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Olmstead T, Spencer JC, Kluz N, Zhan FB, Shokar NK, Pignone M. Costs and Projected Effect of a Federally Qualified Health Center-Based Mailed Colorectal Cancer Screening Program in Texas. Prev Chronic Dis 2024; 21:E30. [PMID: 38696253 PMCID: PMC11086695 DOI: 10.5888/pcd21.230266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
Introduction Mailed stool testing for colorectal cancer (CRC) may improve screening uptake and reduce the incidence and mortality of CRC, especially among patients at federally qualified health centers (FQHCs). To expand screening programs it is important to identify cost-effective approaches. Methods We developed a decision-analytic model to estimate the cost, effects on screening and patient outcomes (CRCs detected, CRCs prevented, CRC deaths prevented), and cost-effectiveness of implementing a state-wide mailed stool testing program over 5 years among unscreened, age-eligible (aged 50-75 y) patients at FQHCs in Texas. We compared various outreach strategies and organizational structures (centralized, regional, or a hybrid). We used data from our existing regional mailed stool testing program and recent systematic reviews to set parameters for the model. Costs included start-up and ongoing activities and were estimated in 2022 US dollars from the perspective of a hypothetical third-party payer. Cost-effectiveness was assessed by using both incremental and average cost-effectiveness ratios. Results Using either a statewide centralized or hybrid organizational configuration to mail stool tests to newly eligible FQHC patients and patients who have responded at least once since program inception is likely to result in the best use of resources over 5 years, enabling more than 110,000 additional screens, detecting an incremental 181 to 194 CRCs, preventing 91 to 98 CRCs, and averting 46 to 50 CRC deaths, at a cost of $10 million to $11 million compared with no program. Conclusions A statewide mailed stool testing program for FQHC patients can be implemented at reasonable cost with considerable effects on CRC screening outcomes, especially when its structure maximizes program efficiency while maintaining effectiveness.
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Affiliation(s)
- Todd Olmstead
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin
- University of Texas at Austin, Lyndon B Johnson School of Public Affairs, 2315 Red River Street, Austin TX 78712
| | - Jennifer C Spencer
- Department of Population Health, The University of Texas at Austin Dell Medical School
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School
- Livestrong Cancer Institutes, The University of Texas at Austin Dell Medical School
| | - Nicole Kluz
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School
- Livestrong Cancer Institutes, The University of Texas at Austin Dell Medical School
| | - F Benjamin Zhan
- Department of Population Health, The University of Texas at Austin Dell Medical School
- Livestrong Cancer Institutes, The University of Texas at Austin Dell Medical School
- Texas Center for Geographic Information Science, Department of Geography and Environmental Studies, Texas State University, San Marcos, Texas
| | - Navkiran K Shokar
- Department of Population Health, The University of Texas at Austin Dell Medical School
- Livestrong Cancer Institutes, The University of Texas at Austin Dell Medical School
| | - Michael Pignone
- Department of Population Health, The University of Texas at Austin Dell Medical School
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School
- Livestrong Cancer Institutes, The University of Texas at Austin Dell Medical School
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Podmore C, Selby K, Jensen CD, Zhao WK, Weiss NS, Levin TR, Schottinger J, Doubeni CA, Corley DA. Colorectal Cancer Screening After Sequential Outreach Components in a Demographically Diverse Cohort. JAMA Netw Open 2024; 7:e245295. [PMID: 38625704 PMCID: PMC11022110 DOI: 10.1001/jamanetworkopen.2024.5295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/31/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Organized screening outreach can reduce differences in colorectal cancer (CRC) incidence and mortality between demographic subgroups. Outcomes associated with additional outreach, beyond universal outreach, are not well known. Objective To compare CRC screening completion by race and ethnicity, age, and sex after universal automated outreach and additional personalized outreach. Design, Setting, and Participants This observational cohort study included screening-eligible individuals aged 50 to 75 years assessed during 2019 in a community-based organized CRC screening program within the Kaiser Permanente Northern California (KPNC) integrated health care delivery setting. For KPNC members who are not up to date with screening by colonoscopy, each year the program first uses automated outreach (mailed prescreening notification postcards and fecal immunochemical test [FIT] kits, automated telephone calls, and postcard reminders), followed by personalized components for nonresponders (telephone calls, electronic messaging, and screening offers during office visits). Data analyses were performed between November 2021 and February 2023 and completed on February 5, 2023. Exposures Completed CRC screening via colonoscopy, sigmoidoscopy, or FIT. Main Outcomes and Measures The primary outcome was the proportion of participants completing an FIT or colonoscopy after each component of the screening process. Differences across subgroups were assessed using the χ2 test. Results This study included 1 046 745 KPNC members. Their mean (SD) age was 61.1 (6.9) years, and more than half (53.2%) were women. A total of 0.4% of members were American Indian or Alaska Native, 18.5% were Asian, 7.2% were Black, 16.2% were Hispanic, 0.8% were Native Hawaiian or Other Pacific Islander, and 56.5% were White. Automated outreach significantly increased screening participation by 31.1%, 38.1%, 29.5%, 31.9%, 31.8%, and 34.5% among these groups, respectively; follow-up personalized outreach further significantly increased participation by absolute additional increases of 12.5%, 12.4%, 13.3%, 14.4%, 14.7%, and 11.2%, respectively (all differences P < .05 compared with White members). Overall screening coverage at the end of the yearly program differed significantly among members who were American Indian or Alaska Native (74.1%), Asian (83.5%), Black (77.7%), Hispanic (76.4%), or Native Hawaiian or Other Pacific Islander (74.4%) compared with White members (82.2%) (all differences P < .05 compared with White members). Screening completion was similar by sex; older members were substantially more likely to be up to date with CRC screening both before and at the end of the screening process. Conclusions and Relevance In this cohort study of a CRC screening program, sequential automated and personalized strategies each contributed to substantial increases in screening completion in all demographic groups. These findings suggest that such programs may potentially reduce differences in CRC screening completion across demographic groups.
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Affiliation(s)
- Clara Podmore
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
- Institute of Family Medicine, University of Fribourg, Fribourg, Switzerland
| | - Kevin Selby
- Department of Ambulatory Care and Community Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Wei K. Zhao
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Noel S. Weiss
- Department of Epidemiology, University of Washington, Shoreline
| | - Theodore R. Levin
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Joanne Schottinger
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
| | | | - Douglas A. Corley
- Division of Research, Kaiser Permanente Northern California, Oakland
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Kimura A, Bell-Brown A, Akinsoto N, Wood J, Peck A, Fang V, Issaka RB. Implementing an Organized Colorectal Cancer Screening Program: Lessons Learned From an Academic-Community Practice. AJPM Focus 2024; 3:100188. [PMID: 38357554 PMCID: PMC10864856 DOI: 10.1016/j.focus.2024.100188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Introduction The effectiveness of mailed fecal immunochemical test outreach might be enhanced through an organized colorectal cancer screening program, yet published real-world experiences are limited. We synthesized the process of implementing a colorectal cancer screening program that used mailed fecal immunochemical test outreach in a large integrated academic-community practice. Methods Data from a pilot mailed fecal immunochemical test program were shared with healthcare system leadership, which inspired the creation of a cross-institutional organized colorectal cancer screening program. In partnership with a centralized population health team and primary care, we defined (1) the institutional approach to colorectal cancer screening, (2) the target population and method for screening, (3) the team responsible for implementation, (4) the healthcare team responsible for decisions and care, (5) a quality assurance structure, and (6) a method for identifying cancer occurrence. Results The Fred Hutch/UW Medicine Population Health Colorectal Cancer Screening Program began in September 2021. The workflow for mailed fecal immunochemical test outreach included a mailed postcard, a MyChart message from the patient's primary care provider, a fecal immunochemical test kit with a letter signed by the primary care provider and program director, and up to 3 biweekly reminders. Patients without a colonoscopy 3 months after an abnormal fecal immunochemical test result received navigation through the program. In the first program year, we identified 9,719 patients eligible for outreach, and in an intention-to-treat analysis, 32% of patients completed colorectal cancer screening by fecal immunochemical test or colonoscopy. Conclusions Real-world experiences detailing how to implement organized colorectal cancer screening programs might increase adoption. In our experience, broadly disseminating pilot data, early institutional support, robust data management, and strong cross-departmental relationships were critical to successfully implementing a colorectal cancer screening program that benefits all patients.
