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Corrêa R, Froner MB, Tabak BM. Assessing the Impact of Behavioral Sciences Interventions on Chronic Disease Prevention and Management: A Systematic Review of Randomized Controlled Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:837. [PMID: 39063414 PMCID: PMC11277013 DOI: 10.3390/ijerph21070837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/15/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024]
Abstract
Studies have highlighted the importance of applying Behavioral Sciences interventions to develop equity in the prevention of chronic diseases in the public health domain. Our study aims to assess the evidence of this influence. We undertook a systematic review study using the electronic databases PubMed, Web of Science, Scopus and Cochrane, searching for work published between 2013 and 2023. The research analyzed the influence of Behavioral Sciences intervention studies on public health. This review was registered and published in PROSPERO, registration number CRD42023412377. The systematic search identified 2951 articles. The review analyzed 26 studies. The quality assessment of the articles showed an overall average of 74%, with the majority of studies being of high quality. The interventions with the best evidence for chronic diseases used framing messages, nudges and vouchers. Messages with incentives also showed satisfactory evidence. The most prevalent outcomes were related to screening tests and patient adherence to treatment. The current state of decision-making remains mainly at the patient level, with potential for further exploration of the roles of healthcare professionals and decision-makers in future research efforts. Limitations relate to the heterogeneity of the study sample, which hinders a more precise analysis of specific interventions and outcomes in chronic diseases.
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Affiliation(s)
- Rafael Corrêa
- School of Public Policy and Government, Getulio Vargas Foundation, SGAN 602 Módulos A,B,C, Asa Norte, Brasília 70830-020, Brazil; (M.B.F.); (B.M.T.)
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Mehta SJ, Palat S, McDonald C, Reitz C, Okorie E, Williams K, Tao J, Shaw PA, Glanz K, Asch DA. A Randomized Trial of Choice Architecture and Mailed Colorectal Cancer Screening Outreach in a Community Health Setting. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00390-2. [PMID: 38697235 DOI: 10.1016/j.cgh.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/03/2024] [Accepted: 04/05/2024] [Indexed: 05/04/2024]
Abstract
BACKGROUND & AIMS Mailed outreach for colorectal cancer (CRC) screening increases uptake but it is unclear how to offer the choice of testing. We evaluated if the active choice between colonoscopy and fecal immunochemical test (FIT), or FIT alone, increased response compared with colonoscopy alone. METHODS This pragmatic, randomized, controlled trial at a community health center included patients between ages 50 and 74 who were not up to date with CRC screening. Patients were randomized 1:1:1 to the following: (1) colonoscopy only, (2) active choice of colonoscopy or FIT, or (3) FIT only. Patients received an outreach letter with instructions for testing (colonoscopy referral and/or an enclosed FIT kit), a reminder letter at 2 months, and another reminder at 3 to 5 months via text message or automated voice recording. The primary outcome was CRC screening completion within 6 months. RESULTS Among 738 patients in the final analysis, the mean age was 58.7 years (SD, 6.2 y); 48.6% were insured by Medicaid and 24.3% were insured by Medicare; and 71.7% were White, 16.9% were Black, and 7.3% were Hispanic/Latino. At 6 months, 5.6% (95% CI, 2.8-8.5) completed screening in the colonoscopy-only arm, 12.8% (95% CI, 8.6-17.0) in the active-choice arm, and 11.3% (95% CI, 7.4-15.3) in the FIT-only arm. Compared with colonoscopy only, there was a significant increase in screening in active choice (absolute difference, 7.1%; 95% CI, 2.0-12.2; P = .006) and FIT only (absolute difference, 5.7%; 95% CI, 0.8-10.6; P = .02). CONCLUSIONS Both choice of testing and FIT alone increased response and may align with patient preferences. TRIAL REGISTRATION clinicaltrials.gov NCT04711473.
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Affiliation(s)
- Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Sanjay Palat
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Evelyn Okorie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keyirah Williams
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jinming Tao
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Care Innovation, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pamela A Shaw
- Biostatistics Division, Kaiser Permanente Washington Health Research Institute, Seattle, Washington; Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Glanz
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Ahadinezhad B, Maleki A, Akhondi A, Kazemi M, Yousefy S, Rezaei F, Khosravizadeh O. Are behavioral economics interventions effective in increasing colorectal cancer screening uptake: A systematic review of evidence and meta-analysis? PLoS One 2024; 19:e0290424. [PMID: 38315699 PMCID: PMC10843112 DOI: 10.1371/journal.pone.0290424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/08/2023] [Indexed: 02/07/2024] Open
Abstract
Various interventions have been investigated to improve the uptake of colorectal cancer screening. In this paper, the authors have attempted to provide a pooled estimate of the effect size of the BE interventions running a systematic review based meta-analysis. In this study, all the published literatures between 2000 and 2022 have been reviewed. Searches were performed in PubMed, Scopus and Cochrane databases. The main outcome was the demanding the one of the colorectal cancer screening tests. The quality assessment was done by two people so that each person evaluated the studies separately and independently based on the individual participant data the modified Jadad scale. Pooled effect size (odds ratio) was estimated using random effects model at 95% confidence interval. Galbraith, Forrest and Funnel plots were used in data analysis. Publication bias was also investigated through Egger's test. All the analysis was done in STATA 15. From the initial 1966 records, 38 were included in the final analysis in which 72612 cases and 71493 controls have been studied. About 72% have been conducted in the USA. The heterogeneity of the studies was high based on the variation in OR (I2 = 94.6%, heterogeneity X2 = 670.01 (d.f. = 36), p < 0.01). The random effect pooled odds ratio (POR) of behavioral economics (BE) interventions was calculated as 1.26 (95% CI: 1.26 to 1.43). The bias coefficient is noteworthy (3.15) and statistically significant (p< 0.01). According to the results of this meta-analysis, health policy and decision makers can improve the efficiency and cost effectiveness of policies to control this type of cancer by using various behavioral economics interventions. It's noteworthy that due to the impossibility of categorizing behavioral economics interventions; we could not perform by group analysis.
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Affiliation(s)
- Bahman Ahadinezhad
- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Aisa Maleki
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Amirali Akhondi
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | | | - Sama Yousefy
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Fatemeh Rezaei
- Student Research Committee, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Omid Khosravizadeh
- Social Determinants of Health Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
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Mehta SJ, McDonald C, Reitz C, Kastuar S, Snider CK, Okorie E, McNelis K, Shaikh H, Cook TS, Goldberg DS, Rothstein K. A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance. Hepatol Commun 2024; 8:e0349. [PMID: 38099859 PMCID: PMC10727671 DOI: 10.1097/hc9.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Caitlin McDonald
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Shivani Kastuar
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | | | - Evelyn Okorie
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Kiernan McNelis
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia, USA
| | - Hamzah Shaikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Tessa S. Cook
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - David S. Goldberg
- Department of Medicine, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Kenneth Rothstein
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Parikh RB, Schriver E, Ferrell WJ, Wakim J, Williamson J, Khan N, Kopinsky M, Balachandran M, Gabriel PE, Schuchter LM, Patel MS, Shulman LN, Manz CR. Remote Patient-Reported Outcomes and Activity Monitoring to Improve Patient-Clinician Communication Regarding Symptoms and Functional Status: A Randomized Controlled Trial. JCO Oncol Pract 2023; 19:1143-1151. [PMID: 37816198 PMCID: PMC10732505 DOI: 10.1200/op.23.00048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/08/2023] [Accepted: 08/29/2023] [Indexed: 10/12/2023] Open
Abstract
PURPOSE Routine collection of patient-generated health data (PGHD) may promote earlier recognition of symptomatic and functional decline. This trial assessed the impact of an intervention integrating remote PGHD collection with patient nudges on symptom and functional status understanding between patients with advanced cancer and their oncology team. METHODS This three-arm randomized controlled trial was conducted from November 19, 2020, to December 17, 2021, at a large tertiary oncology practice. We enrolled patients with stage IV GI and lung cancers undergoing chemotherapy. Over 6 months, patients in two intervention arms received PROStep-weekly text message-based symptom surveys and passive activity monitoring using a wearable accelerometer. PGHD were summarized in dashboards given to patients' oncology team before appointments. One intervention arm received an additional text-based active choice prompt to discuss worsening symptoms or functional status with their clinician. Control patients did not receive PROStep. The coprimary outcomes patient perceptions of oncology team symptom and functional understanding at 6 months were measured on a 1-5 Likert scale (5 = high understanding). RESULTS One hundred eight patients enrolled: 55% male, 81% White, and 77% had GI cancers. Patient-reported clinician understanding did not differ between control and intervention arms for symptoms (4.5 v 4.5; P = .87) or functional status (4.5 v 4.3; P = .31). In the intervention arms, combined patient adherence to weekly symptom reports and daily activity monitoring was 64% and 53%, respectively. Intervention patients in the PROStep versus PROStep + active choice arms reported low burden from wearing the accelerometer (mean burden [standard deviation], 2.7 [1.3] v 2.1 [1.3]; P = .15) and completing surveys (2.1 [1.2] v 1.9 [1.3]; P = .44). CONCLUSION Patients receiving PROStep reported high understanding of symptoms and functional status from their oncology team, although this did not differ from controls.
