use individual and cultural tailoring of cancer screening educational material should be further developed and investigated outside of the USA. Designing effective digital intervention strategies, with components that can be adapted to remote delivery may be an important strategy for reducing health inequities in cancer screening during the coronavirus disease 2019 pandemic.
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Affiliation(s)
| | | | - Jose M. Valderas
- Department of Family Medicine, National University Health System and Yong Loo Lin School of Medicine, Centre for Research in Health Systems Performance, Singapore, Singapore
| | - Shaantanu Donde
- European Developed Markets Medical Affairs Viatris, Hatfield, UK
| | - Seth Woodruff
- North America Medical Affairs, Viatris, New York, USA
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Dodson JA, Schoenthaler A, Fonceva A, Gutierrez Y, Shimbo D, Banco D, Maidman S, Olkhina E, Hanley K, Lee C, Levy NK, Adhikari S. Study design of BETTER-BP: Behavioral economics trial to enhance regulation of blood pressure. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2022; 15:200156. [PMID: 36573193 PMCID: PMC9789360 DOI: 10.1016/j.ijcrp.2022.200156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 07/19/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Abstract
Background Nonadherence to antihypertensive medications remains a persistent problem that leads to preventable morbidity and mortality. Behavioral economic strategies represent a novel way to improve antihypertensive medication adherence, but remain largely untested especially in vulnerable populations which stand to benefit the most. The Behavioral Economics Trial To Enhance Regulation of Blood Pressure (BETTER-BP) was designed in this context, to test whether a digitally-enabled incentive lottery improves antihypertensive adherence and reduces systolic blood pressure (SBP). Design BETTER-BP is a pragmatic randomized trial conducted within 3 safety-net clinics in New York City: Bellevue Hospital Center, Gouveneur Hospital Center, and NYU Family Health Centers - Park Slope. The trial will randomize 435 patients with poorly controlled hypertension and poor adherence (<80% days adherent) in a 2:1 ratio (intervention:control) to receive either an incentive lottery versus passive monitoring. The incentive lottery is delivered via short messaging service (SMS) text messages that are delivered based on (1) antihypertensive adherence tracked via a wireless electronic monitoring device, paired with (2) a probability of lottery winning with variable incentives and a regret component for nonadherence. The study intervention lasts for 6 months, and ambulatory systolic blood pressure (SBP) will be measured at both 6 and 12 months to evaluate immediate and durable lottery effects. Conclusions BETTER-BP will generate knowledge about whether an incentive lottery is effective in vulnerable populations to improve antihypertensive medication adherence. If successful, this could lead to the implementation of this novel strategy on a larger scale to improve outcomes.
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Affiliation(s)
- John A. Dodson
- NYU Langone Medical Center, New York, NY, USA
- Corresponding author. New York University Grossman School of Medicine, 227 East 30th Street, TRB 851, New York, NY, 10016, USA.
| | | | - Ana Fonceva
- NYU Langone Medical Center, New York, NY, USA
| | | | - Daichi Shimbo
- Columbia University Irving Medical Center, New York, NY, USA
| | - Darcy Banco
- NYU Langone Medical Center, New York, NY, USA
| | | | | | | | - Carson Lee
- NYU Langone Medical Center, New York, NY, USA
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Clifton ABW, Mehta SJ, Wainwright JV, Ogden SN, Saia CA, Rendle KA. Exploring Why Financial Incentives Fail to Affect At-home Colorectal Cancer Screening: a Mixed Methods Study. J Gen Intern Med 2022; 37:2751-2758. [PMID: 35037172 PMCID: PMC9411475 DOI: 10.1007/s11606-021-07228-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/19/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Despite success in increasing other health behaviors, financial incentives have shown limited to no effect on colorectal cancer (CRC screening. Little is known about the factors shaping why and for whom incentives improve screening. OBJECTIVE To explore the perspective of participants enrolled in a larger, four-arm pragmatic trial at urban family medicine practices which assessed and failed to detect significant effects of financial incentives on at-home CRC screening completion. DESIGN We performed a mixed methods study with a subset of randomly selected patients, stratified by study arm, following completion of the pragmatic trial. PARTICIPANTS Sixty patients (46.9% enrollment rate) who were eligible and overdue for colorectal cancer screening at the time of trial enrollment and who continued to receive care at family medicine practices affiliated with an urban academic health system completed the interview and questionnaire. MAIN MEASURES Using Andersen's behavioral model, a semi-structured interview guide assessed motivators, barriers, and facilitators to screening completion and the impact of incentives on decision-making. Participants also completed a brief questionnaire evaluating demographics, screening beliefs, and clinical characteristics. KEY RESULTS The majority of patients (n = 49; 82%) reported that incentives would not change their decision to complete or not complete CRC screening, which was confirmed by qualitative data as largely due to high perceived health benefits. Those who stated financial incentives would impact their decision (n = 11) were significantly less likely to agree that CRC screening is beneficial (72.7% vs 95.9%; p < 0.05) or that CRC could be cured if detected early (63.6% vs 98.0%; p < 0.05). CONCLUSIONS Financial incentives are likely not an effective behavioral intervention to increase CRC screening for all but may be powerful for increasing short-term benefit and therefore completion for some. Targeting financial incentive interventions according to patient screening beliefs may prove a cost-effective strategy in primary care outreach programs to increase CRC screening.
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Affiliation(s)
- Alicia B W Clifton
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jocelyn V Wainwright
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA
| | - Shannon N Ogden
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Chelsea A Saia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA
| | - Katharine A Rendle
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA.
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Thompson JC, Ren Y, Romero K, Lew M, Bush AT, Messina JA, Jung SH, Siamakpour-Reihani S, Miller J, Jenq RR, Peled JU, van den Brink MRM, Chao NJ, Shrime MG, Sung AD. Financial incentives to increase stool collection rates for microbiome studies in adult bone marrow transplant patients. PLoS One 2022; 17:e0267974. [PMID: 35507633 PMCID: PMC9067695 DOI: 10.1371/journal.pone.0267974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/19/2022] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION In order to study the role of the microbiome in hematopoietic stem cell transplantation (HCT), researchers collect stool samples from patients at various time points throughout HCT. However, stool collection requires active subject participation and may be limited by patient reluctance to handling stool. METHODS We performed a prospective study on the impact of financial incentives on stool collection rates. The intervention group consisted of allogeneic HCT patients from 05/2017-05/2018 who were compensated with a $10 gas gift card for each stool sample. The intervention group was compared to a historical control group of allogeneic HCT patients from 11/2016-05/2017 who provided stool samples before the incentive was implemented. To control for possible changes in collections over time, we also compared a contemporaneous control group of autologous HCT patients from 05/2017-05/2018 with a historical control group of autologous HCT patients from 11/2016-05/2017; neither autologous HCT group was compensated. The collection rate was defined as the number of samples provided divided by the number of time points we attempted to obtain stool. RESULTS There were 35 allogeneic HCT patients in the intervention group, 19 allogeneic HCT patients in the historical control group, 142 autologous HCT patients in the contemporaneous control group (that did not receive a financial incentive), and 75 autologous HCT patients in the historical control group. Allogeneic HCT patients in the intervention group had significantly higher average overall collection rates when compared to the historical control group allogeneic HCT patients (80% vs 37%, p<0.0001). There were no significant differences in overall average collection rates between the autologous HCT patients in the contemporaneous control and historical control groups (36% vs 32%, p = 0.2760). CONCLUSION Our results demonstrate that a modest incentive can significantly increase collection rates. These results may help to inform the design of future studies involving stool collection.