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Affiliation(s)
- Amanda Kimura
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Ari Bell-Brown
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Nkem Akinsoto
- UW Medicine Primary Care and Population Health, University of Washington, Seattle, Washington
| | - Jerry Wood
- UW Medicine Primary Care and Population Health, University of Washington, Seattle, Washington
| | - Amy Peck
- UW Medicine Primary Care and Population Health, University of Washington, Seattle, Washington
| | - Victoria Fang
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Rachel B. Issaka
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, Washington
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
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Modica C, Lewis JH, Bay RC. Advancing Virtual at-Home Care for Community Health Center Patients Using Patient Self-Care Tools, Technology, and Education. J Multidiscip Healthc 2024; 17:521-531. [PMID: 38328633 PMCID: PMC10849139 DOI: 10.2147/jmdh.s443973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/22/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Health centers are community-based, patient directed primary care providers that offer accessible, high-quality primary care within medically underserved communities. Screening for cancer and managing complex chronic conditions such as diabetes, hypertension, obesity, and depression are vital services for the vulnerable populations seen by community health centers. Delivering care for complex chronic conditions and preventive services using virtual models that integrate self-care tools and technology is an important approach to increasing access for hard-to-reach patients served by health centers. Objective This study aimed to explore the use of a virtual care model, applied using a systems approach and patient-driven tools and technology, on the performance of clinical and patient experience measures. Methods A virtual care model, applied using a systems approach offered by the Value Transformation Framework (VTF), was combined with self-care tools and technology in twenty health centers across 17 states to drive improvement efforts. Changes in clinical measures and patient experience were compared. Results A total of 385 patients were enrolled and 270 (70.1%) completed a baseline visit and at least four virtual visits during the six-month intervention period. Statistically significant improvements were seen in measures for HbA1c, systolic and diastolic blood pressure, and bodyweight. Among the 270 who completed the baseline and at least 4 virtual visits, the percentage up-to-date for colorectal cancer screening increased from 113/270 (41.9%) to 169/270 (62.6%) after six months, p<0.001, a 20.7% increase. Patients completing the baseline visit and at least 4 virtual visits reported a 10.7% decrease in depression and increased satisfaction with virtual care visits compared to in-person visits (p<0.001). Conclusion Health centers applying the Value Transformation Framework's organizing framework to the use of virtual care models together with patient self-care tools, technology, and education, had improvements in measures for chronic and preventive conditions and patient experience.
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Affiliation(s)
- Cheryl Modica
- National Association of Community Health Centers, Bethesda, MD, USA
| | - Joy H Lewis
- Department of Medicine and Public Health, A.T. Still University, School of Osteopathic Medicine, Mesa, AZ, USA
| | - R Curtis Bay
- Department of Interdisciplinary Health Sciences, Arizona School of Health Sciences, A.T. Still University, Mesa, AZ, USA
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Coury J, Coronado G, Currier JJ, Kenzie ES, Petrik AF, Badicke B, Myers E, Davis MM. Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas. Implement Sci Commun 2024; 5:6. [PMID: 38191536 PMCID: PMC10775579 DOI: 10.1186/s43058-023-00540-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 12/14/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings. METHODS SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention's components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up. DISCUSSION Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. TRIAL REGISTRATION Registered at ClinicalTrials.gov (NCT04890054) and at the NCI's Clinical Trials Reporting Program (CTRP no.: NCI-2021-01032) on May 11, 2021.
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Affiliation(s)
- Jennifer Coury
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA.
| | | | - Jessica J Currier
- Division of Oncological Sciences, Knight Cancer Institute, OHSU, Portland, USA
| | - Erin S Kenzie
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- Department of Family Medicine, OHSU, Portland, USA
| | | | - Brittany Badicke
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Emily Myers
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Melinda M Davis
- Oregon Rural Practice-Based Research Network, Oregon Health & Science University (OHSU), 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- OHSU-PSU School of Public Health, OHSU, Portland, USA
- Department of Family Medicine, OHSU, Portland, USA
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6
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Miller EA, Pinsky PF. Changes in uptake of stool-based colorectal cancer screening during the Covid-19 pandemic. Cancer Causes Control 2023; 34:887-895. [PMID: 37310565 DOI: 10.1007/s10552-023-01733-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
PURPOSE Colorectal cancer (CRC) screening is underutilized and endoscopic colon screening includes a number of barriers that were exacerbated by the Covid-19 pandemic. At-home stool-based screening (SBS) increased during the pandemic and potentially reached eligible adults hesitant to be screened by endoscopy. The purpose of this analysis was to examine the change in uptake of SBS during the pandemic among adults not screened within guidelines by endoscopy. METHODS We used data from the 2019 and 2021 National Health Interview Surveys to estimate uptake of SBS among adults aged 50-75 years, without a previous diagnosis of CRC and without guideline-concordant endoscopic screening. We also examined provider recommendations for screening tests. To examine if changes in uptake differed during the pandemic by demographic and health characteristics, we combined survey years and ran logistic regression models with an interaction term for each factor and survey year. RESULTS In our study population, SBS increased 74% overall from 2019 to 2021 (8.7% to 15.1%; p < 0.001), with the largest percent increase among those aged 50-52 years (3.5% to 9.9%; p < 0.001). Among those aged 50-52 years, the ratio of endoscopy to SBS changed from 83%/17% in 2019 to 55%/45% in 2021. Cologuard was the only screening test where recommendations by healthcare providers significantly increased from 2019 (10.6% to 16.1%; p = 0.002). CONCLUSIONS Use and recommendations for SBS increased substantially during the pandemic. Increased awareness among patients could potentially improve future CRC screening rates if uptake of SBS occurs among those unable or unwilling to be screened by endoscopy.