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Affiliation(s)
- Ravi B. Parikh
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Emily Schriver
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia, PA
- Penn Medicine Predictive Healthcare, University of Pennsylvania Health System, Philadelphia, PA
| | - William J. Ferrell
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Wakim
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Joelle Williamson
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Neda Khan
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | - Michael Kopinsky
- Center for Health Care Innovation, Penn Medicine, Philadelphia, PA
| | | | - Peter E. Gabriel
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Lynn M. Schuchter
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | | | - Christopher R. Manz
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Harvard University, Boston, MA
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Yakoubovitch S, Zaki T, Anand S, Pecoriello J, Liang PS. Effect of Behavioral Interventions on the Uptake of Colonoscopy for Colorectal Cancer Screening: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2023; 118:1829-1840. [PMID: 37606070 PMCID: PMC10592067 DOI: 10.14309/ajg.0000000000002478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Screening decreases colorectal cancer incidence and mortality, but uptake in the United States remains suboptimal. Prior studies have investigated the effect of various interventions on overall colorectal cancer screening and stool-based testing, but the effect on colonoscopy-the predominant screening test in the United States-has not been fully examined. We performed a systematic review and meta-analysis to assess the effect of behavioral interventions on screening colonoscopy uptake. METHODS We searched PubMed, Embase, and Cochrane databases through January 2022 for controlled trials that assessed the effect of behavioral interventions on screening colonoscopy uptake. All titles, abstracts, and articles were screened by at least 2 independent reviewers. Odds ratios were extracted from the original article or calculated from the raw data. The primary outcome was the relative increase in screening colonoscopy completion with any behavioral intervention. We performed random-effects meta-analysis, with subgroup analysis by type of intervention. RESULTS A total of 25 studies with 30 behavioral interventions were analyzed. The most common interventions were patient navigation (n = 11) and multicomponent interventions (n = 6). Overall, behavioral interventions increased colonoscopy completion by 54% compared with controls (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.26-1.88). Patient navigation (OR 1.78, 95% CI 1.35-2.34) and multicomponent interventions (OR 1.84, 95% CI 1.17-2.89) had the strongest effect on colonoscopy completion among interventions examined in multiple studies. Significant heterogeneity was observed both overall and by intervention type. There was no evidence of publication bias. DISCUSSION Behavioral interventions increase screening colonoscopy completion and should be adopted in clinical practice. In particular, patient navigation and multicomponent interventions are the best-studied and most effective interventions.
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Affiliation(s)
| | - Timothy Zaki
- Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Sanya Anand
- Department of Medicine, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Jillian Pecoriello
- Department of Obstetrics & Gynecology, NYU Langone Health, New York, New York, USA
| | - Peter S Liang
- Department of Medicine, NYU Langone Health, New York, New York, USA
- Department of Medicine, VA New York Harbor Health Care System, New York, New York, USA
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Samnani S, Khan R, Heitman SJ, Hilsden RJ, Byrne MF, Grover SC, Forbes N. Optimizing adenoma detection in screening-related colonoscopy. Expert Rev Gastroenterol Hepatol 2023:1-14. [PMID: 37158052 DOI: 10.1080/17474124.2023.2212159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Screening-related colonoscopy is a vital component of screening initiatives to both diagnose and prevent colorectal cancer (CRC), with prevention being reliant upon early and accurate detection of pre-malignant lesions. Several strategies, techniques, and interventions exist to optimize endoscopists' adenoma detection rates (ADR). AREAS COVERED This narrative review provides an overview of the importance of ADR and other colonoscopy quality indicators. It then summarizes the available evidence regarding the effectiveness of the following domains in terms of improving ADR: endoscopist factors, pre-procedural parameters, peri-procedural parameters, intra-procedural strategies and techniques, antispasmodics, distal attachment devices, enhanced colonoscopy technologies, enhanced optics, and artificial intelligence. These summaries are based on an electronic search of the databases Embase, Pubmed, and Cochrane performed on December 12, 2022. EXPERT OPINION Given the prevalence and associated morbidity and mortality of CRC, the quality of screening-related colonoscopy quality is appropriately prioritized by patients, endoscopists, units, and payers alike. Endoscopists performing colonoscopy should be up to date regarding available strategies, techniques, and interventions to optimize their performance.
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Affiliation(s)
- Sunil Samnani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rishad Khan
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Steven J Heitman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert J Hilsden
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael F Byrne
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Korous KM, Cuevas AG, Chahoud J, Ogbonnaya UC, Brooks E, Rogers CR. Examining the relationship between household wealth and colorectal cancer screening behaviors among U.S. men aged 45-75. SSM Popul Health 2022; 19:101222. [PMID: 36105558 PMCID: PMC9464961 DOI: 10.1016/j.ssmph.2022.101222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 11/12/2022] Open
Abstract
Colorectal cancer (CRC) is the third leading cause of cancer-related death among men in the United States (U.S.), particularly among men aged 45 years and older. Early-detection screening remains a key method of decreasing CRC-related deaths, yet socioeconomic barriers exist to planning and completing CRC screening. While accumulating evidence shows income disparities in CRC screening prevalence, a dearth of research has investigated wealth disparities. This study aimed to determine whether household wealth was associated with CRC screening uptake and future screening intent. In February 2022, we sent an online survey to potential participants; U.S. men aged 45–75 years were eligible to participate. We examined four CRC screening behaviors as outcomes: ever completing a stool-based or exam-based screening test, current screening status, and future screening intent. Household net wealth, determined by self-reported household wealth and debt, was the primary predictor. We used logistic regression to estimate odds ratios (ORs) and their 95% confidence interval (CI). Of the study participants (N = 499), most self-identified as Non-Hispanic White, were aged 50–64 years, and had previously completed a CRC screening test. Results revealed that, among men aged 45–49 years, higher net wealth decreased the odds of ever completing a stool- or exam-based test (OR = 0.58, 95% CI: 0.33, 0.98; OR = 0.55, 95% CI: 0.31, 0.94, respectively). By contrast, among men aged 50–75 years, higher net wealth increased the odds of being current with CRC screening (OR = 1.40, 95% CI: 1.03, 1.92). Net wealth was unassociated with CRC screening intent. These findings suggest that household net wealth, rather than income, is an important socioeconomic factor to consider in relation to uptake of CRC early-detection screening. The financial and social cognitive mechanisms linking household wealth to CRC screening behaviors merit future research and intervention. Wealth was associated with U.S men's adherence to screening for colorectal cancer. Age modified the association between wealth and colorectal cancer screening uptake. Wealth reduced the odds of past colorectal screening completion for men 45–49 years.