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Affiliation(s)
- Jillian C. Thompson
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Yi Ren
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kristi Romero
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Meagan Lew
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Amy T. Bush
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julia A. Messina
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sharareh Siamakpour-Reihani
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julie Miller
- Center for Advanced Hindsight, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Robert R. Jenq
- Departments of Genomic Medicine and Stem Cell Transplantation Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas, United States of America
| | - Jonathan U. Peled
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Marcel R. M. van den Brink
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Nelson J. Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Mark G. Shrime
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anthony D. Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
- * E-mail:
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11
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Taylor LC, Kerrison RS, Herrmann B, Stoffel ST. Effectiveness of behavioural economics-based interventions to improve colorectal cancer screening participation: A rapid systematic review of randomised controlled trials. Prev Med Rep 2022; 26:101747. [PMID: 35284211 PMCID: PMC8914541 DOI: 10.1016/j.pmedr.2022.101747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/18/2022] [Accepted: 02/26/2022] [Indexed: 12/22/2022] Open
Abstract
We searched PubMed, PsycInfo and EconLit for RCTs that evaluated BE interventions in CRC screening. We identified 1027 papers for title and abstract review. 30 studies were eligible for the review. The most frequently tested BE intervention was incentives, followed by default principle and salience. Default-based interventions were most likely to be effective. Incentives had mixed evidence. BE remains a promising field of interest in relation to influencing CRC screening behaviours.
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Affiliation(s)
- Lily C. Taylor
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Robert S. Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
- School of Health Sciences, University of Surrey, Surrey, UK
| | | | - Sandro T. Stoffel
- Research Department of Behavioural Science and Health, University College London, London, UK
- European Commission, Joint Research Centre (JRC), Ispra, Italy
- Institute for Pharmaceutical Medicine, University of Basel, Basel, Switzerland
- Corresponding author at: Research Department of Behavioural Science and Health, University College London, London, UK.
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12
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Wang M, Yang HL, Liu XL, Mo BR, Kynoch K, Ramis MA. Evaluating behavioral economic interventions for promoting cancer screening uptake and adherence in targeted populations: a systematic review protocol. JBI Evid Synth 2022; 20:1113-1119. [PMID: 35013041 DOI: 10.11124/jbies-21-00265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to determine the effectiveness of behavioral economic interventions for promoting uptake of and adherence to cancer screening recommended by guidelines. INTRODUCTION Cancer screening has been found to help reduce incidence of and mortality from advanced cancer. However, adherence to recommended cancer screening services is low in asymptomatic adults with average risk possibly due to systematic decision biases. The findings of this review will demonstrate whether interventions informed by behavioral economic insights can help improve uptake of and adherence to cancer screening. INCLUSION CRITERIA This review will consider studies that meet the following inclusion criteria: experimental, quasi-experimental, and analytical observational studies that i) evaluate the effects of behavioral economic interventions in adults eligible for guideline-recommended cancer screening, and that ii) report the number/percentage of individuals who used screening services; number/percentage of individuals who completed screening recommended by guidelines; participant self-reported intentions, choice, and satisfaction regarding the use of screening services; detection rates of early-stage cancers; use of early intervention for cancers; and cancer-related mortality. METHODS A systematic literature search will be performed by one reviewer. After removing duplicates, two reviewers will independently screen and appraise eligible studies according to the JBI methodology for systematic reviews of effectiveness. Five databases will be searched: CINAHL, the Cochrane Library, PsycINFO, PubMed, and Web of Science. Sources of gray literature and registered clinical trials will also be searched for potential studies. There will be no limits to publication date or language. Data synthesis will be conducted using meta-analysis and narrative synthesis where appropriate. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42021258370.
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Affiliation(s)
- Mian Wang
- Department of Nursing, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, Guangdong Province, China Nanshan Evidence Based Nursing Centre: A JBI Affiliated Group, Shenzhen, Guangdong Province, China School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China College of Nursing and Midwifery, Charles Darwin University, Brisbane, QLD, Australia Mater Health, Evidence in Practice Unit, South Brisbane, QLD, Australia The Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Institute Centre of Excellence, Brisbane, QLD, Australia
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13
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Bartholomew T, Colleoni M, Schmidt H. Financial incentives for breast cancer screening undermine informed choice. BMJ 2022; 376:e065726. [PMID: 35012959 DOI: 10.1136/bmj-2021-065726] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
| | | | - Harald Schmidt
- Department of Medical Ethics and Health Policy, University of Pennsylvania, USA
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14
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Kumar AD, Durham DD, Lane L, Perera P, Rivera MP, Henderson LM. Randomized control trial of unconditional versus conditional incentives to increase study enrollment rates in participants at increased risk of lung cancer. J Clin Epidemiol 2022; 141:11-17. [PMID: 34469801 PMCID: PMC8903037 DOI: 10.1016/j.jclinepi.2021.08.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/05/2021] [Accepted: 08/21/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Understanding how incentives and their timing influence study enrollment rates is important to efficient study design and increasing the generalizability of findings. This 2-arm, parallel randomized trial evaluated how conditional vs. unconditional mailed incentives of a $20 gift card affected study enrollment in a sample of participants screened for lung cancer screening. METHODS Eligible participants included Black and White adults who underwent lung cancer screening with low-dose CT and had negative screening results at two North Carolina imaging facilities in 2018. We used a stratified randomization scheme, by sex and race, to assign incentive type (conditional vs. unconditional). We used the Tailored Design Method with six points of mailed contact to engage participants. We compared study enrollment rates using chi-square tests and logistic regression analyses. RESULTS After adjusting for sex, race, age, smoking status, participant residence, and screening site, participants who received unconditional incentives were 74% more likely to enroll than those who received conditional incentives (adjusted OR = 1.74 (95% CI: 1.01, 3.00). CONCLUSIONS Type of incentive can play a role in increasing study enrollment, especially mailed surveys that target individuals who currently or previously smoked. Unconditional incentives may be worth the initial cost to engage study participants.