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Affiliation(s)
- Eric A Miller
- Division of Cancer Prevention, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA.
| | - Paul F Pinsky
- Division of Cancer Prevention, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD, 20850, USA
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Scott RE, Chang P, Kluz N, Baykal-Caglar E, Agrawal D, Pignone M. Equitable Implementation of Mailed Stool Test-Based Colorectal Cancer Screening and Patient Navigation in a Safety Net Health System. J Gen Intern Med 2023; 38:1631-1637. [PMID: 36456842 PMCID: PMC10212848 DOI: 10.1007/s11606-022-07952-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Mailed stool testing programs increase colorectal cancer (CRC) screening in diverse settings, but whether uptake differs by key demographic characteristics is not well-studied and has health equity implications. OBJECTIVE To examine the uptake and equity of the first cycle of a mailed stool test program implemented over a 3-year period in a Central Texas Federally Qualified Health Center (FQHC) system. DESIGN Retrospective cohort study within a single-arm intervention. PARTICIPANTS Patients in an FQHC aged 50-75 at average CRC risk identified through electronic health records (EHR) as not being up to date with screening. INTERVENTIONS Mailed outreach in English/Spanish included an introductory letter, free-of-charge fecal immunochemical test (FIT), and lab requisition with postage-paid mailer, simple instructions, and a medical records update postcard. Patients were asked to complete the FIT or postcard reporting recent screening. One text and one letter reminded non-responders. A bilingual patient navigator guided those with positive FIT toward colonoscopy. MAIN MEASURES Proportions of patients completing mailed FIT in response to initial cycle of outreach and proportion of those with positive FIT completing colonoscopy; comparison of whether proportions varied by demographics and insurance status obtained from the EHR. KEY RESULTS Over 3 years, 33,606 patients received an initial cycle of outreach. Overall, 19.9% (n = 6672) completed at least one mailed FIT, 5.6% (n = 374) tested positive during that initial cycle, and 72.5% (n = 271 of 374) of those with positive FIT completed a colonoscopy. Hispanic/Latinx, Spanish-speaking, and uninsured patients were more likely to complete mailed FIT compared with white, English-speaking, and commercially insured patients. Spanish-speaking patients were more likely to complete colonoscopy after positive FIT compared with English-speaking patients. CONCLUSIONS Mailed FIT outreach with patient navigation implemented in an FQHC system was effective in equitably reaching patients not up to date for CRC screening.
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Affiliation(s)
- Rebekah E Scott
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Patrick Chang
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, USA
| | - Nicole Kluz
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Eda Baykal-Caglar
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, USA
- CommUnityCare Health Centers, Austin, TX, USA
| | - Deepak Agrawal
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA
| | - Michael Pignone
- Department of Internal Medicine, Dell Medical School, The University of Texas at Austin, Austin, TX, USA.
- Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, USA.
- Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, USA.
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Falah N, Terry A, Umer A, Kastner M, Oliverio KL, Matthews N, Kelly KM, Kellar-Guenther Y. A pilot study of home-based genetic testing completion rate in telegenetics cancer clinics in West Virginia Appalachia. Am J Med Genet A 2023; 191:1013-1019. [PMID: 36637370 DOI: 10.1002/ajmg.a.63109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 11/09/2022] [Accepted: 12/10/2022] [Indexed: 01/14/2023]
Abstract
Telegenetics has shifted some genetic testing performance to the patient's own home, with the patient collecting his/her own sample. Little is known regarding the rate of test completion of such home-based genetic testing. This study compared the completion rate of home-based genetic tests before and after a reminder system was implemented. In the pre-reminder group, we reviewed medical records for patients who were seen via telegenetics and agreed to complete genetic testing using an at-home test kit. In the reminder group, a prospective analysis of the genetic test completion rate was performed taking a clinical quality improvement approach where three reminders were provided for patients who had not submitted their at-home genetic testing. Our study included 94 patients' records: 46 pre-reminders and 48 reminders. The lab received 24 patient samples (52.2%) in the pre-reminder group. In the reminder group, 30 patients returned their kits (62.5%). Despite a higher percentage of patients completing their test in the reminder group, there was no statistically significant difference between the pre-reminder and reminder groups. The rate of test completion in our pilot test was statistically similar between the two groups, but the reminder group was trending toward a higher percent of completion which may be clinically meaningful.
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Affiliation(s)
- Nadia Falah
- Department of Pediatrics, Division of Genetics, West Virginia University Medicine Children's Hospital, Morgantown, West Virginia, USA.,West Virginia University Cancer Institute, Morgantown, West Virginia, USA
| | - Alissa Terry
- New York Mid-Atlantic Caribbean (NYMAC) Regional Genetics Network, Wadsworth Center, New York, USA
| | - Amna Umer
- Department of Pediatrics, West Virginia University Robert C. Byrd Health Sciences Center, Morgantown, West Virginia, USA
| | - Marlee Kastner
- School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Kathryn L Oliverio
- West Virginia University Cancer Institute, Morgantown, West Virginia, USA
| | - Nicole Matthews
- Department of Pediatrics, Division of Genetics, West Virginia University Medicine Children's Hospital, Morgantown, West Virginia, USA
| | - Kimberly M Kelly
- West Virginia University Cancer Institute, Morgantown, West Virginia, USA.,School of Pharmacy, West Virginia University, Morgantown, West Virginia, USA
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Hohl SD, Maxwell AE, Sharma KP, Sun J, Vu TT, DeGroff A, Escoffery C, Schlueter D, Hannon PA. Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement. Prev Sci 2023:10.1007/s11121-023-01496-3. [PMID: 36952143 PMCID: PMC10034905 DOI: 10.1007/s11121-023-01496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 03/24/2023]
Abstract
Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics' adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.
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Affiliation(s)
- Sarah D Hohl
- Health Promotion Research Center, University of Washington, Seattle, WA, USA.
- Office of Community Health, Department of Family Medicine and Community Health, Madison, WI, USA.
| | - Annette E Maxwell
- Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA, USA
| | - Krishna P Sharma
- Totally Joined for Achieving Collaborative Techniques, Atlanta, GA, USA
| | - Juzhong Sun
- Totally Joined for Achieving Collaborative Techniques, Atlanta, GA, USA
| | - Thuy T Vu
- Health Promotion Research Center, University of Washington, Seattle, WA, USA
| | - Amy DeGroff
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA, USA
| | - Cam Escoffery
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Dara Schlueter
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC, Atlanta, GA, USA
| | - Peggy A Hannon
- Health Promotion Research Center, University of Washington, Seattle, WA, USA
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Rahimi F, Rezayatmand R, Shojaeenejad J, Tabesh E, Ravankhah Z, Adibi P. Costs and outcomes of colorectal cancer screening program in Isfahan, Iran. BMC Health Serv Res 2023; 23:13. [PMID: 36604670 PMCID: PMC9817386 DOI: 10.1186/s12913-022-09010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 12/26/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Colorectal cancer is one of the most prevalent gastrointestinal cancers in Iran i.e., the fourth and the second prevalent cancer among Iranian males and females, respectively. A routine screening program is effective in the early detection of disease which can reduce the cancer burden both for individuals and society. In 2015, Iran's Package of Essential Non- communicable Diseases program had been piloted in Shahreza city in Isfahan province. Colorectal cancer screening for the population aged 50-70 was a part of this program. So far, there was no study about the cost and outcomes of that program. Thus, this study aimed to analyze the costs and outcomes of colorectal cancer screening done from 2016 to 2019 in Shahreza. METHODS This cost-outcome description study used the data of 19,392 individuals who were 50-70 years old experienced a fecal immunochemical test (FIT) and had an electronic health record. All direct costs including personnel, building space, equipment, training, etc. were extracted from the financial documents existing in the Isfahan province Health Center. The outcome was defined as positive FIT, detection of adenoma or malignancy as recorded in the E-integrated health system. RESULTS The results of this study indicated that the direct costs of the colorectal cancer screening program during the years 2016-2019 were 7,368,707,574 Rials (321,029 PPP$) in Shahreza, Isfahan province. These costs resulted in identifying 821 people with a positive FIT test, of those 367 individuals were undergone colonoscopy. Of whom 8 cases of colorectal cancer, and 151 cases with polyps were diagnosed. CONCLUSION This study showed that by paying a small amount of 320 thousand international dollars we could prevent 151 cases of polyps to be progressed to colorectal cancer,resulting in a significant reduction in colorectal cancer incidence.