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Affiliation(s)
- Kevin M Korous
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, 84108, USA.,Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
| | - Adolfo G Cuevas
- Community Health, School of Arts and Sciences, Tufts University, Medford, MA, 02155, USA
| | - Jad Chahoud
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, 33612, USA
| | - Uchenna C Ogbonnaya
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, 84108, USA
| | - Ellen Brooks
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, 84108, USA
| | - Charles R Rogers
- Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, UT, 84108, USA.,Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, 53226, USA
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Shaukat A, Tuskey A, Rao VL, Dominitz JA, Murad MH, Keswani RN, Bazerbachi F, Day LW. Interventions to improve adenoma detection rates for colonoscopy. Gastrointest Endosc 2022; 96:171-183. [PMID: 35680469 DOI: 10.1016/j.gie.2022.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/25/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Anne Tuskey
- Division of Gastroenterology, Department of Medicine, University of Virginia, Arlington, Virginia, USA
| | - Vijaya L Rao
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, Puget Sound Veterans Affairs Medical Center and University of Washington, Seattle, Washington, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology, CentraCare, Interventional Endoscopy Program, St Cloud, Minnesota, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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Clifton ABW, Mehta SJ, Wainwright JV, Ogden SN, Saia CA, Rendle KA. Exploring Why Financial Incentives Fail to Affect At-home Colorectal Cancer Screening: a Mixed Methods Study. J Gen Intern Med 2022; 37:2751-2758. [PMID: 35037172 PMCID: PMC9411475 DOI: 10.1007/s11606-021-07228-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/19/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Despite success in increasing other health behaviors, financial incentives have shown limited to no effect on colorectal cancer (CRC screening. Little is known about the factors shaping why and for whom incentives improve screening. OBJECTIVE To explore the perspective of participants enrolled in a larger, four-arm pragmatic trial at urban family medicine practices which assessed and failed to detect significant effects of financial incentives on at-home CRC screening completion. DESIGN We performed a mixed methods study with a subset of randomly selected patients, stratified by study arm, following completion of the pragmatic trial. PARTICIPANTS Sixty patients (46.9% enrollment rate) who were eligible and overdue for colorectal cancer screening at the time of trial enrollment and who continued to receive care at family medicine practices affiliated with an urban academic health system completed the interview and questionnaire. MAIN MEASURES Using Andersen's behavioral model, a semi-structured interview guide assessed motivators, barriers, and facilitators to screening completion and the impact of incentives on decision-making. Participants also completed a brief questionnaire evaluating demographics, screening beliefs, and clinical characteristics. KEY RESULTS The majority of patients (n = 49; 82%) reported that incentives would not change their decision to complete or not complete CRC screening, which was confirmed by qualitative data as largely due to high perceived health benefits. Those who stated financial incentives would impact their decision (n = 11) were significantly less likely to agree that CRC screening is beneficial (72.7% vs 95.9%; p < 0.05) or that CRC could be cured if detected early (63.6% vs 98.0%; p < 0.05). CONCLUSIONS Financial incentives are likely not an effective behavioral intervention to increase CRC screening for all but may be powerful for increasing short-term benefit and therefore completion for some. Targeting financial incentive interventions according to patient screening beliefs may prove a cost-effective strategy in primary care outreach programs to increase CRC screening.
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Affiliation(s)
- Alicia B W Clifton
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jocelyn V Wainwright
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA
| | - Shannon N Ogden
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
| | - Chelsea A Saia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA
| | - Katharine A Rendle
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, 51 N 39th St., PPMC Mutch Building, Floor 7, Philadelphia, PA, 19104, USA.
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11
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Stoffel ST, Bombagi M, Kerrison RS, von Wagner C, Herrmann B. Testing Enhanced Active Choice to Optimize Acceptance and Participation in a Population-Based Colorectal Cancer Screening Program in Malta. Behav Med 2022; 48:141-146. [PMID: 33710942 DOI: 10.1080/08964289.2020.1828254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Opt-out strategies have been shown to improve participation in cancer screening; however, there are ethical concerns regarding the presumed consent. In this study, we tested an alternative opt-in strategy, called: "enhanced active choice," in which the response options summarize the consequences of the decision. The study was conducted as part of the Maltese colorectal cancer screening program, which offers men and women, aged 60-64, a "one-off" fecal immunochemical test (FIT). A total of 8349 individuals were randomly assigned to receive either an invitation letter that featured a standard opt-in strategy (control condition), or an alternative letter with a modified opt-in strategy (enhanced active choice condition). Our primary outcome was participation three months after the invitation was delivered. Additionally, we also compared the proportion who said they wanted to take part in screening. We used multivariable logistic regression for the analysis. Overall, 48.4% (N = 4042) accepted the invitation and 42.4% (N = 3542) did the screening test. While there were no statistically significant differences between the two conditions in terms of acceptance and participation, enhanced active choice did increase acceptance among men by 4.6 percentage points, which translated to a significant increase in participation of 3.4 percentage points. We conclude that enhanced active choice can improve male screening participation. Given the higher risk of CRC in men, as well as their lower participation screening, we believe this to be an important finding.
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Affiliation(s)
- Sandro T Stoffel
- Joint Research Centre, European Commission, Ispra, Italy.,Research Department of Behavioural Science and Health, University College London, London, UK.,Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland
| | | | - Robert S Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
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12
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Parikh RB, Ferrell W, Wakim J, Williamson J, Khan N, Kopinsky M, Balachandran M, Gabriel PE, Zhang Y, Schuchter LM, Shulman LN, Chen J, Patel MS, Manz CR. Patient and clinician nudges to improve symptom management in advanced cancer using patient-generated health data: study protocol for the PROStep randomised controlled trial. BMJ Open 2022; 12:e054675. [PMID: 35551088 PMCID: PMC9109034 DOI: 10.1136/bmjopen-2021-054675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Patients with advanced cancers often face significant symptoms from their cancer and adverse effects from cancer-associated therapy. Patient-generated health data (PGHD) are routinely collected information about symptoms and activity levels that patients either directly report or passively record using devices such as wearable accelerometers. The objective of this study was to test the impact of an intervention integrating remote collection of PGHD with clinician and patient nudges to inform communication between patients with advanced cancer and their oncology team regarding symptom burden and functional status. METHODS AND ANALYSIS This single-centre prospective randomised controlled trial randomises patients with metastatic gastrointestinal or lung cancers into one of three arms: (A) usual care, (B) an intervention that integrates PGHD (including weekly text-based symptom surveys and passively recorded step counts) into a dashboard delivered to oncology clinicians at each visit and (C) the same intervention as arm B but with an additional text-based active choice intervention to patients to encourage discussing their symptoms with their oncology team. The study will enrol approximately 125 participants. The coprimary outcomes are patient perceptions of their oncology team's understanding of their symptoms and their functional status. Secondary outcomes are intervention utility and adherence. ETHICS AND DISSEMINATION This study has been approved by the institutional review board at the University of Pennsylvania. Study results will be disseminated using methods that describe the results in ways that key stakeholders can best understand and implement. TRIAL REGISTRATION NUMBERS NCT04616768 and 843 616.
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Affiliation(s)
- Ravi B Parikh
- Abramson Cancer Center, Philadelphia, Pennsylvania, USA
- Departments of Medical Ethics and Health Policy and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - William Ferrell
- Departments of Medical Ethics and Health Policy and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jonathan Wakim
- Departments of Medical Ethics and Health Policy and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joelle Williamson
- Departments of Medical Ethics and Health Policy and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Neda Khan
- Departments of Medical Ethics and Health Policy and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Michael Kopinsky
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Mohan Balachandran
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | | | - Yichen Zhang
- Departments of Medical Ethics and Health Policy and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | - Jinbo Chen
- Abramson Cancer Center, Philadelphia, Pennsylvania, USA
| | - Mitesh S Patel
- Departments of Medical Ethics and Health Policy and Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher R Manz
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medical Oncology, Harvard Medical School, Boston, Massachusetts, USA
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13
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Thompson JC, Ren Y, Romero K, Lew M, Bush AT, Messina JA, Jung SH, Siamakpour-Reihani S, Miller J, Jenq RR, Peled JU, van den Brink MRM, Chao NJ, Shrime MG, Sung AD. Financial incentives to increase stool collection rates for microbiome studies in adult bone marrow transplant patients. PLoS One 2022; 17:e0267974. [PMID: 35507633 PMCID: PMC9067695 DOI: 10.1371/journal.pone.0267974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/19/2022] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION In order to study the role of the microbiome in hematopoietic stem cell transplantation (HCT), researchers collect stool samples from patients at various time points throughout HCT. However, stool collection requires active subject participation and may be limited by patient reluctance to handling stool. METHODS We performed a prospective study on the impact of financial incentives on stool collection rates. The intervention group consisted of allogeneic HCT patients from 05/2017-05/2018 who were compensated with a $10 gas gift card for each stool sample. The intervention group was compared to a historical control group of allogeneic HCT patients from 11/2016-05/2017 who provided stool samples before the incentive was implemented. To control for possible changes in collections over time, we also compared a contemporaneous control group of autologous HCT patients from 05/2017-05/2018 with a historical control group of autologous HCT patients from 11/2016-05/2017; neither autologous HCT group was compensated. The collection rate was defined as the number of samples provided divided by the number of time points we attempted to obtain stool. RESULTS There were 35 allogeneic HCT patients in the intervention group, 19 allogeneic HCT patients in the historical control group, 142 autologous HCT patients in the contemporaneous control group (that did not receive a financial incentive), and 75 autologous HCT patients in the historical control group. Allogeneic HCT patients in the intervention group had significantly higher average overall collection rates when compared to the historical control group allogeneic HCT patients (80% vs 37%, p<0.0001). There were no significant differences in overall average collection rates between the autologous HCT patients in the contemporaneous control and historical control groups (36% vs 32%, p = 0.2760). CONCLUSION Our results demonstrate that a modest incentive can significantly increase collection rates. These results may help to inform the design of future studies involving stool collection.