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Affiliation(s)
- Anjali D. Kumar
- Department of Epidemiology, University of North Carolina, Chapel Hill,Corresponding author.
| | | | - Lindsay Lane
- Department of Radiology, University of North Carolina, Chapel Hill
| | - Pasangi Perera
- Department of Radiology, University of North Carolina, Chapel Hill
| | - M. Patricia Rivera
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of North Carolina, Chapel Hill,Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill
| | - Louise M. Henderson
- Department of Epidemiology, University of North Carolina, Chapel Hill,Department of Radiology, University of North Carolina, Chapel Hill,Lineberger Comprehensive Cancer Center, University of North Carolina Chapel Hill
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15
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Wainwright JV, Mehta SJ, Clifton A, Bocage C, Ogden SN, Cohen S, Rendle KA. Persistent Barriers to Colorectal Cancer Screening Completion Amid Centralized Outreach: A Mixed Methods Study. Am J Health Promot 2021; 36:697-705. [PMID: 34970929 PMCID: PMC9109679 DOI: 10.1177/08901171211064492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To understand patient experiences and persistent barriers to colorectal cancer (CRC) screening amid centralized outreach at urban family medicine practices. APPROACH Following a pragmatic trial assessing mailed fecal immunochemical test (FIT) outreach, we invited a subset of participants to complete a semi-structured qualitative interview and structured questionnaire. SETTING Single urban academic healthcare system. PARTICIPANTS Sixty patients who were eligible and overdue for CRC screening at the time of trial enrollment. METHOD Using Andersen's Behavioral Model, we developed an interview guide to systematically assess factors shaping screening decisions and FIT uptake. Close-ended responses were analyzed using descriptive statistics. Qualitative data were analyzed using the constant comparative method. RESULTS Most participants (82%) self-reported that they had ever completed any modality of CRC screening, and nearly half (43%) completed the mailed FIT during the trial. Most patients (60%) preferred FIT to colonoscopy due to its private, convenient, and non-invasive nature; however, persistent barriers related to screening beliefs including fear of test results and cancer treatment still prevented some patients from completing any form of CRC screening. CONCLUSIONS Mailed FIT can overcome many structural barriers to CRC screening, yet clear communication and follow-up amid centralized outreach are essential. For some patients, tailored outreach or navigation to address screening-related fears or other screening beliefs may be needed to ensure timely completion of CRC screening.
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Affiliation(s)
- Jocelyn V Wainwright
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Alicia Clifton
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Claire Bocage
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Shannon N Ogden
- Department of Health Law, Policy and Management, 27118Boston University School of Public Health, Boston, MA, USA
| | - Sarah Cohen
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA
| | - Katharine A Rendle
- Department of Family Medicine and Community Health, Perelman School of Medicine, 14640University of Pennsylvania, Philadelphia, PA, USA.,Penn Center for Cancer Care Innovation, Abramson Cancer Center, 14640University of Pennsylvania, Philadelphia, PA, USA
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16
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Wilding S, O'Connor DB, Conner M. Financial incentives for bowel cancer screening: Results from a mixed methods study in the United Kingdom. Br J Health Psychol 2021; 27:741-755. [PMID: 34747113 DOI: 10.1111/bjhp.12570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purpose of bowel cancer screening is to test for signs of cancer before symptoms develop. Financial incentives are one potential method to increase participation rates. Few studies have tested incentives in relation to bowel screening in the United Kingdom (UK). The current research explored reactions to different financial incentives to participate in population-level bowel cancer screening in a UK sample. DESIGN An online mixed methods study. Recruitment was via a study recruitment website (https://prolific.ac/). METHODS 499 participants (aged 60-74 years) completed a survey on invitations for population-level bowel cancer screening using different levels of financial incentives. RESULT Respondents were generally positive about the use of financial incentives. A £10 voucher was most frequently selected as the appropriate amount to incentivise screening participation. The current invitation method with no voucher was judged to be most acceptable but suggested to produce the lowest likelihood of others participating. Offering a £10 voucher that the NHS would not be charged for if not used was the second most acceptable invitation method. There were few differences between invitation methods on own perceived likelihood of participation in bowel screening. Offering a £10 voucher was seen as leading to the greatest likelihood of others participating in bowel screening. Findings were largely unaffected by participant demographics. CONCLUSION The use of small financial incentives to increase bowel cancer screening uptake was generally well received. Impacts of incentives on actual bowel screening rates in UK samples need to be established in the light of the current findings.
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Affiliation(s)
| | | | - Mark Conner
- School of Psychology, University of Leeds, UK
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17
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Heisser T, Cardoso R, Guo F, Moellers T, Hoffmeister M, Brenner H. Strongly Divergent Impact of Adherence Patterns on Efficacy of Colorectal Cancer Screening: The Need to Refine Adherence Statistics. Clin Transl Gastroenterol 2021; 12:e00399. [PMID: 34506306 PMCID: PMC8437219 DOI: 10.14309/ctg.0000000000000399] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 07/13/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The performance of colorectal cancer (CRC) screening programs depends on the adherence to screening offers. However, identical adherence levels may result from varying patterns of the population's screening behavior. We quantified the effects of different adherence patterns on the long-term performance of CRC screening for annual fecal immunochemical testing and screening colonoscopy at 10-year intervals. METHODS Using a multistate Markov model, we simulated scenarios where, while at the same overall adherence level, a certain proportion of the population adheres to all screening offers (selective adherence) or the entire population uses the screening offers at some point(s) of time, albeit not in the recommended frequency (sporadic adherence). Key outcomes for comparison were the numbers of prevented CRC cases and prevented CRC deaths after 50 simulated years. RESULTS For screening with annual fecal immunochemical testing at adherence levels of 10%-50%, ratios of prevented CRC cases (CRC deaths) resulting from a sporadic vs a selective pattern ranged from 1.8 to 4.4 (1.9-5.3) for men and from 1.7 to 3.6 (1.8-4.4) for women, i.e., up to 4-5 times more CRC cases and deaths were prevented when the population followed a sporadic instead of a selective adherence pattern. Comparisons of simulated scenarios for screening colonoscopy revealed similar patterns. DISCUSSION Over a lifelong time frame, large numbers of irregular screening attendees go along with much larger preventive effects than small numbers of perfectly adhering individuals. In clinical practice, efforts to reach as many people as possible at least sporadically should be prioritized over efforts to maximize adherence to repeat screening offers.