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Affiliation(s)
- Farimah Rahimi
- grid.411036.10000 0001 1498 685XHealth Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Reza Rezayatmand
- grid.411036.10000 0001 1498 685XHealth Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Javad Shojaeenejad
- grid.411036.10000 0001 1498 685XDepartment of Health Economics, School of Management and Medical Information Sciences Isfahan University of Medical Science, Isfahan, Iran
| | - Elham Tabesh
- grid.411036.10000 0001 1498 685XIsfahan Gastroenterology and Hepatology Research Center (IGHRC), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Zahra Ravankhah
- grid.411036.10000 0001 1498 685XCancer Registry of Health Deputy, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Peyman Adibi
- grid.411036.10000 0001 1498 685XIsfahan Gastroenterology and Hepatology Research Center (IGHRC), Isfahan University of Medical Sciences, Isfahan, Iran
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Subramanian S, Tangka FKL, Hoover S, DeGroff A. Integrated interventions and supporting activities to increase uptake of multiple cancer screenings: conceptual framework, determinants of implementation success, measurement challenges, and research priorities. Implement Sci Commun 2022; 3:105. [PMID: 36199098 PMCID: PMC9532830 DOI: 10.1186/s43058-022-00353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 09/19/2022] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Screening for colorectal, breast, and cervical cancer has been shown to reduce mortality; however, not all men and women are screened in the USA. Further, there are disparities in screening uptake by people from racial and ethnic minority groups, people with low income, people who lack health insurance, and those who lack access to care. The Centers for Disease Control and Prevention funds two programs-the Colorectal Cancer Control Program and the National Breast and Cervical Cancer Early Detection Program-to help increase cancer screenings among groups that have been economically and socially marginalized. The goal of this manuscript is to describe how programs and their partners integrate evidence-based interventions (e.g., patient reminders) and supporting activities (e.g., practice facilitation to optimize electronic medical records) across colorectal, breast, and cervical cancer screenings, and we suggest research areas based on implementation science. METHODS We conducted an exploratory assessment using qualitative and quantitative data to describe implementation of integrated interventions and supporting activities for cancer screening. We conducted 10 site visits and follow-up telephone interviews with health systems and their partners to inform the integration processes. We developed a conceptual model to describe the integration processes and reviewed screening recommendations of the United States Preventive Services Task Force to illustrate challenges in integration. To identify factors important in program implementation, we asked program implementers to rank domains and constructs of the Consolidated Framework for Implementation Research. RESULTS Health systems integrated interventions for all screenings across single and multiple levels. Although potentially efficient, there were challenges due to differing eligibility of screenings by age, gender, frequency, and location of services. Program implementers ranked complexity, cost, implementation climate, and engagement of appropriate staff in implementation among the most important factors to success. CONCLUSION Integrating interventions and supporting activities to increase uptake of cancer screenings could be an effective and efficient approach, but we currently do not have the evidence to recommend widescale adoption. Detailed multilevel measures related to process, screening, and implementation outcomes, and cost are required to evaluate integrated programs. Systematic studies can help to ascertain the benefits of integrating interventions and supporting activities for multiple cancer screenings, and we suggest research areas that might address current gaps in the literature.
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Affiliation(s)
- Sujha Subramanian
- grid.62562.350000000100301493RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452-8413 USA
| | - Florence K. L. Tangka
- grid.416781.d0000 0001 2186 5810Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
| | - Sonja Hoover
- grid.62562.350000000100301493RTI International, 307 Waverley Oaks Road, Suite 101, Waltham, MA 02452-8413 USA
| | - Amy DeGroff
- grid.416781.d0000 0001 2186 5810Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA USA
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Kruse-Diehr AJ, Dignan M, Cromo M, Carman AL, Rogers M, Gross D, Russell S. Building Cancer Prevention and Control Research Capacity in Rural Appalachian Kentucky Primary Care Clinics During COVID-19: Development and Adaptation of a Multilevel Colorectal Cancer Screening Project. J Cancer Educ 2022; 37:1407-1413. [PMID: 33599967 PMCID: PMC7890393 DOI: 10.1007/s13187-021-01972-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/07/2021] [Indexed: 06/12/2023]
Abstract
This study describes the development of a colorectal cancer (CRC) screening multilevel intervention with four primary care clinics in rural Appalachian Kentucky. We also discuss barriers experienced by the clinics during COVID-19 and how clinic limitations and needs informed project modifications. Four primary care clinics were recruited, key informant interviews with clinic providers were conducted, electronic health record (EHR) capacity to collect data related to CRC screening and follow-up was assessed, and a series of meetings were held with clinic champions to discuss implementation of strategies to impact clinic CRC screening rates. Analysis of interviews revealed multilevel barriers to CRC screening. Patient-level barriers included fatalism, competing priorities, and financial and literacy concerns. The main provider- and clinic-level barriers were provider preference for colonoscopy over stool-based testing and EHR tracking concerns. Clinics selected strategies to address barriers, but the onset of COVID-19 necessitated modifications to these strategies. Due to COVID-19, changes in clinic staffing and workflow occurred, including provider furloughs, a state-mandated pause in elective procedures, and an increase in telehealth. Clinics adapted screening strategies to match changing needs, including shifting from paper to digital educational tools and using telehealth to increase annual wellness visits for screening promotion. While significant delays persist for scheduling colonoscopies, clinics were encouraged to promote stool-based tests as a primary screening modality for average-risk patients.
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Affiliation(s)
- Aaron J Kruse-Diehr
- University of Kentucky College of Public Health, 151 Washington Avenue, Bowman Hall 345, Lexington, KY, 40536, USA.
- Markey Cancer Center, Lexington, KY, USA.
| | - Mark Dignan
- Markey Cancer Center, Lexington, KY, USA
- University of Kentucky College of Medicine, Prevention Research Center, Lexington, KY, USA
| | - Mark Cromo
- University of Kentucky College of Medicine, Prevention Research Center, Lexington, KY, USA
| | - Angela L Carman
- University of Kentucky College of Public Health, 151 Washington Avenue, Bowman Hall 345, Lexington, KY, 40536, USA
| | | | - David Gross
- Northeast Kentucky Area Health Education Center, Morehead, KY, USA
| | - Sue Russell
- Northeast Kentucky Area Health Education Center, Morehead, KY, USA
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Kapinos KA, Halm EA, Murphy CC, Santini NO, Loewen AC, Skinner CS, Singal AG. Cost Effectiveness of Mailed Outreach Programs for Colorectal Cancer Screening: Analysis of a Pragmatic, Randomized Trial. Clin Gastroenterol Hepatol 2022; 20:2383-2392.e4. [PMID: 35144024 PMCID: PMC9357235 DOI: 10.1016/j.cgh.2022.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 01/21/2022] [Accepted: 01/24/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Clinical guidelines for colorectal cancer (CRC) screening suggest use of either stool-based tests or colonoscopy - modalities that differ in recommended screening intervals, adherence, and costs. We know little about the long-term cost differences in population-health outreach strategies to promote these strategies. METHODS We conducted a cost-effectiveness analysis to compare 2 mailed outreach strategies to increase CRC screening from a pragmatic, randomized clinical trial: mailed fecal immunochemical test (FIT) kits vs invitations to complete a screening colonoscopy. We built a 10-year Markov chain Monte Carlo microsimulation model to account for differences in screening intervals, adherence, and costs. RESULTS Mailed FIT kits had a lower 10-year average per-person cost of screening relative to colonoscopy invitations ($1139 vs $1725) but with 10.89 fewer months of compliance and 60 fewer advanced neoplasia detected (37 advanced adenomas and 23 CRC). Incremental cost effectiveness ratios for colonoscopy invitations compared with mailed FIT kits were $55.23, $15.84, and $25.48 per additional covered month, advanced adenoma, and CRC, respectively. Although FIT was the preferred strategy at low willingness-to-pay thresholds, the 2 strategies were equal at a willingness-to-pay threshold of $41.31 per covered month gained. CONCLUSION Mailed FIT or colonoscopy invitations are both options to improve CRC screening completion and advanced neoplasia detection, and the choice of outreach strategy may differ by a health system's willingness-to-pay threshold. Mailed FIT kits are less expensive than colonoscopy invitations but result in fewer months of screening compliance and advanced neoplasia detected.