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Affiliation(s)
- Jillian C. Thompson
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Yi Ren
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Kristi Romero
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Meagan Lew
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Amy T. Bush
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julia A. Messina
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sin-Ho Jung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sharareh Siamakpour-Reihani
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Julie Miller
- Center for Advanced Hindsight, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Robert R. Jenq
- Departments of Genomic Medicine and Stem Cell Transplantation Cellular Therapy, MD Anderson Cancer Center, University of Texas, Houston, Texas, United States of America
| | - Jonathan U. Peled
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Marcel R. M. van den Brink
- Department of Medicine, Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Nelson J. Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Mark G. Shrime
- Department of Otolaryngology Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Anthony D. Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, North Carolina, United States of America
- * E-mail:
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14
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Taylor LC, Kerrison RS, Herrmann B, Stoffel ST. Effectiveness of behavioural economics-based interventions to improve colorectal cancer screening participation: A rapid systematic review of randomised controlled trials. Prev Med Rep 2022; 26:101747. [PMID: 35284211 PMCID: PMC8914541 DOI: 10.1016/j.pmedr.2022.101747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/18/2022] [Accepted: 02/26/2022] [Indexed: 12/22/2022] Open
Abstract
We searched PubMed, PsycInfo and EconLit for RCTs that evaluated BE interventions in CRC screening. We identified 1027 papers for title and abstract review. 30 studies were eligible for the review. The most frequently tested BE intervention was incentives, followed by default principle and salience. Default-based interventions were most likely to be effective. Incentives had mixed evidence. BE remains a promising field of interest in relation to influencing CRC screening behaviours.
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Affiliation(s)
- Lily C. Taylor
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, UK
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Robert S. Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
- School of Health Sciences, University of Surrey, Surrey, UK
| | | | - Sandro T. Stoffel
- Research Department of Behavioural Science and Health, University College London, London, UK
- European Commission, Joint Research Centre (JRC), Ispra, Italy
- Institute for Pharmaceutical Medicine, University of Basel, Basel, Switzerland
- Corresponding author at: Research Department of Behavioural Science and Health, University College London, London, UK.
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15
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Wang M, Yang HL, Liu XL, Mo BR, Kynoch K, Ramis MA. Evaluating behavioral economic interventions for promoting cancer screening uptake and adherence in targeted populations: a systematic review protocol. JBI Evid Synth 2022; 20:1113-1119. [PMID: 35013041 DOI: 10.11124/jbies-21-00265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The objective of this review is to determine the effectiveness of behavioral economic interventions for promoting uptake of and adherence to cancer screening recommended by guidelines. INTRODUCTION Cancer screening has been found to help reduce incidence of and mortality from advanced cancer. However, adherence to recommended cancer screening services is low in asymptomatic adults with average risk possibly due to systematic decision biases. The findings of this review will demonstrate whether interventions informed by behavioral economic insights can help improve uptake of and adherence to cancer screening. INCLUSION CRITERIA This review will consider studies that meet the following inclusion criteria: experimental, quasi-experimental, and analytical observational studies that i) evaluate the effects of behavioral economic interventions in adults eligible for guideline-recommended cancer screening, and that ii) report the number/percentage of individuals who used screening services; number/percentage of individuals who completed screening recommended by guidelines; participant self-reported intentions, choice, and satisfaction regarding the use of screening services; detection rates of early-stage cancers; use of early intervention for cancers; and cancer-related mortality. METHODS A systematic literature search will be performed by one reviewer. After removing duplicates, two reviewers will independently screen and appraise eligible studies according to the JBI methodology for systematic reviews of effectiveness. Five databases will be searched: CINAHL, the Cochrane Library, PsycINFO, PubMed, and Web of Science. Sources of gray literature and registered clinical trials will also be searched for potential studies. There will be no limits to publication date or language. Data synthesis will be conducted using meta-analysis and narrative synthesis where appropriate. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO CRD42021258370.
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Affiliation(s)
- Mian Wang
- Department of Nursing, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, Guangdong Province, China Nanshan Evidence Based Nursing Centre: A JBI Affiliated Group, Shenzhen, Guangdong Province, China School of Nursing, The Hong Kong Polytechnic University, Hong Kong SAR, China College of Nursing and Midwifery, Charles Darwin University, Brisbane, QLD, Australia Mater Health, Evidence in Practice Unit, South Brisbane, QLD, Australia The Queensland Centre for Evidence Based Nursing and Midwifery: A JBI Institute Centre of Excellence, Brisbane, QLD, Australia
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16
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Stoffel S, Kioupi S, Ioannou D, Kerrison RS, von Wagner C, Herrmann B. Testing messages from behavioral economics to improve participation in a population-based colorectal cancer screening program in Cyprus: Results from two randomized controlled trials. Prev Med Rep 2021; 24:101499. [PMID: 34430189 PMCID: PMC8371188 DOI: 10.1016/j.pmedr.2021.101499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 06/17/2021] [Accepted: 07/13/2021] [Indexed: 11/04/2022] Open
Abstract
•Behavioral economic-based interventions have been suggested to increase uptake in CRC screening programmes.•This study tested the effectiveness of six behavioral economic-based messages in two field trials.•None of the messages increased screening participation.
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Affiliation(s)
- Sandro Stoffel
- Joint Research Centre, European Commission, Ispra, Italy
- Research Department of Behavioural Science and Health, University College London, London, UK
- Institute of Pharmaceutical Medicine, University of Basel, Basel, Switzerland
| | - Stala Kioupi
- Ministry of Health, Government of the Republic of Cyprus, Nicosia, Cyprus
| | - Despina Ioannou
- Ministry of Health, Government of the Republic of Cyprus, Nicosia, Cyprus
| | - Robert S. Kerrison
- Research Department of Behavioural Science and Health, University College London, London, UK
- School of Health Science, University of Surrey, Surrey, UK
| | - Christian von Wagner
- Research Department of Behavioural Science and Health, University College London, London, UK
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17
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Facciorusso A, Demb J, Mohan BP, Gupta S, Singh S. Addition of Financial Incentives to Mailed Outreach for Promoting Colorectal Cancer Screening: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2122581. [PMID: 34432010 PMCID: PMC8387849 DOI: 10.1001/jamanetworkopen.2021.22581] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Although screening decreases incidence of and mortality from colorectal cancer (CRC), screening rates are low. Health-promoting financial incentives may increase uptake of cancer screening. OBJECTIVE To evaluate the relative and absolute benefit associated with adding financial incentives to the uptake of CRC screening. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, and Web of Science were searched from inception to July 31, 2020. Keywords and Medical Subject Headings terms were used to identify published studies on the topic. The search strategy identified 835 studies. STUDY SELECTION Randomized clinical trials (RCTs) were selected that involved adults older than 50 years who were eligible for CRC screening, who received either various forms of financial incentives along with mailed outreach or no financial incentives but mailed outreach and reminders alone, and who reported screening completion by using recommended tests at different time points. Observational or nonrandomized studies and a few RCTs were excluded. DATA EXTRACTION AND SYNTHESIS The review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Data were abstracted and risk of bias was assessed by 2 independent reviewers. Random-effects meta-analysis was conducted, heterogeneity was examined through subgroup analysis and metaregression, and quality of evidence was appraised. MAIN OUTCOMES AND MEASURES The primary outcome was CRC screening completion within 12 months of receiving the intervention. RESULTS A total of 8 RCTs that were conducted in the United States and reported between January 1, 2014, and December 31, 2020, were included. The trials involved 110 644 participants, of whom 53 444 (48.3%) were randomized to the intervention group (received financial incentives) and 57 200 (51.7%) were randomized to the control group (received no financial incentives). Participants were predominantly male, with 59 113 men (53.4%). Low-quality evidence (rated down for risk of bias and heterogeneity) suggested that adding financial incentives may be associated with a small benefit of increasing CRC screening vs no financial incentives (odds ratio [OR], 1.25; 95% CI, 1.05-1.49). With mailed outreach having a 30% estimated CRC screening completion rate, adding financial incentives may increase the rate to 33.5% (95% CI, 30.8%-36.2%). On metaregression, the magnitude of benefit decreased as the proportion of participants with low income and/or from racial/ethnic minority groups increased. No significant differences were observed by type of behavioral economic intervention (fixed amount: OR, 1.26 [95% CI, 1.05-1.52] vs lottery: OR, 1.06 [95% CI, 0.80-1.40]; P = .32), amount of incentive (≤$5: OR, 1.09 [95% CI, 1.01-1.18] vs >$5: OR, 1.25 [95% CI, 1.02-1.54]; P = .22), or screening modality (stool-based test: OR, 1.14 [95% CI, 0.92-1.41] vs colonoscopy: OR, 1.63 [95% CI, 1.01-2.64]; P = .18). CONCLUSIONS AND RELEVANCE Adding financial incentives appeared to be associated with a small benefit of increasing CRC screening uptake, with marginal benefits in underserved populations with adverse social determinants of health. Alternative approaches to enhancing CRC screening uptake are warranted.