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Affiliation(s)
- Thomas Heisser
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Rafael Cardoso
- Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
| | - Feng Guo
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Tobias Moellers
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
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18
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Facciorusso A, Demb J, Mohan BP, Gupta S, Singh S. Addition of Financial Incentives to Mailed Outreach for Promoting Colorectal Cancer Screening: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2122581. [PMID: 34432010 PMCID: PMC8387849 DOI: 10.1001/jamanetworkopen.2021.22581] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Although screening decreases incidence of and mortality from colorectal cancer (CRC), screening rates are low. Health-promoting financial incentives may increase uptake of cancer screening. OBJECTIVE To evaluate the relative and absolute benefit associated with adding financial incentives to the uptake of CRC screening. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to July 31, 2020. Keywords and Medical Subject Headings terms were used to identify published studies on the topic. The search strategy identified 835 studies. STUDY SELECTION Randomized clinical trials (RCTs) were selected that involved adults older than 50 years who were eligible for CRC screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone, and who reported screening completion by using recommended tests at different time points. Observational or nonrandomized studies and a few RCTs were excluded. DATA EXTRACTION AND SYNTHESIS The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Data were abstracted and risk of bias was assessed by 2 independent reviewers. Random-effects meta-analysis was conducted, heterogeneity was examined through subgroup analysis and metaregression, and quality of evidence was appraised. MAIN OUTCOMES AND MEASURES The primary outcome was CRC screening completion within 12 months of receiving the intervention. RESULTS A total of 8 RCTs that were conducted in the United States and reported between January 1, 2014, and December 31, 2020, were included. The trials involved 110 644 participants, of whom 53 444 (48.3%) were randomized to the intervention group (received financial incentives) and 57 200 (51.7%) were randomized to the control group (received no financial incentives). Participants were predominantly male, with 59 113 men (53.4%). Low-quality evidence (rated down for risk of bias and heterogeneity) suggested that adding financial incentives may be associated with a small benefit of increasing CRC screening vs no financial incentives (odds ratio [OR], 1.25; 95% CI, 1.05-1.49). With mailed outreach having a 30% estimated CRC screening completion rate, adding financial incentives may increase the rate to 33.5% (95% CI, 30.8%-36.2%). On metaregression, the magnitude of benefit decreased as the proportion of participants with low income and/or from racial/ethnic minority groups increased. No significant differences were observed by type of behavioral economic intervention (fixed amount: OR, 1.26 [95% CI, 1.05-1.52] vs lottery: OR, 1.06 [95% CI, 0.80-1.40]; P = .32), amount of incentive (≤$5: OR, 1.09 [95% CI, 1.01-1.18] vs >$5: OR, 1.25 [95% CI, 1.02-1.54]; P = .22), or screening modality (stool-based test: OR, 1.14 [95% CI, 0.92-1.41] vs colonoscopy: OR, 1.63 [95% CI, 1.01-2.64]; P = .18). CONCLUSIONS AND RELEVANCE Adding financial incentives appeared to be associated with a small benefit of increasing CRC screening uptake, with marginal benefits in underserved populations with adverse social determinants of health. Alternative approaches to enhancing CRC screening uptake are warranted.
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Affiliation(s)
| | - Joshua Demb
- Moores Cancer Center, University of California at San Diego, La Jolla
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City
| | - Samir Gupta
- Moores Cancer Center, University of California at San Diego, La Jolla
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California
- Division of Gastroenterology, University of California at San Diego, La Jolla
| | - Siddharth Singh
- Division of Gastroenterology, University of California at San Diego, La Jolla
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19
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Mehta SJ, Reitz C, Niewood T, Volpp KG, Asch DA. Effect of Behavioral Economic Incentives for Colorectal Cancer Screening in a Randomized Trial. Clin Gastroenterol Hepatol 2021; 19:1635-1641.e1. [PMID: 32623005 PMCID: PMC7775888 DOI: 10.1016/j.cgh.2020.06.047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Financial incentives might increase participation in prevention such as screening colonoscopy. We studied whether incentives informed by behavioral economics increase participation in risk assessment for colorectal cancer (CRC) and completion of colonoscopy for eligible adults. METHODS Employees of a large academic health system (50-64 y old; n = 1977) were randomly assigned to groups that underwent risk assessment for CRC screening and direct access colonoscopy scheduling (control), or risk assessment, direct access colonoscopy scheduling, a $10 loss-framed incentive to complete risk assessment, and a $25 unconditional incentive for colonoscopy completion (incentive). The primary outcome was the percentage of participants who completed screening colonoscopy within 3 months of initial outreach. Secondary outcomes included the percentage of participants who scheduled colonoscopy and the percentage who completed the risk assessment. RESULTS At 3 months, risk assessment was completed by 19.5% of participants in the control group (95% CI, 17.0-21.9%) and 31.9% of participants in the incentive group (95% CI, 29.0-34.8%) (P < .001). At 3 months, 0.7% of controls had completed a colonoscopy (95% CI, .2%-1.2%) compared with 1.2% of subjects in the incentive group (95% CI, .5%-1.9%) (P = .25). CONCLUSIONS In a randomized trial of participants who underwent risk assessment for CRC with vs without financial incentive, the financial incentive increased CRC risk assessment completion but did not result in a greater completion of screening colonoscopy. Clinicaltrials.gov no: NCT03068052.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania
| | - Tess Niewood
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center
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20
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Stecher C, Mukasa B, Linnemayr S. Uncovering a behavioral strategy for establishing new habits: Evidence from incentives for medication adherence in Uganda. JOURNAL OF HEALTH ECONOMICS 2021; 77:102443. [PMID: 33831632 PMCID: PMC8122069 DOI: 10.1016/j.jhealeco.2021.102443] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 01/06/2021] [Accepted: 02/24/2021] [Indexed: 05/14/2023]
Abstract
Incentives are used to improve many health-related behaviors, but evidence is mixed for their effectiveness both during the incentivization period and, even more so, on the persistence of the behavior after incentives are withdrawn. In this paper, we present the results of a randomized controlled trial that successfully uses incentives to improve medication adherence among HIV-infected patients in Uganda over 20 months, and follows the sample for another 6 months to measure the persistence of these behavioral improvements. Our study contributes to the literature on habit formation by identifying a behavioral strategy that is associated with persistently high medication adherence after controlling for observable individual-level characteristics and the receipt of incentives. We find evidence supporting a psychological theory of habits as reflexive context-behavior associations, which suggests new ways of designing incentive-based interventions for better promoting persistent, healthier behaviors.
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Affiliation(s)
- Chad Stecher
- Arizona State University, 500 N 3rd Street, Phoenix, AZ 85004, United States.
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21
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Inadomi JM, Issaka RB, Green BB. What Multilevel Interventions Do We Need to Increase the Colorectal Cancer Screening Rate to 80%? Clin Gastroenterol Hepatol 2021; 19:633-645. [PMID: 31887438 PMCID: PMC8288035 DOI: 10.1016/j.cgh.2019.12.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/05/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023]
Abstract
Screening reduces colorectal cancer mortality; however, this remains the second leading cause of cancer deaths in the United States and adherence to colorectal cancer screening falls far short of the National Colorectal Cancer Roundtable goal of 80%. Numerous studies have examined the effectiveness of interventions to increase colorectal cancer screening uptake. Outreach is the active dissemination of screening outside of the primary care setting, such as mailing fecal blood tests to individuals' homes. Navigation uses trained personnel to assist individuals through the screening process. Patient education may take the form of brochures, videos, or websites. Provider education can include feedback about screening rates of patient panels. Reminders to healthcare providers can be provided by dashboards of patients due for screening. Financial incentives provide monetary compensation to individuals when they complete screening tests, either as fixed payments or via a lottery. Individual preference for specific screening strategies has also been examined in several trials, with a choice of screening strategies yielding higher adherence than recommendation of a single strategy.