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Affiliation(s)
- Kandice A Kapinos
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas; RAND Corporation, Arlington, Virginia.
| | - Ethan A Halm
- Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Caitlin C Murphy
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; School of Public Health, University of Texas Health Science Center at Houston (UTHealth), Houston, Texas
| | | | - Adam C Loewen
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Celette Sugg Skinner
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
| | - Amit G Singal
- The Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas; Harold C. Simmons Comprehensive Cancer Center, Dallas, Texas
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Levitz CE, Kuo ES, Guo M, Ruiz E, Torres-Ozadali E, Brar Prayaga R, Escaron A. Using Text Messages and Fotonovelas to Increase Return of Home-Mailed Colorectal Cancer Screening Tests: Evaluation of a Quality Improvement Project (Preprint). JMIR Cancer 2022. [DOI: 10.2196/39645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
IMPORTANCE Health care was disrupted in the US during the first quarter of 2020 with the emergence of the COVID-19 pandemic. Early reports in selected samples suggested that cancer screening services decreased greatly, but population-based estimates of cancer screening prevalence during 2020 have not yet been reported. OBJECTIVE To examine changes in breast cancer (BC), cervical cancer (CC), and colorectal cancer (CRC) screening prevalence with contemporary national, population-based Behavioral Risk Factor Surveillance System (BRFSS) data. DESIGN, SETTING, AND PARTICIPANTS This survey study included respondents from the 2014, 2016, 2018, and 2020 BRFSS surveys who were eligible for BC (women aged 50-74 years), CC (women aged 25-64 years), and CRC (women and men aged 50-75 years) screening. Data analysis was performed from September 2021 to February 2022. EXPOSURES Calendar year. MAIN OUTCOMES AND MEASURES Self-reported receipt of a recent (defined as in the past year) BC, CC, and CRC screening test. Adjusted prevalence ratios (aPRs) comparing 2020 vs 2018 prevalence and 95% CIs were computed. RESULTS In total, 479 248 individuals were included in the analyses of BC screening, 301 453 individuals were included in CC screening, and 854 210 individuals were included in CRC screening, In 2020, among respondents aged 50 to 75 years, 14 815 (11.4%) were Black, 12 081 (12.6%) were Hispanic, 156 198 (67.3%) were White, and 79 234 (29.9%) graduated from college (all percentages are weighted). After 4 years (2014-2018) of nearly steady prevalence, past-year BC screening decreased by 6% between 2018 and 2020 (from 61.6% in 2018 to 57.8% in 2020; aPR, 0.94; 95% CI, 0.92-0.96), and CC screening decreased by 11% (from 58.3% in 2018 to 51.9% in 2020; aPR, 0.89; 95% CI, 0.87-0.91). The magnitude of these decreases was greater in people with lower educational attainment and Hispanic persons. CRC screening prevalence remained steady; past-year stool testing increased by 7% (aPR, 1.07; 95% CI, 1.02-1.12), offsetting a 16% decrease in colonoscopy (aPR, 0.84; 95% CI, 0.82-0.88) between 2018 and 2020. CONCLUSIONS AND RELEVANCE In this survey study, stool testing increased and counterbalanced a decrease in colonoscopy during 2020, and BC and CC screening modestly decreased. How these findings might be associated with outcomes is not yet known, but they will be important to monitor, especially in populations with lower socioeconomic status, who experienced greater screening decreases during the COVID-19 pandemic.
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Affiliation(s)
- Stacey A. Fedewa
- Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
- Now with Department of Hematology and Oncology, Emory University, Atlanta, Georgia
| | - Jessica Star
- Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
| | - Priti Bandi
- Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
| | - Adair Minihan
- Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
| | - Xuesong Han
- Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
| | - K. Robin Yabroff
- Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Surveillance and Health Equity Sciences, American Cancer Society, Atlanta, Georgia
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Schneider R, Syrogiannouli L, Bissig S, Scharf T, Bulliard JL, Ducros C, Del Giovane C, Tal K, Zwahlen M, Selby K, Auer R. Ten-year changes in colorectal cancer screening in Switzerland: The Swiss Health Interview Survey 2007, 2012 and 2017. Prev Med Rep 2022; 27:101815. [PMID: 35656207 PMCID: PMC9152794 DOI: 10.1016/j.pmedr.2022.101815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/13/2022] [Accepted: 04/30/2022] [Indexed: 11/08/2022] Open
Abstract
Colorectal Cancer testing rate increased in Switzerland from 2007 to 2017. Colonoscopies are the first screening methods used in Switzerland. Low CRC screening rate is associated with age 50–59, high-deductible and basic insurance coverage. There is regional disparities in CRC screening rate in Switzerland.
Recent recommendations for colorectal cancer (CRC) screening suggest fecal occult blood test (FOBT) or colonoscopy. Since 2013, mandatory health insurance in Switzerland reimburse CRC screening. We set out to determine if CRC testing rate and type of CRC screening changed in Switzerland from 2007 to 2017 and between the three main language regions. We extracted data on 50–75-year-olds from the Swiss Health Interview Survey (SHIS) 2007, 2012 and 2017 to determine rates of self-reported testing with FOBT within last 2 years and colonoscopy within last 10 years. We estimated prevalence ratio (PR) in multivariate-adjusted logistic regression models and compared rates in German-, French- and Italian-speaking regions, adjusting for sociodemographic, self-rated health and insurance variables. Overall testing rates (FOBT or colonoscopy) increased in all regions from 2007 to 2017 (German-speaking 33.6% to 48.3%; French-speaking 30.8% to 48.8%; Italian-speaking 37.9% to 46.8%), mainly because of an increase in colonoscopy rate for screening reasons (p < 0.001 in all regions). Rates of FOBT testing fell significantly in the German-speaking region (11.9% to 4.4%, p < 0.001), but not in the Italian- (13.9% to 8.5%, p = 0.052) and French-speaking regions (7.6% to 7.4%, p = 0.138). Overall CRC testing rate rose from 33.2% in 2007 to 48.4% in 2017, mainly because of an increase of colonoscopy rate for screening reasons. Coverage remains below the 65% target of European guidelines. Organized screening programs encouraging FOBT screening could contribute to further increasing the CRC testing rate.