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Affiliation(s)
| | - Joshua Demb
- Moores Cancer Center, University of California at San Diego, La Jolla
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City
| | - Samir Gupta
- Moores Cancer Center, University of California at San Diego, La Jolla
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California
- Division of Gastroenterology, University of California at San Diego, La Jolla
| | - Siddharth Singh
- Division of Gastroenterology, University of California at San Diego, La Jolla
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18
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Mehta SJ, Reitz C, Niewood T, Volpp KG, Asch DA. Effect of Behavioral Economic Incentives for Colorectal Cancer Screening in a Randomized Trial. Clin Gastroenterol Hepatol 2021; 19:1635-1641.e1. [PMID: 32623005 PMCID: PMC7775888 DOI: 10.1016/j.cgh.2020.06.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 06/15/2020] [Accepted: 06/21/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Financial incentives might increase participation in prevention such as screening colonoscopy. We studied whether incentives informed by behavioral economics increase participation in risk assessment for colorectal cancer (CRC) and completion of colonoscopy for eligible adults. METHODS Employees of a large academic health system (50-64 y old; n = 1977) were randomly assigned to groups that underwent risk assessment for CRC screening and direct access colonoscopy scheduling (control), or risk assessment, direct access colonoscopy scheduling, a $10 loss-framed incentive to complete risk assessment, and a $25 unconditional incentive for colonoscopy completion (incentive). The primary outcome was the percentage of participants who completed screening colonoscopy within 3 months of initial outreach. Secondary outcomes included the percentage of participants who scheduled colonoscopy and the percentage who completed the risk assessment. RESULTS At 3 months, risk assessment was completed by 19.5% of participants in the control group (95% CI, 17.0-21.9%) and 31.9% of participants in the incentive group (95% CI, 29.0-34.8%) (P < .001). At 3 months, 0.7% of controls had completed a colonoscopy (95% CI, .2%-1.2%) compared with 1.2% of subjects in the incentive group (95% CI, .5%-1.9%) (P = .25). CONCLUSIONS In a randomized trial of participants who underwent risk assessment for CRC with vs without financial incentive, the financial incentive increased CRC risk assessment completion but did not result in a greater completion of screening colonoscopy. Clinicaltrials.gov no: NCT03068052.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania
| | - Tess Niewood
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania,Center for Health Care Innovation, University of Pennsylvania,Center for Health Incentives and Behavioral Economics, University of Pennsylvania,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center
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19
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Lieberman A, Gneezy A, Berry E, Miller S, Koch M, Argenbright KE, Gupta S. The effect of deadlines on cancer screening completion: a randomized controlled trial. Sci Rep 2021; 11:13876. [PMID: 34230556 PMCID: PMC8260724 DOI: 10.1038/s41598-021-93334-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 06/23/2021] [Indexed: 01/08/2023] Open
Abstract
Cancer is the second leading cause of death in the United States. Although screening facilitates prevention and early detection and is one of the most effective approaches to reducing cancer mortality, participation is low—particularly among underserved populations. In a large, preregistered field experiment (n = 7711), we tested whether deadlines—both with and without monetary incentives tied to them—increase colorectal cancer (CRC) screening. We found that all screening invitations with an imposed deadline increased completion, ranging from 2.5% to 7.3% relative to control (ps < .004). Most importantly, individuals who received a short deadline with no incentive were as likely to complete screening (9.7%) as those whose invitation included a deadline coupled with either a small (9.1%) or large declining financial incentive (12.0%; ps = .57 and .04, respectively). These results suggest that merely imposing deadlines—especially short ones—can significantly increase CRC screening completion, and may also have implications for other forms of cancer screening.
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Affiliation(s)
- Alicea Lieberman
- Anderson School of Management, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Ayelet Gneezy
- Rady School of Management, University of California, San Diego, La Jolla, CA, USA
| | - Emily Berry
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA
| | - Stacie Miller
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA
| | - Mark Koch
- Department of Family Medicine, John Peter Smith Health Network, Fort Worth, TX, USA
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, TX, USA.,University of Texas Southwestern Medical Center Harold C. Simmons Cancer Center, Dallas, TX, USA.,Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Samir Gupta
- San Diego Veterans Affairs Healthcare System, San Diego, CA, USA.,Department of Internal Medicine, Division of Gastroenterology, and the Moores Cancer Center, University of California San Diego, San Diego, CA, USA
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20
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Inadomi JM, Issaka RB, Green BB. What Multilevel Interventions Do We Need to Increase the Colorectal Cancer Screening Rate to 80%? Clin Gastroenterol Hepatol 2021; 19:633-645. [PMID: 31887438 PMCID: PMC8288035 DOI: 10.1016/j.cgh.2019.12.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/05/2019] [Accepted: 12/19/2019] [Indexed: 02/07/2023]
Abstract
Screening reduces colorectal cancer mortality; however, this remains the second leading cause of cancer deaths in the United States and adherence to colorectal cancer screening falls far short of the National Colorectal Cancer Roundtable goal of 80%. Numerous studies have examined the effectiveness of interventions to increase colorectal cancer screening uptake. Outreach is the active dissemination of screening outside of the primary care setting, such as mailing fecal blood tests to individuals' homes. Navigation uses trained personnel to assist individuals through the screening process. Patient education may take the form of brochures, videos, or websites. Provider education can include feedback about screening rates of patient panels. Reminders to healthcare providers can be provided by dashboards of patients due for screening. Financial incentives provide monetary compensation to individuals when they complete screening tests, either as fixed payments or via a lottery. Individual preference for specific screening strategies has also been examined in several trials, with a choice of screening strategies yielding higher adherence than recommendation of a single strategy.
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Affiliation(s)
- John M. Inadomi
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA,Divisions of Clinical Research and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA,Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Rachel B. Issaka
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, WA,Divisions of Clinical Research and Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA
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21
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Shay LA, Kimbel KJ, Dorsey CN, Jauregui LC, Vernon SW, Kullgren JT, Green BB. Patients' Reactions to Being Offered Financial Incentives to Increase Colorectal Screening: A Qualitative Analysis. Am J Health Promot 2021; 35:421-429. [PMID: 33504161 DOI: 10.1177/0890117120987836] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To explore financial incentives as an intervention to improve colorectal cancer screening (CRCS) adherence among traditionally disadvantaged patients who have never been screened or are overdue for screening. APPROACH We used qualitative methods to describe patients' attitudes toward the offer of incentives, plans for future screening, and additional barriers and facilitators to CRCS. SETTING Kaiser Permanente Washington (KPWA). PARTICIPANTS KPWA patients who were due or overdue for CRCS. METHOD We conducted semi-structured qualitative interviews with 37 patients who were randomized to 1 of 2 incentives (guaranteed $10 or a lottery for $50) to complete CRCS. Interview transcripts were analyzed using a qualitative content approach. RESULTS Patients generally had positive attitudes toward both types of incentives, however, half did not recall the incentive offer at the time of the interview. Among those who recalled the offer, 95% were screened compared to only 25% among those who did not remember the offer. Most screeners stated that staying healthy was their primary motivator for screening, but many suggested that the incentive helped them prioritize and complete screening. CONCLUSIONS Incentives to complete CRCS may help motivate patients who would like to screen but have previously procrastinated. Future studies should ensure that the incentive offer is noticeable and shorten the deadline for completion of FIT screening.
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Affiliation(s)
- L Aubree Shay
- 12340University of Texas Health Science Center at Houston, Houston, TX, USA
| | | | | | | | - Sally W Vernon
- 12340University of Texas Health Science Center at Houston, Houston, TX, USA
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Application of Behavioral Economics Principles Improves Participation in Mailed Outreach for Colorectal Cancer Screening. Clin Transl Gastroenterol 2020; 11:e00115. [PMID: 31972609 PMCID: PMC7056051 DOI: 10.14309/ctg.0000000000000115] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION: Colorectal cancer (CRC) is a major cause of cancer-related morbidity and mortality in the United States. Although various interventions have improved screening rates, they often require abundant resources and can be difficult to implement. Social psychology and behavioral economics principles offer an opportunity for low-cost and easy-to-implement strategies but are less common in clinical settings. METHODS: We randomized 2,000 patients aged 50–75 years eligible for CRC screening to one of the 2 mailed interventions: a previously used text-based letter describing and offering fecal immunochemical testing (FIT) and colonoscopy (usual care arm); or a letter leveraging social psychology and behavioral economics principles (e.g., implied scarcity and choice architecture), minimal text, and multiple images to offer FIT and colonoscopy (intervention arm). We compared total screening uptake, FIT uptake, and colonoscopy uptake at 1-month intervals in each group. RESULTS: There were 1,882 patients included in the final analysis. The mean age was 69.3 years, and baseline characteristics in the 2 groups were similar. Screening completion at 26 weeks was 19.5% in the usual care arm (16.3% FIT vs 3.2% colonoscopy, P < 0.01) and 24.1% in the intervention arm (22.1% FIT vs 2.0% colonoscopy, P < 0.01) (P = 0.02). DISCUSSION: Among primary care patients aged 50–75 years in an academic setting, mailed CRC outreach employing social psychology and behavioral economics principles led to a higher participation in CRC screening than usual care mailed outreach. TRANSLATIONAL IMPACT: Mailed interventions to increase CRC screening should incorporate social psychology and behavioral economics principles to improve participation.