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Affiliation(s)
- John M. Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA,Divisions of Clinical Research and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA,Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Rachel B. Issaka
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA,Divisions of Clinical Research and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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22
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Gruner LF, Amitay EL, Heisser T, Guo F, Niedermaier T, Gies A, Hoffmeister M, Brenner H. The Effects of Different Invitation Schemes on the Use of Fecal Occult Blood Tests for Colorectal Cancer Screening: Systematic Review of Randomized Controlled Trials. Cancers (Basel) 2021; 13:cancers13071520. [PMID: 33806234 PMCID: PMC8037417 DOI: 10.3390/cancers13071520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary There is large heterogeneity in invitation schemes and participation rates in colorectal cancer screening programs offering fecal occult blood tests (nowadays mostly fecal immunochemical tests). It is unclear what the most effective invitation strategies are for fecal occult blood tests. In this systematic review, advance notification, mailed fecal occult blood test, and reminders had major, consistent, and complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening. Our findings show that the effectiveness of invitations for fecal occult blood test-based colorectal cancer screening can be substantially increased across several settings by the implementation of comprehensive invitation strategies. Abstract Personal invitations for fecal occult blood tests (nowadays mostly fecal immunochemical tests) are increasingly used to raise their usage for colorectal cancer screening. However, there is a large heterogeneity in applied invitation schemes. We aimed to review evidence for the effectiveness of various invitation schemes. The main outcome was the fecal occult blood test usage rate. A systematic search was performed in Medline and Web of Science (up to 9 July 2020). Randomized controlled trials or cluster-randomized controlled trials were eligible, which reported on general invitations for fecal occult blood test-based colorectal cancer screening sent to the general population at average colorectal cancer risk. (PROSPERO 2020 CRD42020169409). Overall, 34 studies were included. Invitations with an attached, i.e., mailed fecal occult blood test consistently increased test usage by 4–19.7% points, compared to other methods of test provision. Likewise, the introduction of advance notification consistently led to a higher usage rate, with an increase of 3.3–10.8% points. Reminders showed positive but varying effects by method. With an increase of 8.5–15.8% points, letter or email reminders were more effective than reminders by phone call or text message (0.6–6.5% points). Inconsistent results were found for financial incentives ((−8.4)–20% points) and for added or changed invitation material ((−3.5)–11.8% points). With 3.5–24.7% points, the strongest increases in use were achieved by multifaceted invitation, implementing multiple components. Any invitation scheme was superior over no invitation. Advance notification, mailing of fecal occult blood test, and reminders were consistently shown to have major, complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening settings.
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Affiliation(s)
- Laura F. Gruner
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Medical Faculty Heidelberg, Heidelberg University, 69120 Heidelberg, Germany
| | - Efrat L. Amitay
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Thomas Heisser
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Medical Faculty Heidelberg, Heidelberg University, 69120 Heidelberg, Germany
| | - Feng Guo
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Tobias Niedermaier
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Anton Gies
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
| | - Michael Hoffmeister
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Hermann Brenner
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-421300; Fax: +49-6221-4213002
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Shay LA, Kimbel KJ, Dorsey CN, Jauregui LC, Vernon SW, Kullgren JT, Green BB. Patients' Reactions to Being Offered Financial Incentives to Increase Colorectal Screening: A Qualitative Analysis. Am J Health Promot 2021; 35:421-429. [PMID: 33504161 DOI: 10.1177/0890117120987836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To explore financial incentives as an intervention to improve colorectal cancer screening (CRCS) adherence among traditionally disadvantaged patients who have never been screened or are overdue for screening. APPROACH We used qualitative methods to describe patients' attitudes toward the offer of incentives, plans for future screening, and additional barriers and facilitators to CRCS. SETTING Kaiser Permanente Washington (KPWA). PARTICIPANTS KPWA patients who were due or overdue for CRCS. METHOD We conducted semi-structured qualitative interviews with 37 patients who were randomized to 1 of 2 incentives (guaranteed $10 or a lottery for $50) to complete CRCS. Interview transcripts were analyzed using a qualitative content approach. RESULTS Patients generally had positive attitudes toward both types of incentives, however, half did not recall the incentive offer at the time of the interview. Among those who recalled the offer, 95% were screened compared to only 25% among those who did not remember the offer. Most screeners stated that staying healthy was their primary motivator for screening, but many suggested that the incentive helped them prioritize and complete screening. CONCLUSIONS Incentives to complete CRCS may help motivate patients who would like to screen but have previously procrastinated. Future studies should ensure that the incentive offer is noticeable and shorten the deadline for completion of FIT screening.
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Affiliation(s)
- L Aubree Shay
- 12340University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | | | - Sally W Vernon
- 12340University of Texas Health Science Center at Houston, Houston, TX, USA
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Doubeni CA, Selby K, Gupta S. Framework and Strategies to Eliminate Disparities in Colorectal Cancer Screening Outcomes. Annu Rev Med 2020; 72:383-398. [PMID: 33208026 DOI: 10.1146/annurev-med-051619-035840] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preventable differences in colorectal cancer (CRC) mortality across racial/ethnic, economic, geographic, and other groups can be eliminated by assuring equitable access and quality across the care continuum, but few interventions have been demonstrated to do so. Multicomponent strategies designed with a health equity framework may be effective. A health equity framework takes into account social determinants of health, multilevel influences (policy, community, delivery, and individual levels), screening processes, and community engagement. Effective strategies for increasing screening uptake include patient navigation and other interventions for structural barriers, reminders and clinical decision support, and data to continuously track metrics and guide targets for improvement. Community resource gaps should be addressed to assure high-quality services irrespective of racial/ethnic and socioeconomic status. One model combinespopulation-based proactive outreach screening with screening delivery at in-person or virtual points of contact, as well as community engagement. Patient- and provider-based behavioral interventions may be considered for increasing screening demand and delivery. Providing a choice of screening tests is recommended for CRC screening, and access to colonoscopy is required for completion of the CRC screening process.
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Affiliation(s)
- Chyke A Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota 55905, USA; .,Department of Family Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), Lausanne 1011, Switzerland;
| | - Samir Gupta
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California 92161, USA.,Department of Medicine, University of California at San Diego, La Jolla, California 92103, USA; .,Moores Cancer Center, University of California at San Diego, La Jolla, California 92103, USA
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25
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Abstract
Screening for cancer has contributed to substantial reductions in death from several cancers and is one of the most cost-effective preventive interventions in all of health care. In the United States, primary care clinicians, their clinical teams, and the systems in which they work are primarily responsible for ensuring that screening occurs. In order to achieve the highest possible population-wide screening rates, primary care clinicians must embrace the responsibility to screen their entire enrolled patient population, institute several overarching general approaches to screening, and implement a combination of evidence-based interventions.
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Affiliation(s)
- Richard Wender
- Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Andrew Mutch Building, 51 N. 39th Street, Philadelphia, PA 19104, USA.