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Pignone M, Lanier B, Kluz N, Valencia V, Chang P, Olmstead T. Effectiveness and Cost-effectiveness of Mailed FIT in a Safety Net Clinic Population. J Gen Intern Med 2021; 36:3441-3447. [PMID: 33929646 PMCID: PMC8606361 DOI: 10.1007/s11606-021-06691-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 02/28/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Mailed fecal immunochemical testing (FIT) can increase colorectal cancer (CRC) screening rates, including for vulnerable patients, but its cost-effectiveness is unclear. OBJECTIVE We sought to examine the effectiveness and cost-effectiveness of the initial cycle of our mailed FIT program from November 2017 to July 2019 in a federally qualified health center (FQHC) system in Central Texas. DESIGN Single group intervention and economic analysis PARTICIPANTS: Eligible patients were those ages 50-75 who had been seen recently in a system practice and were not up to date with screening. INTERVENTION The program mailing packet included an introductory letter in plain language, the FIT itself, easy to read instructions, and a postage-paid lab mailer, supplemented with written and text messaging reminders. MAIN MEASURES We measured effectiveness based on completion of mailed FIT and cost-effectiveness in terms of cost per person screened. Costs were measured using detailed micro-costing techniques from the perspective of a third-party payer and expressed in 2019 US dollars. Direct costs were based on material supply costs and detailed observations of labor required, valued at the wage rate. KEY RESULTS Of the 22,838 eligible patients who received program materials, mean age was 59.0, 51.5% were female, and 43.9% were Latino. FIT were successfully completed by 19.2% (4395/22,838) patients at an average direct cost of $5275.70 per 500-patient mailing. Assuming completed tests from the mailed intervention represent incremental screening, the direct cost per patient screened, compared with no intervention, was $54.83. Incorporating start-up and indirect costs increases total costs to $7014.45 and cost per patient screened to $72.90. Alternately, assuming 2.5% and 5% screening without the intervention increased the direct (total) cost per patient screened to $60.03 ($80.80) and $67.05 ($91.47), respectively. CONCLUSIONS Mailed FIT is an effective and cost-effective population health strategy for CRC screening in vulnerable patients.
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Affiliation(s)
- Michael Pignone
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX, USA. .,Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA. .,Livestrong Cancer Institutes, The University of Texas at Austin Dell Medical School, Austin, USA.
| | - Brennan Lanier
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Nicole Kluz
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Victoria Valencia
- Department of Internal Medicine, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Patrick Chang
- Department of Population Health, The University of Texas at Austin Dell Medical School, Austin, USA
| | - Todd Olmstead
- Lyndon B Johnson School of Public Affairs, The University of Texas at Austin, Austin, USA
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Deng YY, Min YJ, Zhou K, Yang QS, Peng M, Cui ZR, Zhu XL, Liu H, Wang M, Zhang X, Liu LX. Identification of the tumor‑suppressive role of circular RNA‑FOXO3 in colorectal cancer via regulation of miR‑543/LATS1 axis. Oncol Rep 2021; 46:239. [PMID: 34549306 PMCID: PMC8485021 DOI: 10.3892/or.2021.8190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 07/31/2020] [Indexed: 12/13/2022] Open
Abstract
Colorectal cancer (CRC) is a common malignancy with significant prevalence and mortality rates. Circular RNA FOXO3 (circ-FOXO3; hsa_circ_0006404) has been reported to be involved in cancer regulation; however, its role in CRC is yet to be fully elucidated. Therefore, the aim of the present study was to investigate the effect of circ-FOXO3 on CRC progression and identify its underlying mechanism. In the present study, the expression of circ-FOXO3 was investigated in CRC tissues and cells via reverse transcription-quantitative PCR. A Cell Counting Kit-8 and colony formation assays were used to assess cell proliferation. The cell migratory and invasive abilities were detected using the Transwell migration and invasion assays. The luciferase assay and RNA pull-down assay were conducted to verify the relationship of circ-FOXO3, microRNA (miR)-543 and Large tumor suppressor kinase 1 (LATS1). The results demonstrated that circ-FOXO3 expression was downregulated in CRC tissues and cells, and was associated with poor overall survival of patients with CRC. Moreover, circ-FOXO3 was associated with tumor size, distant metastasis, differentiation, lymph node metastasis and TMN stages of patients with CRC. circ-FOXO3 overexpression suppressed CRC cell proliferation, migration and invasion. Luciferase assay and RNA pull-down assay results indicated that circ-FOXO3 functioned as a sponge for miR-543. In addition, circ-FOXO3 increased the expression of LATS1 via sponging miR-543, thus inhibiting CRC cell aggressive features. Collectively, the present results suggested that circ-FOXO3 inhibited CRC metastasis and progression via elevated LATS1 expression by sponging miR-543. Therefore, circ-FOXO3 may be a promising target for CRC therapy.
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Affiliation(s)
- Yun-Yao Deng
- Department of General Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong 510630, P.R. China
| | - Yu-Juan Min
- Department of General Surgery, The Second Clinical Medical College of North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Kun Zhou
- Department of General Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong 510630, P.R. China
| | - Qing-Song Yang
- Department of General Surgery, Suzhou Sunset Care Institute, Suzhou, Jiangsu 215008, P.R. China
| | - Mei Peng
- Department of General Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong 510630, P.R. China
| | - Zhao-Rui Cui
- Department of General Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Xiang-Lian Zhu
- Department of General Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Hao Liu
- Department of General Surgery, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong 510630, P.R. China
| | - Min Wang
- Department of General Surgery, Women and Children's Hospital of Hunan, Changsha, Hunan 410008, P.R. China
| | - Xie Zhang
- Department of General Surgery, Xiangtan Medicine and Health Vocational College, Xiangtan, Hunan 411104, P.R. China
| | - Li-Xin Liu
- Department of General Surgery, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong 510630, P.R. China
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Ramli NS, Manaf MRA, Hassan MR, Ismail MI, Nawi AM. Effectiveness of Colorectal Cancer Screening Promotion Using E-Media Decision Aids: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health 2021; 18:ijerph18158190. [PMID: 34360481 PMCID: PMC8345994 DOI: 10.3390/ijerph18158190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 07/30/2021] [Accepted: 07/30/2021] [Indexed: 12/09/2022]
Abstract
Colorectal cancer (CRC)-screening reduces mortality, yet remains underutilized. The use of electronic media (e-media) decision aids improves saliency and fosters informed decision-making. This systematic review aimed to determine the effectiveness of CRC-screening promotion, using e-media decision aids in primary healthcare (PHC) settings. Three databases (MEDLINE, Web of Science, and the Cochrane Library) were searched for eligible studies. Studies that evaluated e-media decision aids compared to usual care or other conditions were selected. Quality was assessed by using Cochrane tools. Their effectiveness was measured by CRC-screening completion rates, and meta-analysis was conducted to calculate the pooled estimates. Ten studies involving 9393 patients were included in this review. Follow-up durations spanned 3–24 months. The two types of decision-aid interventions used were videos and interactive multimedia programs, with durations of 6–15 min. Data from nine feasible studies with low or some risk of bias were synthesized for meta-analysis. A random-effects model revealed that CRC-screening promotion using e-media decision aids were almost twice as likely to have screening completion than their comparisons (OR 1.62, 95% CI: 1.03–2.62, p < 0.05). CRC-screening promotion through e-media has great potential for increasing screening participation in PHC settings. Thus, its development should be prioritized, and it should be integrated into existing programs.
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Affiliation(s)
- Nur Suhada Ramli
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Cheras, Kuala Lumpur 56000, Malaysia; (N.S.R.); (M.R.A.M.); (M.R.H.)