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Doubeni CA, Selby K, Gupta S. Framework and Strategies to Eliminate Disparities in Colorectal Cancer Screening Outcomes. Annu Rev Med 2020; 72:383-398. [PMID: 33208026 DOI: 10.1146/annurev-med-051619-035840] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Preventable differences in colorectal cancer (CRC) mortality across racial/ethnic, economic, geographic, and other groups can be eliminated by assuring equitable access and quality across the care continuum, but few interventions have been demonstrated to do so. Multicomponent strategies designed with a health equity framework may be effective. A health equity framework takes into account social determinants of health, multilevel influences (policy, community, delivery, and individual levels), screening processes, and community engagement. Effective strategies for increasing screening uptake include patient navigation and other interventions for structural barriers, reminders and clinical decision support, and data to continuously track metrics and guide targets for improvement. Community resource gaps should be addressed to assure high-quality services irrespective of racial/ethnic and socioeconomic status. One model combinespopulation-based proactive outreach screening with screening delivery at in-person or virtual points of contact, as well as community engagement. Patient- and provider-based behavioral interventions may be considered for increasing screening demand and delivery. Providing a choice of screening tests is recommended for CRC screening, and access to colonoscopy is required for completion of the CRC screening process.
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Affiliation(s)
- Chyke A Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota 55905, USA; .,Department of Family Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
| | - Kevin Selby
- Center for Primary Care and Public Health (Unisanté), Lausanne 1011, Switzerland;
| | - Samir Gupta
- Section of Gastroenterology, Veterans Affairs San Diego Healthcare System, San Diego, California 92161, USA.,Department of Medicine, University of California at San Diego, La Jolla, California 92103, USA; .,Moores Cancer Center, University of California at San Diego, La Jolla, California 92103, USA
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24
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Levan ML, Waldram MM, DiBrito SR, Thomas AG, Al Ammary F, Ottman S, Bannon J, Brennan DC, Massie AB, Scalea J, Barth RN, Segev DL, Garonzik-Wang JM. Financial incentives versus standard of care to improve patient compliance with live kidney donor follow-up: protocol for a multi-center, parallel-group randomized controlled trial. BMC Nephrol 2020; 21:465. [PMID: 33167882 PMCID: PMC7654057 DOI: 10.1186/s12882-020-02117-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 10/21/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Live kidney donors (LKDs) account for nearly a third of kidney transplants in the United States. While donor nephrectomy poses minimal post-surgical risk, LKDs face an elevated adjusted risk of developing chronic diseases such as hypertension, diabetes, and end-stage renal disease. Routine screening presents an opportunity for the early detection and management of chronic conditions. Transplant hospital reporting requirements mandate the submission of laboratory and clinical data at 6-months, 1-year, and 2-years after kidney donation, but less than 50% of hospitals are able to comply. Strategies to increase patient engagement in follow-up efforts while minimizing administrative burden are needed. We seek to evaluate the effectiveness of using small financial incentives to promote patient compliance with LKD follow-up. METHODS/DESIGN We are conducting a two-arm randomized controlled trial (RCT) of patients who undergo live donor nephrectomy at The Johns Hopkins Hospital Comprehensive Transplant Center (MDJH) and the University of Maryland Medical Center Transplant Center (MDUM). Eligible donors will be recruited in-person at their first post-surgical clinic visit or over the phone. We will use block randomization to assign LKDs to the intervention ($25 gift card at each follow-up visit) or control arm (current standard of care). Follow-up compliance will be tracked over time. The primary outcome will be complete (all components addressed) and timely (60 days before or after expected visit date), submission of LKD follow-up data at required 6-month, 1-year, and 2-year time points. The secondary outcome will be transplant hospital-level compliance with federal reporting requirements at each visit. Rates will be compared between the two arms following the intention-to-treat principle. DISCUSSION Small financial incentivization might increase patient compliance in the context of LKD follow-up, without placing undue administrative burden on transplant providers. The findings of this RCT will inform potential center- and national-level initiatives to provide all LKDs with small financial incentives to promote engagement with post-donation monitoring efforts. TRIAL REGISTRATION ClinicalTrials.gov number: NCT03090646 Date of registration: March 2, 2017 Sponsors: Johns Hopkins University, University of Maryland Medical Center Funding: The Living Legacy Foundation of Maryland.
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Affiliation(s)
- Macey L. Levan
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD USA
| | - Madeleine M. Waldram
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Sandra R. DiBrito
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Alvin G. Thomas
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC USA
| | - Fawaz Al Ammary
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Shane Ottman
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Jaclyn Bannon
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Daniel C. Brennan
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
| | - Allan B. Massie
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD USA
| | - Joseph Scalea
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD USA
| | - Rolf N. Barth
- Division of Transplantation, University of Maryland School of Medicine, Baltimore, MD USA
| | - Dorry L. Segev
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, MD USA
- Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD USA
| | - Jacqueline M. Garonzik-Wang
- Department of Surgery, Division of Transplantation, Johns Hopkins University School of Medicine, 2000 E. Monument Street, Baltimore, MD 21205 USA
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25
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Mehta SJ, Oyalowo A, Reitz C, Dean O, McAuliffe T, Asch DA, Doubeni CA. Text messaging and lottery incentive to improve colorectal cancer screening outreach at a community health center: A randomized controlled trial. Prev Med Rep 2020; 19:101114. [PMID: 32477853 PMCID: PMC7251946 DOI: 10.1016/j.pmedr.2020.101114] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 04/28/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
Efforts to boost colorectal cancer (CRC) screening rates in underserved populations have been limited by effectiveness and scalability. We evaluate the impact of adding a lottery-based financial incentive to a text messaging program that asks patients to opt-in to receive mailed fecal immunochemical testing (FIT). This is a two-arm pragmatic randomized controlled trial at a community health center in Southwest Philadelphia from April to July 2017. We included CRC screening-eligible patients between ages 50-74 years who had a mobile phone, active health insurance, and at least one visit to the clinic in the past 12 months. Patients received a text message about CRC screening with the opportunity to opt-in to receive mailed FIT. They were randomized 1:1 to the following: (1) text messaging outreach alone (text), or (2) text messaging with lottery for a 1-in-5 chance of winning $100 after FIT completion (text + lottery). The primary outcome was the percentage of patients completing the mailed FIT within 3 months of initial outreach. 281 patients were included in the intent-to-treat analysis. The FIT completion rate was 12.1% (95% CI, 6.7%-17.5%) in the text message arm and 12.1% (95% CI, 6.7%-17.5%) in the lottery arm, with no statistical difference between arms. The majority of post-intervention interview respondents found text messaging to be acceptable and convenient. Opt-in text messaging is a feasible option to promote the uptake of mailed FIT screening, but the addition of a lottery-based incentive did not improve completion rates. Trial Registration: clinicaltrials.gov (NCT03072095).
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
| | - Akinbowale Oyalowo
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Owen Dean
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, United States
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, United States
- Center for Health Care Innovation, University of Pennsylvania, United States
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, United States
| | - Chyke A. Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, United States
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Soriano CT, McGarrity TJ, Zhu J, Loloi J, Peiffer LP, Cooper J. An Electronic Questionnaire to Survey Colorectal Cancer Screening Status and Identify High-Risk Cohorts in Large Health Care Organizations. Am J Med Qual 2020; 36:163-170. [PMID: 32605378 DOI: 10.1177/1062860620937236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Though improved screening practices have reduced the incidence and mortality of colorectal cancer (CRC), screening rates continue to be suboptimal. This is especially true of high-risk individuals, who are difficult for clinicians to identify during a typical health care encounter. The authors developed an electronic patient questionnaire that determined an individual's CRC screening status and identified high-risk individuals. The questionnaire was administered to employees through the Department of Human Resources. The response rate was 44.7%; 81.2% of respondents aged ≥50 years were up-to-date on CRC screening; 878 high-risk individuals were identified, 77.7% of whom were up-to-date on CRC screening. However, among high-risk individuals aged 40 to 49 years, only 45.8% reported up-to-date CRC screening. The questionnaire was effective in measuring CRC screening rates and identifying high-risk individuals. Dissemination by the Department of Human Resources was novel, effective, and was not dependent on a health care encounter to assess screening or high-risk status.