| | - Andrew M D Wolf
- University of Virginia School of Medicine, Box 800744 UVA Health System, Charlottesville, VA 22908, USA
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26
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Myers L, Goodwin B, Ralph N, Castro O, March S. Implementation Strategies for Interventions Aiming to Increase Participation in Mail-Out Bowel Cancer Screening Programs: A Realist Review. Front Oncol 2020; 10:543732. [PMID: 33117681 PMCID: PMC7550731 DOI: 10.3389/fonc.2020.543732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Bowel cancer is the third most commonly diagnosed cancer and the third most common cause of cancer-related death, with 1,849,518 new cases of bowel diagnosed and 880,792 deaths reported globally in 2018 alone. Survival can be improved through early detection via national mail-out bowel cancer screening programs; however, participation remains low in many countries. Behavior change is therefore required to increase participation. This realist review aims to (a) identify the behavior change techniques (BCTs) used in each intervention, (b) understand the mechanisms of action (MoAs) responsible for the BCT effectiveness, and (c) apply a behavior change model to inform how MoAs can be combined to increase screening participation. Methods: We systematically reviewed the literature for interventions aiming to increase participation in mail-out bowel cancer screening. We used a four-stage realist synthesis approach whereby (1) interventions were extracted from each study; (2) BCTs applied in each intervention were identified and coded using the BCT Taxonomy-v1; (3) the Theory and Techniques Tool was used to link BCTs to their MoA; and (4) BCTs and MoAs were categorized according to their effectiveness and what Health Action Process Approach (HAPA) stage of change they would affect. Results: We identified 68 intervention trials using 26 unique BCTs and 13 MoAs to increase participation. Sixteen BCTs and 10 MoAs were identified within the interventions that successfully increased participation rates. Interventions targeting both stages of the HAPA model had a higher success rate (80%) than those targeting one stage of change (51%). When targeting only one stage, interventions targeting the volitional stage had a higher success rate (71%) than interventions targeting only the motivational stage of change (26%). Conclusion: Importantly, this review identified a suite of BCTs and MoAs effective for increasing participation in mail-out bowel cancer screening programs. With increased participation in bowel cancer screening leading to improved survival, our findings are key to informing the improvement of policy and interventions that aim to increase screening using specific strategies at key stages of health decision-making.
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Affiliation(s)
- Larry Myers
- Centre for Health, Informatics, and Economic Research, University of Southern Queensland, Springfield Central, QLD, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Belinda Goodwin
- School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia.,Cancer Research Centre, Cancer Council Queensland, Brisbane, QLD, Australia
| | - Nicholas Ralph
- Cancer Research Centre, Cancer Council Queensland, Brisbane, QLD, Australia.,School of Nursing & Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia.,Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Oscar Castro
- Physically Active Lifestyles Research Group, Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Sonja March
- Centre for Health, Informatics, and Economic Research, University of Southern Queensland, Springfield Central, QLD, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
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27
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Rogers CR, Matthews P, Xu L, Boucher K, Riley C, Huntington M, Le Duc N, Okuyemi KS, Foster MJ. Interventions for increasing colorectal cancer screening uptake among African-American men: A systematic review and meta-analysis. PLoS One 2020; 15:e0238354. [PMID: 32936812 PMCID: PMC7494124 DOI: 10.1371/journal.pone.0238354] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 08/07/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND African-American men have the lowest 5-year survival rate in the U.S. for colorectal cancer (CRC) of any racial group, which may partly stem from low screening adherence. It is imperative to synthesize the literature evaluating the effectiveness of interventions on CRC screening uptake in this population. MATERIALS AND METHODS In this systematic review and meta-analysis, Medline, CINAHL, Embase, and Cochrane CENTRAL were searched for U.S.-based interventions that: were published after 1998-January 2020; included African-American men; and evaluated CRC screening uptake explicitly. Checklist by Cochrane Collaboration and Joanna Brigg were utilized to assess risk of bias, and meta-regression and sensitivity analyses were employed to identify the most effective interventions. RESULTS Our final sample comprised 41 studies with 2 focused exclusively on African-American men. The most frequently adopted interventions were educational materials (39%), stool-based screening kits (14%), and patient navigation (11%). Most randomized controlled trials failed to provide details about the blinding of the participant recruitment method, allocation concealment method, and/or the outcome assessment. Due to high heterogeneity, meta-analysis was conducted among 17 eligible studies. Interventions utilizing stool-based kits or patient navigation were most effective at increasing CRC screening completion, with odds ratios of 9.60 (95% CI 2.89-31.82, p = 0.0002) and 2.84 (95% CI 1.23-6.49, p = 0.01). No evidence of publication bias was present for this study registered with the International Prospective Registry of Systematic Reviews (PROSPERO 2019 CRD42019119510). CONCLUSIONS Additional research is warranted to uncover effective, affordable interventions focused on increasing CRC screening completion among African-American men. When designing and implementing future multicomponent interventions, employing 4 or fewer interventions types may reduce bias risk. Since only 5% of the interventions solely focused on African-American men, future theory-driven interventions should consider recruiting samples comprised solely of this population.
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Affiliation(s)
- Charles R. Rogers
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Phung Matthews
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Lei Xu
- Department of Health Education and Promotion, East Carolina University, Greenville, NC, United States of America
| | - Kenneth Boucher
- Cancer Biostatistics Shared Resource, Huntsman Cancer Institute, Salt Lake City, UT, United States of America
| | - Colin Riley
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Matthew Huntington
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Nathan Le Duc
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Kola S. Okuyemi
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Margaret J. Foster
- Medical Sciences Library, Texas A&M University, College Station, TX, United States of America
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28
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Mehta SJ, Oyalowo A, Reitz C, Dean O, McAuliffe T, Asch DA, Doubeni CA. Text messaging and lottery incentive to improve colorectal cancer screening outreach at a community health center: A randomized controlled trial. Prev Med Rep 2020; 19:101114. [PMID: 32477853 PMCID: PMC7251946 DOI: 10.1016/j.pmedr.2020.101114] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 04/28/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
Efforts to boost colorectal cancer (CRC) screening rates in underserved populations have been limited by effectiveness and scalability. We evaluate the impact of adding a lottery-based financial incentive to a text messaging program that asks patients to opt-in to receive mailed fecal immunochemical testing (FIT). This is a two-arm pragmatic randomized controlled trial at a community health center in Southwest Philadelphia from April to July 2017. We included CRC screening-eligible patients between ages 50-74 years who had a mobile phone, active health insurance, and at least one visit to the clinic in the past 12 months. Patients received a text message about CRC screening with the opportunity to opt-in to receive mailed FIT. They were randomized 1:1 to the following: (1) text messaging outreach alone (text), or (2) text messaging with lottery for a 1-in-5 chance of winning $100 after FIT completion (text + lottery). The primary outcome was the percentage of patients completing the mailed FIT within 3 months of initial outreach. 281 patients were included in the intent-to-treat analysis. The FIT completion rate was 12.1% (95% CI, 6.7%-17.5%) in the text message arm and 12.1% (95% CI, 6.7%-17.5%) in the lottery arm, with no statistical difference between arms. The majority of post-intervention interview respondents found text messaging to be acceptable and convenient. Opt-in text messaging is a feasible option to promote the uptake of mailed FIT screening, but the addition of a lottery-based incentive did not improve completion rates. Trial Registration: clinicaltrials.gov (NCT03072095).