- Ministry of Health, Malaysia, Federal Government Administrative Centre, Putrajaya 62514, Malaysia
| | - Mohd Rizal Abdul Manaf
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Cheras, Kuala Lumpur 56000, Malaysia; (N.S.R.); (M.R.A.M.); (M.R.H.)
| | - Mohd Rohaizat Hassan
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Cheras, Kuala Lumpur 56000, Malaysia; (N.S.R.); (M.R.A.M.); (M.R.H.)
| | - Muhamad Izwan Ismail
- Department of Surgery, Hospital Sultanah Aminah, Jalan Persiaran Abu Bakar Sultan, Johor Bahru 80100, Malaysia;
| | - Azmawati Mohammed Nawi
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaakob Latif, Cheras, Kuala Lumpur 56000, Malaysia; (N.S.R.); (M.R.A.M.); (M.R.H.)
- Correspondence:
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Davis MM, Schneider JL, Gunn R, Rivelli JS, Vaughn KA, Coronado GD. A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program. Transl Behav Med 2021; 11:540-548. [PMID: 32083287 PMCID: PMC7963281 DOI: 10.1093/tbm/ibaa010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English- and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2-3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-Based Research Network, Department of Family Medicine, and School of Public Health, Oregon Health and Science University, Mail Code, Portland, OR, USA
| | | | - Rose Gunn
- Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland, OR, USA
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Katherine A Vaughn
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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21
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Wang A, Lee B, Patel S, Whitaker E, Issaka RB, Somsouk M. Selection of patients for large mailed fecal immunochemical test colorectal cancer screening outreach programs: A systematic review. J Med Screen 2021; 28:379-388. [PMID: 33683155 DOI: 10.1177/0969141321997482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Digital health care offers an opportunity to scale and personalize cancer screening programs, such as mailed outreach for colorectal cancer (CRC) screening. However, studies that describe the patient selection strategy and process for CRC screening are limited. Our objective was to evaluate implementation strategies for selecting patients for CRC screening programs in large health care systems. METHODS We conducted a systematic review of 30 studies along with key informant surveys and interviews to describe programmatic implementation strategies for selecting patients for CRC screening. PubMed and Embase were searched since inception through December 2018, and hand searches were performed of the retrieved reference lists but none were incorporated (n = 0). No language exclusions were applied. RESULTS Common criteria for outreach exclusion included: being up-to-date with routine CRC screening (n = 22), comorbidities (n = 20), and personal history (n = 22) or family history of cancer (n = 9). Key informant surveys and interviews were performed (n = 28) to understand data sources and practices for patient outreach selection, and found that 13 studies leveraged electronic medical care records, 10 studies leveraged a population registry (national, municipal, community, health), 4 studies required patient opt-in, and 1 study required primary care provider referral. Broad ranges in fecal immunochemical test completion were observed in community clinic (n = 8, 31.0-59.6%), integrated health system (n = 5, 21.2-82.7%), and national regional CRC screening programs (n = 17, 23.0-64.7%). Six studies used technical codes, and four studies required patient self-reporting from a questionnaire to participate. CONCLUSION This systematic review provides health systems with the diverse outreach practices and technical tools to support efforts to automate patient selection for CRC screening outreach.
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Affiliation(s)
- Andrew Wang
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA.,College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Briton Lee
- Department of Medicine, New York University Langone Medical Center, New York, NY, USA
| | - Shreya Patel
- Division of Gastroenterology, University of California, San Francisco, CA, USA
| | - Evans Whitaker
- University of California San Francisco Medical Library, University of California, San Francisco, CA, USA
| | - Rachel B Issaka
- Clinical Research and Public Health Science Divisions, Fred Hutchinson, Seattle, WA, USA.,Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Ma Somsouk
- Division of Gastroenterology, University of California, San Francisco, CA, USA.,Center for Vulnerable Populations, University of California, San Francisco, CA, USA
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Petrik AF, Green B, Schneider J, Miech EJ, Coury J, Retecki S, Coronado GD. Factors Influencing Implementation of a Colorectal Cancer Screening Improvement Program in Community Health Centers: an Applied Use of Configurational Comparative Methods. J Gen Intern Med 2020; 35:815-822. [PMID: 33107003 PMCID: PMC7652967 DOI: 10.1007/s11606-020-06186-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 08/25/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence-based programs such as mailed fecal immunochemical test (FIT) outreach can only affect health outcomes if they can be successfully implemented. However, attempts to implement programs are often limited by organizational-level factors. OBJECTIVES As part of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) pragmatic trial, we evaluated how organizational factors impacted the extent to which health centers implemented a mailed FIT outreach program. DESIGN Eight health centers participated in STOP CRC. The intervention consisted of customized electronic health record tools and clinical staff training to facilitate mailing of an introduction letter, FIT kit, and reminder letter. Health centers had flexibility in how they delivered the program. MAIN MEASURES We categorized the health centers' level of implementation based on the proportion of eligible patients who were mailed a FIT kit, and applied configurational comparative methods to identify combinations of relevant organizational-level and program-level factors that distinguished among high, medium, and low implementing health centers. The factors were categorized according to the Consolidated Framework for Implementation Research model. KEY RESULTS FIT tests were mailed to 21.0-81.7% of eligible participants at each health center. We identified a two-factor solution that distinguished among levels of implementation with 100% consistency and 100% coverage. The factors were having a centralized implementation team (inner setting) and mailing the introduction letter in advance of the FIT kit (intervention characteristics). Health centers with high levels of implementation had the joint presence of both factors. In health centers with medium levels of implementation, only one factor was present. Health centers with low levels of implementation had neither factor present. CONCLUSIONS Full implementation of the STOP CRC intervention relied on a centralized implementation team with dedicated staffing time, and the advance mailing of an introduction letter. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01742065 Registered 05 December 2012-Prospectively registered.
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Affiliation(s)
- Amanda F Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA.
| | - Beverly Green
- Health Research Institute, Kaiser Permanente Washington, Seattle, WA, USA
| | - Jennifer Schneider
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | | | | | | | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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23
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Kim KE, Tangka FKL, Jayaprakash M, Randal FT, Lam H, Freedman D, Carrier LA, Sargant C, Maene C, Hoover S, Joseph D, French C, Subramanian S. Effectiveness and Cost of Implementing Evidence-Based Interventions to Increase Colorectal Cancer Screening Among an Underserved Population in Chicago. Health Promot Pract 2020; 21:884-890. [PMID: 32990041 DOI: 10.1177/1524839920954162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
With funding from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, The University of Chicago Center for Asian Health Equity partnered with a federally qualified health center (FQHC) to implement multiple evidence-based interventions (EBIs) in order to improve colorectal cancer (CRC) screening uptake. The purpose of this study is to determine the effectiveness and cost of implementing a provider reminder system entered manually and supplemented with patient reminders and provider assessment and feedback. The FQHC collected demographic characteristics of the FQHC and outcome data from January 2015 through December 2015 (preimplementation period) and cost from January 2016 through September 2017 (implementation period). Cost data were collected for the implementation period. We report on the demographics of the eligible population, CRC screening order, completion rates by sociodemographic characteristics, and, overall, the effectiveness and cost of implementation. From the preimplementation phase to the implementation phase, there was a 21.2 percentage point increase in CRC screens completed. The total cost of implementing EBIs was $40908.97. We estimated that an additional 283 screens were completed because of the interventions, and the implementation cost of the interventions was $144.65 per additional screen. With the interventions, CRC screening uptake in Chicago increased for all race/ethnicity and demographic backgrounds at the FQHC, particularly for patients aged 50 to 64 years and for Asian, Hispanic, and uninsured patients.