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Affiliation(s)
- Christopher T Soriano
- Penn State Milton S. Hershey Medical Center, Hershey, PA Penn State Cancer Institute, Hershey, PA Pennsylvania State University College of Medicine, Hershey, PA
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27
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Carethers JM, Doubeni CA. Causes of Socioeconomic Disparities in Colorectal Cancer and Intervention Framework and Strategies. Gastroenterology 2020; 158:354-367. [PMID: 31682851 PMCID: PMC6957741 DOI: 10.1053/j.gastro.2019.10.029] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 10/23/2019] [Accepted: 10/25/2019] [Indexed: 12/18/2022]
Abstract
Colorectal cancer (CRC) disproportionately affects people from low socioeconomic backgrounds and some racial minorities. Disparities in CRC incidence and outcomes might result from differences in exposure to risk factors such as unhealthy diet and sedentary lifestyle; limited access to risk-reducing behaviors such as chemoprevention, screening, and follow-up of abnormal test results; or lack of access to high-quality treatment resources. These factors operate at the individual, provider, health system, community, and policy levels to perpetuate CRC disparities. However, CRC disparities can be eliminated. Addressing the complex factors that contribute to development and progression of CRC with multicomponent, adaptive interventions, at multiple levels of the care continuum, can reduce gaps in mortality. These might be addressed with a combination of health care and community-based interventions and policy changes that promote healthy behaviors and ensure access to high-quality and effective measures for CRC prevention, diagnosis, and treatment. Improving resources and coordinating efforts in communities where people of low socioeconomic status live and work would increase access to evidence-based interventions. Research is also needed to understand the role and potential mechanisms by which factors in diet, intestinal microbiome, and/or inflammation contribute to differences in colorectal carcinogenesis. Studies of large cohorts with diverse populations are needed to identify epidemiologic and molecular factors that contribute to CRC development in different populations.
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Affiliation(s)
- John M Carethers
- Division of Gastroenterology, Department of Internal Medicine, Department of Human Genetics and Rogel Cancer Center, University of Michigan, Ann Arbor, Michigan.
| | - Chyke A Doubeni
- Center for Health Equity and Community Engagement Research, Mayo Clinic, Rochester, Minnesota; Department of Family Medicine, Mayo Clinic, Rochester, Minnesota
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28
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Ramai D, Shahnazarian V, Etienne D, Ayide G, Reddy M. Assessing urban minority attitudes for colorectal cancer screening using financial incentives. MINERVA GASTROENTERO 2019; 65:241-243. [PMID: 31617697 DOI: 10.23736/s1121-421x.19.02583-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Daryl Ramai
- Department of Medicine, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA -
| | - Vahe Shahnazarian
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA
| | - Denzil Etienne
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA
| | - Gloria Ayide
- Cancer Services Program of Brooklyn, New York, NY, USA
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York, NY, USA
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29
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Lieberman A, Gneezy A, Berry E, Miller S, Koch M, Ahn C, Balasubramanian BA, Argenbright KE, Gupta S. Financial Incentives to Promote Colorectal Cancer Screening: A Longitudinal Randomized Control Trial. Cancer Epidemiol Biomarkers Prev 2019; 28:1902-1908. [PMID: 31387970 DOI: 10.1158/1055-9965.epi-19-0039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/22/2019] [Accepted: 07/31/2019] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Financial incentives may improve health behaviors. We tested the impact of offering financial incentives for mailed fecal immunochemical test (FIT) completion annually for 3 years. METHODS Patients, ages 50 to 64 years, not up-to-date with screening were randomized to receive either a mailed FIT outreach (n = 6,565), outreach plus $5 (n = 1,000), or $10 (n = 1,000) incentive for completion. Patients who completed the test were reinvited using the same incentive the following year, for 3 years. In year 4, patients who returned the kit in all preceding 3 years were reinvited without incentives. Primary outcome was FIT completion among patients offered any incentive versus outreach alone each year. Secondary outcomes were FIT completion for groups offered $5 versus outreach alone, $10 versus outreach alone, and $5 versus $10. RESULTS Year 1 FIT completion was 36.9% with incentives versus 36.2% outreach alone (P = 0.59) and was not statistically different for $10 (34.6%; P = 0.31) or $5 (39.2%; P = 0.070) versus outreach alone. Year 2 completion was 61.6% with incentives versus 60.8% outreach alone (P = 0.75) and not statistically different for $10 or $5 versus outreach alone. Year 3 completion was 79.4% with incentives versus 74.8% outreach alone (P = 0.080), and was higher for $10 (82.4%) versus outreach alone (P = 0.033), but not for $5 versus outreach alone. Completion was similar across conditions in year 4 (no incentives). CONCLUSIONS Offering small incentives did not increase FIT completion relative to standard outreach. IMPACT This was the first longitudinal study testing the impact of repeated financial incentives, and their withdrawal, on FIT completion.
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Affiliation(s)
- Alicea Lieberman
- Rady School of Management, University of California San Diego, La Jolla, California
| | - Ayelet Gneezy
- Rady School of Management, University of California San Diego, La Jolla, California
| | - Emily Berry
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas
| | - Stacie Miller
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas
| | - Mark Koch
- Department of Family Medicine, John Peter Smith Health Network, Fort Worth, Texas
| | - Chul Ahn
- 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
| | - Bijal A Balasubramanian
- Department of Epidemiology, Genetics, & Environmental Science, UT Health School of Public Health, Dallas, Texas
| | - Keith E Argenbright
- University of Texas Southwestern Medical Center, Moncrief Cancer Institute, Fort Worth, Texas.,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
| | - Samir Gupta
- San Diego Veterans Affairs Healthcare System, San Diego, California. .,Department of Internal Medicine, Division of Gastroenterology, and the Moores Cancer Center, University of California San Diego, San Diego, California
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Mehta SJ, Induru V, Santos D, Reitz C, McAuliffe T, Orellana C, Volpp KG, Asch DA, Doubeni CA. Effect of Sequential or Active Choice for Colorectal Cancer Screening Outreach: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e1910305. [PMID: 31469393 PMCID: PMC6724166 DOI: 10.1001/jamanetworkopen.2019.10305] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/11/2019] [Indexed: 12/26/2022] Open
Abstract
Importance Colonoscopy and fecal immunochemical testing (FIT) are considered top-tier tests for colorectal cancer (CRC) screening. Behavioral economic insights about "choice architecture" suggest that participation could be influenced by how people are presented test options. Objective To investigate response rates for offering colonoscopy only compared with sequential choice (colonoscopy and then FIT) or active choice (colonoscopy or FIT) through mailed outreach. Design, Setting, and Participants Three-arm pragmatic randomized clinical trial conducted between November 14, 2017, and May 14, 2018. The setting was primary care practices at an academic health system. Patients aged 50 to 74 years with at least 2 primary care visits in the 2-year preenrollment period were included if they were eligible but not up to date on CRC screening. Interventions Eligible patients received mailed outreach about CRC screening. Equal numbers of eligible patients were randomly assigned to 3 outreach groups to receive mailings about CRC screening with the following options: (1) direct phone number to call for scheduling colonoscopy (colonoscopy only), (2) direct phone number to call for colonoscopy and a mailed FIT kit if no response within 4 weeks (sequential choice), or (3) direct phone number to call for colonoscopy and a mailed FIT kit offered at the same time (active choice). Main Outcomes and Measures The primary outcome was CRC screening completion (FIT or colonoscopy) within 4 months of initial outreach. The secondary outcomes were CRC screening completion within 6 months of outreach and the choice of colonoscopy as a screening test. Results In total, 438 patients were included in the intent-to-treat analysis, with a median age of 56 years (interquartile range, 52-63 years); 55.0% were women. At 4 months, the CRC screening completion rates were 14.4% (95% CI, 8.7%-20.1%) in the colonoscopy-only arm, 17.1% (95% CI, 11.0%-23.2%) in the sequential choice arm, and 19.9% (95% CI, 13.4%-26.4%) in the active choice arm. Neither choice arm achieved a screening rate statistically greater than that in the colonoscopy-alone arm. Among those who completed CRC screening at 4 months, 90.5% (95% CI, 78.0%-103.0%) chose colonoscopy in the colonoscopy-only arm, which was significantly higher than the 52.0% (95% CI, 32.4%-71.6%; P = .005) and 37.9% (95% CI, 20.2%-55.6%; P < .001) in the sequential choice and active choice arms, respectively. Conclusions and Relevance There was no significant increase in CRC screening when offering sequential or active choice, but there was a lower rate of colonoscopy in the choice arms than in the colonoscopy-only arm. Subtle changes in sequencing or defaults can alter patient decision making related to preventive health. Trial Registration ClinicalTrials.gov identifier: NCT03246438.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Vikranth Induru
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David Santos
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Charles Orellana
- Clinical Care Associates, University of Pennsylvania, Philadelphia
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Chyke A. Doubeni
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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31
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Green BB, Anderson ML, Cook AJ, Chubak J, Fuller S, Kimbel KJ, Kullgren JT, Meenan RT, Vernon SW. Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e196570. [PMID: 31276178 PMCID: PMC6789432 DOI: 10.1001/jamanetworkopen.2019.6570] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Importance Colorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups. Objective To examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates. Design, Setting, and Participants This parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled. Interventions Interventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion). Main Outcomes and Measures The primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures. Results A total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%-15.1%) in the mail and monetary group and 7.1% (95% CI, -0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%-64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, -0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03). Conclusions and Relevance Financial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups. Trial Registration ClinicalTrials.gov identifier: NCT00697047.