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
| | - Akinbowale Oyalowo
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Owen Dean
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, United States
| | - Chyke A. Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, United States
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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] [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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30
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Decruz GM, Ng CH, Lim KT, Devi MK, Lim F, Tai CH, Chong CS. Afterthoughts on colonoscopy. Was it that bad? J Med Screen 2020; 28:63-69. [PMID: 32438893 DOI: 10.1177/0969141320923381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Colorectal cancer is among the top three most common cancers globally. In order to reduce the health burden, it is important to improve the uptake of colorectal cancer screening by understanding the barriers and facilitators encountered. There are numerous reports in the literature on the views of the general public on cancer screening. However, the experiences of colonoscopy patients are not as well studied. This paper maps their perceptions. METHODS Keyword searches for terms such as 'colorectal', 'colonoscopy' and 'qualitative' were conducted on 3 December 2019 in five databases: Medline, Embase, CINAHL, PsycINFO and Web of Science Core Collection. Qualitative articles that quoted colonoscopy-experienced patients with no prior history of colorectal cancer were included for the thematic analysis. The systematic review was then synthesized according to PRISMA guidelines. RESULTS The major themes were distilled into three categories: pre-procedure, during and post-procedure. The factors identified in the pre-procedure phase include the troublesome bowel preparation, poor quality of information provided and the dynamics within a support network. Perceptions of pain, emotional discomfort and the role of providers mark the experience during the procedure. The receipt of results, opportunities given for discussion and finances relating to colonoscopy are important post-procedure events. CONCLUSION Understanding colorectal cancer screening behaviour is fundamental for healthcare providers and authorities to develop system and personal level changes for the improvement of colorectal cancer screening services. The key areas include patient comfort, the use of clearer instructional aids and graphics, establishing good patient rapport, and the availability of individualized options for sedation and the procedure.
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Affiliation(s)
- Glenn M Decruz
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Cheng H Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Kia T Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - M K Devi
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore, Singapore
| | - Frances Lim
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
| | - Chia H Tai
- Department of Surgery, University Surgical Cluster, National University Health System, Singapore, Singapore
| | - Choon S Chong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore, Singapore
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31
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Gruner LF, Hoffmeister M, Ludwig L, Brenner H. Effect of Various Invitation Schemes on the Use of Fecal Immunochemical Tests for Colorectal Cancer Screening: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e16413. [PMID: 32242518 PMCID: PMC7165303 DOI: 10.2196/16413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/22/2022] Open
Abstract
Background Fecal occult blood testing has been offered for many years in the German health care system, but participation rates have been notoriously low. Objective The aim of this study is to evaluate the effect of various personal invitation schemes on the use of fecal immunochemical tests (FITs) in persons aged 50-54 years. Methods This study consists of a three-armed randomized controlled trial: (1) arm A: an invitation letter from a health insurance plan including a FIT test kit, (2) arm B: an invitation letter from a health insurance plan including an offer to receive a free FIT test kit by mail upon easy-to-handle request (ie, by internet, fax, or reply mail), and (3) arm C: an information letter on an existing colonoscopy offer (ie, control). Within arms A and B, a random selection of 50% of the study population will receive reminder letters, the effects of which are to be evaluated in a substudy. Results A total of 17,532 persons aged 50-54 years in a statutory health insurance plan in the southwest of Germany—AOK Baden-Wuerttemberg—were sent an initial invitation, and 5825 reminder letters were sent out. The primary end point is FIT usage within 1 year from receipt of invitation or information letter. The main secondary end points include gender-specific FIT usage within 1 year, rates of positive test results, rates of colonoscopies following a positive test result, and detection rates of advanced neoplasms. The study was launched in September 2017. Data collection and workup were completed in fall 2019. Conclusions This randomized controlled trial will provide important empirical evidence for enhancing colorectal cancer screening offers in the German health care system. Trial Registration German Clinical Trials Register (DRKS) DRKS00011858; https://bit.ly/2UBTIdt International Registered Report Identifier (IRRID) DERR1-10.2196/16413
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Affiliation(s)
- Laura Fiona Gruner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Medical Faculty Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Michael Hoffmeister
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Leopold Ludwig
- Gastroentereologische Schwerpunktpraxis, Dornstadt, Germany
| | - Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Division of Preventive Oncology, German Cancer Research Center and National Center for Tumor Diseases, Heidelberg, Germany.,German Cancer Consortium, German Cancer Research Center, Heidelberg, Germany
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Castañeda SF, Bharti B, Rojas M, Mercado S, Bearse AM, Camacho J, Lopez MS, Muñoz F, O'Connell S, Liu L, Talavera GA, Gupta S. Outreach and Inreach Strategies for Colorectal Cancer Screening Among Latinos at a Federally Qualified Health Center: A Randomized Controlled Trial, 2015-2018. Am J Public Health 2020; 110:587-594. [PMID: 32078353 PMCID: PMC7067111 DOI: 10.2105/ajph.2019.305524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2019] [Indexed: 12/30/2022]
Abstract
Objectives. To compare usual care, inreach consisting of one-on-one education, mailed outreach offering a fecal immunochemical test (FIT), and a combination of outreach and inreach for promoting colorectal cancer (CRC) screening.Methods. We conducted a 4-arm randomized controlled trial from 2015 to 2018 at a US federally qualified health center near the California-Mexico border primarily serving low-income Hispanics/Latinos. A total of 673 individuals aged 50 to 75 years not up to date with screening were assigned to 1 of the 4 intervention groups. The primary outcome was CRC screening through 6 months follow-up.Results. A total of 671 patients were included in intention-to-screen analyses. Their mean age was 59.9 years, 48.9% were male, and 86.3% were primarily Spanish-speaking. Screening was 27.5% for usual care (95% confidence interval [CI] = 0.21, 0.34), 52.7% for inreach (95% CI = 0.45, 0.60), 77.2% for outreach (95% CI = 0.71, 0.83), and 78.9% for combination of inreach and outreach (95% CI = 0.73, 0.85; P < .001 for all comparisons except P = .793 for outreach vs combination).Conclusions. Among individuals at high risk for noncompletion, inreach with one-on-one education nearly doubled, and outreach offering mailed FIT alone or in combination with inreach nearly tripled screening compared with usual care. Mailed FIT outreach was superior to inreach for promoting screening.
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Affiliation(s)
- Sheila F Castañeda
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Balambal Bharti
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Marielena Rojas
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Silvia Mercado
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Adriana M Bearse
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Jasmine Camacho
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Manuel Song Lopez
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Fatima Muñoz
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Shawne O'Connell
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Lin Liu
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Gregory A Talavera
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
| | - Samir Gupta
- Sheila F. Castañeda and Gregory A. Talavera are with the Department of Psychology, San Diego State University, Chula Vista, CA. Balambal Bharti, Lin Liu, and Samir Gupta are with the Moores Cancer Center, University of California, San Diego, La Jolla. Marielena Rojas, Silvia Mercado, Adriana M. Bearse, Jasmine Camacho, Manuel Song Lopez, and Fatima Muñoz are with San Ysidro Health, San Diego, CA. Shawne O'Connell is with Kimochi Inc, San Francisco, CA
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Carethers JM, Doubeni CA. Causes of Socioeconomic Disparities in Colorectal Cancer and Intervention Framework and Strategies. Gastroenterology 2020; 158:354-367. [PMID: 31682851 PMCID: PMC6957741 DOI: 10.1053/j.gastro.2019.10.029] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 12/18/2022]
Abstract
Colorectal cancer (CRC) disproportionately affects people from low socioeconomic backgrounds and some racial minorities. Disparities in CRC incidence and outcomes might result from differences in exposure to risk factors such as unhealthy diet and sedentary lifestyle; limited access to risk-reducing behaviors such as chemoprevention, screening, and follow-up of abnormal test results; or lack of access to high-quality treatment resources. These factors operate at the individual, provider, health system, community, and policy levels to perpetuate CRC disparities. However, CRC disparities can be eliminated. Addressing the complex factors that contribute to development and progression of CRC with multicomponent, adaptive interventions, at multiple levels of the care continuum, can reduce gaps in mortality. These might be addressed with a combination of health care and community-based interventions and policy changes that promote healthy behaviors and ensure access to high-quality and effective measures for CRC prevention, diagnosis, and treatment. Improving resources and coordinating efforts in communities where people of low socioeconomic status live and work would increase access to evidence-based interventions. Research is also needed to understand the role and potential mechanisms by which factors in diet, intestinal microbiome, and/or inflammation contribute to differences in colorectal carcinogenesis. Studies of large cohorts with diverse populations are needed to identify epidemiologic and molecular factors that contribute to CRC development in different populations.