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Affiliation(s)
| | | | | | | | - Helen Lam
- University of Chicago, Chicago, IL, USA
| | | | | | | | | | | | - Djenaba Joseph
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Cynthia French
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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24
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Barajas M, Tangka FKL, Schultz J, Tantod K, Kempster YM, Omelu N, Hoover S, Thomas M, Richmond-Reese V, Subramanian S. Examining the Effectiveness of Provider Incentives to Increase CRC Screening Uptake in Neighborhood Healthcare: A California Federally Qualified Health Center. Health Promot Pract 2020; 21:898-904. [PMID: 32990046 DOI: 10.1177/1524839920954166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
As an awardee of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, the California Department of Public Health partnered with Neighborhood Healthcare to implement evidence-based interventions and provider incentives (incentives offered to support staff, e.g., medical assistants, phlebotomists, front office staff, lab technicians) to improve colorectal cancer screening uptake. The objective of this study was to evaluate the effectiveness and cost of the provider incentive intervention implemented by Neighborhood Healthcare to increase colorectal cancer screening uptake. We collected and analyzed process and cost data to assess fecal immunochemical test (FIT) kit return rates to the health centers and the number of completed FIT kits. We estimated the costs of the preexisting interventions and the new interventions. Analyses were conducted for two time periods: preimplementation and implementation. Most Neighborhood Healthcare health centers experienced an increase in the percentage of FIT kit returns (average of 3.6 percentage points) and individuals screened (an average increase of 111 FIT kits per month) from the baseline period through the implementation period. The cost of the incentive intervention for each additional screen was $66.79. In conclusion, the results indicate that incentive programs can have an overall positive impact on both the percentage of FIT kits returned and the number of individuals screened.
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Affiliation(s)
| | | | | | | | | | - Ndukaku Omelu
- California Department of Public Health, Sacramento, CA, USA
| | | | - Melonie Thomas
- Centers for Disease Control and Prevention, Atlanta, GA, USA
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25
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Wheeler SB, O’Leary MC, Rhode J, Yang JY, Drechsel R, Plescia M, Reuland DS, Brenner AT. Comparative cost-effectiveness of mailed fecal immunochemical testing (FIT)-based interventions for increasing colorectal cancer screening in the Medicaid population. Cancer 2020; 126:4197-4208. [PMID: 32686116 PMCID: PMC10588542 DOI: 10.1002/cncr.32992] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mailed reminders to promote colorectal cancer (CRC) screening by fecal immunochemical testing (FIT) have been shown to be effective in the Medicaid population, in which screening is underused. However, little is known regarding the cost-effectiveness of these interventions, with or without an included FIT kit. METHODS The authors conducted a cost-effectiveness analysis of a randomized controlled trial that compared the effectiveness of a reminder + FIT intervention versus a reminder-only intervention in increasing FIT screening. The analysis compared the costs per person screened for CRC screening associated with the reminder + FIT versus the reminder-only alternative using a 1-year time horizon. Input data for a cohort of 35,000 unscreened North Carolina Medicaid enrollees ages 52 to 64 years were derived from the trial and microcosting. Inputs and outputs were estimated from 2 perspectives-the Medicaid/state perspective and the health clinic/facility perspective-using probabilistic sensitivity analysis to evaluate uncertainty. RESULTS The anticipated number of CRC screenings, including both FIT and screening colonoscopies, was higher for the reminder + FIT alternative (n = 8131; 23.2%) than for the reminder-only alternative (n = 5533; 15.8%). From the Medicaid/state perspective, the reminder + FIT alternative dominated the reminder-only alternative, with lower costs and higher screening rates. From the health clinic/facility perspective, the reminder + FIT versus the reminder-only alternative resulted in an incremental cost-effectiveness ratio of $116 per person screened. CONCLUSIONS The reminder + FIT alternative was cost saving per additional Medicaid enrollee screened compared with the reminder-only alternative from the Medicaid/state perspective and likely cost-effective from the health clinic/facility perspective. The results also demonstrate that health departments and state Medicaid programs can efficiently mail FIT kits to large numbers of Medicaid enrollees to increase CRC screening completion.
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Affiliation(s)
- Stephanie B. Wheeler
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
| | - Meghan C. O’Leary
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
| | - Jewels Rhode
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Jeff Y. Yang
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Epidemiology, Chapel Hill, NC
| | | | - Marcus Plescia
- Association of State and Territorial Health Officials, Charlotte, NC
| | - Daniel S. Reuland
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- University of North Carolina School of Medicine, Division of General Medicine & Clinical Epidemiology, Chapel Hill, NC
| | - Alison T. Brenner
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- University of North Carolina School of Medicine, Division of General Medicine & Clinical Epidemiology, Chapel Hill, NC
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26
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Gupta S, Coronado GD, Argenbright K, Brenner AT, Castañeda SF, Dominitz JA, Green B, Issaka RB, Levin TR, Reuland DS, Richardson LC, Robertson DJ, Singal AG, Pignone M. Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention-sponsored Summit. CA Cancer J Clin 2020; 70:283-298. [PMID: 32583884 PMCID: PMC7523556 DOI: 10.3322/caac.21615] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023] Open
Abstract
Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.
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Affiliation(s)
- Samir Gupta
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California
- Department of Medicine, University of California at San Diego, La Jolla, California
- Moores Cancer Center, University of California at San Diego, La Jolla, California
| | | | - Keith Argenbright
- University of Texas Southwestern Medical Center, Harold C. Simmons Cancer Center, Dallas, Texas
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas
| | - Alison T Brenner
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Sheila F Castañeda
- Department of Psychology, School of Public Health, San Diego State University, San Diego, California
| | - Jason A Dominitz
- Gastroenterology Section, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Beverly Green
- Kaiser Permanente Washington, Seattle, Washington
- Health Research Institute, Kaiser Permanente Washington, Seattle, Washington
- Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Rachel B Issaka
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Theodore R Levin
- Gastroenterology Department, Kaiser Permanente Medical Center, Walnut Creek, California
- Division of Research, Kaiser Permanente, Oakland, California
| | - Daniel S Reuland
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
- Lineberger Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Douglas J Robertson
- Department of Medicine, Veterans Affairs Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Amit G Singal
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael Pignone
- Department of Internal Medicine and LiveStrong Cancer Institutes, Dell Medical School, University of Texas Austin, Austin, Texas
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27
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Subramanian S, Hoover S, Tangka FKL, DeGroff A, Soloe CS, Arena LC, Schlueter DF, Joseph DA, Wong FL. A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program. Cancer 2018; 124:4154-4162. [PMID: 30359464 DOI: 10.1002/cncr.31686] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/12/2018] [Accepted: 06/13/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community. METHODS The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program. RESULTS Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions. CONCLUSIONS Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality.
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Affiliation(s)
| | | | - Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Amy DeGroff
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Dara F Schlueter
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Djenaba A Joseph
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Faye L Wong
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Tangka FKL, Subramanian S, DeGroff AS, Wong FL, Richardson LC. Identifying optimal approaches to implement colorectal cancer screening through participation in a learning laboratory. Cancer 2018; 124:4118-4120. [PMID: 30359478 DOI: 10.1002/cncr.31679] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 08/22/2016] [Accepted: 06/28/2018] [Indexed: 01/23/2023]
Affiliation(s)
- Florence K L Tangka
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Amy S DeGroff
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Faye L Wong
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Lisa C Richardson
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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