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Affiliation(s)
- John M. Carethers
- Division of Gastroenterology, Department of Internal Medicine, Department of Human Genetics and Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan
| | - Chyke A. Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, MN,Department of Family Medicine, Mayo Clinic, Rochester, MN
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Mehta SJ, Induru V, Santos D, Reitz C, McAuliffe T, Orellana C, Volpp KG, Asch DA, Doubeni CA. Effect of Sequential or Active Choice for Colorectal Cancer Screening Outreach: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1910305. [PMID: 31469393 PMCID: PMC6724166 DOI: 10.1001/jamanetworkopen.2019.10305] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/11/2019] [Indexed: 12/26/2022] Open
Abstract
Importance Colonoscopy and fecal immunochemical testing (FIT) are considered top-tier tests for colorectal cancer (CRC) screening. Behavioral economic insights about "choice architecture" suggest that participation could be influenced by how people are presented test options. Objective To investigate response rates for offering colonoscopy only compared with sequential choice (colonoscopy and then FIT) or active choice (colonoscopy or FIT) through mailed outreach. Design, Setting, and Participants Three-arm pragmatic randomized clinical trial conducted between November 14, 2017, and May 14, 2018. The setting was primary care practices at an academic health system. Patients aged 50 to 74 years with at least 2 primary care visits in the 2-year preenrollment period were included if they were eligible but not up to date on CRC screening. Interventions Eligible patients received mailed outreach about CRC screening. Equal numbers of eligible patients were randomly assigned to 3 outreach groups to receive mailings about CRC screening with the following options: (1) direct phone number to call for scheduling colonoscopy (colonoscopy only), (2) direct phone number to call for colonoscopy and a mailed FIT kit if no response within 4 weeks (sequential choice), or (3) direct phone number to call for colonoscopy and a mailed FIT kit offered at the same time (active choice). Main Outcomes and Measures The primary outcome was CRC screening completion (FIT or colonoscopy) within 4 months of initial outreach. The secondary outcomes were CRC screening completion within 6 months of outreach and the choice of colonoscopy as a screening test. Results In total, 438 patients were included in the intent-to-treat analysis, with a median age of 56 years (interquartile range, 52-63 years); 55.0% were women. At 4 months, the CRC screening completion rates were 14.4% (95% CI, 8.7%-20.1%) in the colonoscopy-only arm, 17.1% (95% CI, 11.0%-23.2%) in the sequential choice arm, and 19.9% (95% CI, 13.4%-26.4%) in the active choice arm. Neither choice arm achieved a screening rate statistically greater than that in the colonoscopy-alone arm. Among those who completed CRC screening at 4 months, 90.5% (95% CI, 78.0%-103.0%) chose colonoscopy in the colonoscopy-only arm, which was significantly higher than the 52.0% (95% CI, 32.4%-71.6%; P = .005) and 37.9% (95% CI, 20.2%-55.6%; P < .001) in the sequential choice and active choice arms, respectively. Conclusions and Relevance There was no significant increase in CRC screening when offering sequential or active choice, but there was a lower rate of colonoscopy in the choice arms than in the colonoscopy-only arm. Subtle changes in sequencing or defaults can alter patient decision making related to preventive health. Trial Registration ClinicalTrials.gov identifier: NCT03246438.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Vikranth Induru
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David Santos
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Charles Orellana
- Clinical Care Associates, University of Pennsylvania, Philadelphia
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Green BB, Anderson ML, Cook AJ, Chubak J, Fuller S, Kimbel KJ, Kullgren JT, Meenan RT, Vernon SW. Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e196570. [PMID: 31276178 PMCID: PMC6789432 DOI: 10.1001/jamanetworkopen.2019.6570] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Importance Colorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups. Objective To examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates. Design, Setting, and Participants This parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled. Interventions Interventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion). Main Outcomes and Measures The primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures. Results A total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%-15.1%) in the mail and monetary group and 7.1% (95% CI, -0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%-64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, -0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03). Conclusions and Relevance Financial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups. Trial Registration ClinicalTrials.gov identifier: NCT00697047.
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Affiliation(s)
- Beverly B Green
- Kaiser Permanente Washington, Seattle
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | | | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Kilian J Kimbel
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jeffrey T Kullgren
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Richard T Meenan
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Sally W Vernon
- Department of Health Promotion and Behavior Sciences, University of Texas School of Public Health, Houston
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Nisa CF, Bélanger JJ, Schumpe BM. Parts greater than their sum: randomized controlled trial testing partitioned incentives to increase cancer screening. Ann N Y Acad Sci 2019; 1449:46-55. [PMID: 31111509 DOI: 10.1111/nyas.14115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/31/2019] [Accepted: 04/12/2019] [Indexed: 01/03/2023]
Abstract
Promoting healthy behavior is a challenge for public health officials, especially in the context of asking patients to participate in preventive cancer screenings. Small financial incentives are sometimes used, but there is a little scientific basis to support a compelling description of the best-practice implementation of such incentives. We present a simple behavioral strategy based on mental accounting from prospect theory that maximizes the impact of incentives with no additional cost. We show how the partition of one incentive into two smaller incentives of equivalent total amount produces substantial behavioral changes, demonstrated in the context of colorectal cancer screening. In a randomized controlled trial, eligible patients aged 50-74 (n = 1652 patients) were allocated to receive either one €10 incentive (upon completion of screening) or two €5 incentives (at the beginning and at the end of screening). We show that cancer screening rates were dramatically increased by partitioning the financial incentive (61.1%), compared with a single installment at the end (41.4%). These results support the hedonic editing hypothesis from prospect theory, and underline the importance of implementing theoretically grounded healthcare interventions. Our results suggest that, when patient incentives are feasible, healthcare procedures should be framed as multistage events with smaller incentives offered at multiple points in time.
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Affiliation(s)
- Claudia F Nisa
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jocelyn J Bélanger
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Birga M Schumpe
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
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Errors in Text and Conflict of Interest Disclosures. JAMA Netw Open 2019; 2:e193771. [PMID: 31026018 PMCID: PMC6487564 DOI: 10.1001/jamanetworkopen.2019.3771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Affiliation(s)
- Liam Rose
- Stanford Surgery Policy Improvement Research and Education (S-SPIRE) Center, Stanford University, Stanford, California
- Health Economics Resource Center, Department of Veterans Affairs, Menlo Park, California
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