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Affiliation(s)
- Beverly B Green
- Kaiser Permanente Washington, Seattle
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | | | - Andrea J Cook
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Biostatistics, University of Washington School of Public Health, Seattle
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Family Medicine, University of Washington School of Medicine, Seattle
| | - Sharon Fuller
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Kilian J Kimbel
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jeffrey T Kullgren
- Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
| | - Richard T Meenan
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Sally W Vernon
- Department of Health Promotion and Behavior Sciences, University of Texas School of Public Health, Houston
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Nisa CF, Bélanger JJ, Schumpe BM. Parts greater than their sum: randomized controlled trial testing partitioned incentives to increase cancer screening. Ann N Y Acad Sci 2019; 1449:46-55. [PMID: 31111509 DOI: 10.1111/nyas.14115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 03/31/2019] [Accepted: 04/12/2019] [Indexed: 01/03/2023]
Abstract
Promoting healthy behavior is a challenge for public health officials, especially in the context of asking patients to participate in preventive cancer screenings. Small financial incentives are sometimes used, but there is a little scientific basis to support a compelling description of the best-practice implementation of such incentives. We present a simple behavioral strategy based on mental accounting from prospect theory that maximizes the impact of incentives with no additional cost. We show how the partition of one incentive into two smaller incentives of equivalent total amount produces substantial behavioral changes, demonstrated in the context of colorectal cancer screening. In a randomized controlled trial, eligible patients aged 50-74 (n = 1652 patients) were allocated to receive either one €10 incentive (upon completion of screening) or two €5 incentives (at the beginning and at the end of screening). We show that cancer screening rates were dramatically increased by partitioning the financial incentive (61.1%), compared with a single installment at the end (41.4%). These results support the hedonic editing hypothesis from prospect theory, and underline the importance of implementing theoretically grounded healthcare interventions. Our results suggest that, when patient incentives are feasible, healthcare procedures should be framed as multistage events with smaller incentives offered at multiple points in time.
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Affiliation(s)
- Claudia F Nisa
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jocelyn J Bélanger
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Birga M Schumpe
- Psychology Division, New York University Abu Dhabi, Abu Dhabi, United Arab Emirates
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Sarma EA, Silver MI, Kobrin SC, Marcus PM, Ferrer RA. Cancer screening: health impact, prevalence, correlates, and interventions. Psychol Health 2019; 34:1036-1072. [DOI: 10.1080/08870446.2019.1584673] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Elizabeth A. Sarma
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Michelle I. Silver
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Sarah C. Kobrin
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Pamela M. Marcus
- Healthcare Delivery Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
| | - Rebecca A. Ferrer
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA
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Mehta SJ, Pepe RS, Gabler NB, Kanneganti M, Reitz C, Saia C, Teel J, Asch DA, Volpp KG, Doubeni CA. Effect of Financial Incentives on Patient Use of Mailed Colorectal Cancer Screening Tests: A Randomized Clinical Trial. JAMA Netw Open 2019; 2:e191156. [PMID: 30901053 PMCID: PMC6583304 DOI: 10.1001/jamanetworkopen.2019.1156] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 02/03/2019] [Indexed: 12/26/2022] Open
Abstract
Importance Mailing fecal immunochemical test (FIT) kits to patients' homes has been shown to boost colorectal cancer screening rates, but response rates remain limited, and organized programs typically require repeated outreach attempts. Behavioral economics has shown that offering salient financial incentives to patients may increase participation in preventive health. Objective To compare the impact of different financial incentives for mailed FIT outreach. Design, Setting, and Participants This 4-parallel-arm randomized clinical trial included patients aged 50 to 75 years who had an established primary care clinician, at least 2 visits in the prior 2 years, and were eligible for colorectal cancer screening and not up-to-date. This study was conducted at urban primary care practices at an academic health system from December 2015 to February 2018. Data analysis was conducted from March 2018 to September 2018. Interventions Eligible patients received a letter from their primary care clinician that included a mailed FIT kit and instructions for use. They were randomized in a 1:1:1:1 ratio to receive (1) no financial incentive; (2) an unconditional $10 incentive included with the mailing; (3) a $10 incentive conditional on FIT completion; or (4) a conditional lottery with a 1-in-10 chance of winning $100 after FIT completion. Main Outcomes and Measures Fecal immunochemical test completion within 2 and 6 months of initial outreach. Results A total of 897 participants were randomized, with a median age of 57 years (interquartile range, 52-62 years); 56% were women, and 69% were black. The overall completion rate across all arms was 23.5% at 2 months. The completion rate at 2 months was 26.0% (95% CI, 20.4%-32.3%) in the no incentive arm, 27.2% (95% CI, 21.5%-33.6%) in the unconditional incentive arm, 23.2% (95% CI, 17.9%-29.3%) in the conditional incentive arm, and 17.7% (95% CI, 13.0%-23.3%) in the lottery incentive arm. None of the arms with an incentive were statistically superior to the arm without incentive. The overall FIT completion rate across all arms was 28.9% at 6 months, and there was also no difference by arm. The completion rate at 6 months was 32.7% (95% CI, 26.6%-39.3%) in the no incentive arm, 31.7% (95% CI, 25.7%-38.2%) in the unconditional incentive arm, 26.8% (95% CI, 21.1%-33.1%) in the conditional incentive arm, and 24.3% (95% CI, 18.9%-30.5%) in the lottery incentive arm. Conclusions and Relevance Mailed FIT resulted in high colorectal cancer screening response rates in this population, but different forms of financial incentives of the same expected value ($10) did not incrementally increase FIT completion rates. The incentive value may have been too small or financial incentives may not be effective in this context. Trial Registration ClinicalTrials.gov Identifier: NCT02594150.
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Affiliation(s)
- Shivan J. Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia
| | - Rebecca S. Pepe
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole B. Gabler
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mounika Kanneganti
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Chelsea Saia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Joseph Teel
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David A. Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Kevin G. Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Chyke A. Doubeni
- Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Mehta SJ, Khan T, Guerra C, Reitz C, McAuliffe T, Volpp KG, Asch DA, Doubeni CA. A Randomized Controlled Trial of Opt-in Versus Opt-Out Colorectal Cancer Screening Outreach. Am J Gastroenterol 2018; 113:1848-1854. [PMID: 29925915 PMCID: PMC6768589 DOI: 10.1038/s41395-018-0151-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/14/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES METHODS:: RESULTS:: Patients randomized to opt-in agreed to participate 23.1% of the time, and only 2.5% of those in opt-out chose not to participate. FIT kits were mailed to 22.4% and 93% of patients in opt-in and opt-out arms, respectively. In intention-to-screen analysis, patients in the opt-out arm had a higher FIT completion rate (29.1%) than in the opt-in arm (9.6%) (absolute difference 19.5%; 95% confidence interval, 10.9-27.9%; P < .001). Results were similar in subgroup analysis of those sent initial messaging through the EHR portal (9.5% opt-in versus 37.5% in opt-out). CONCLUSIONS .
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Affiliation(s)
- Shivan J Mehta
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Tanya Khan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Carmen Guerra
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Catherine Reitz
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Timothy McAuliffe
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Kevin G Volpp
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| | - Chyke A Doubeni
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Incentives and Behavioral Economics, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. Leonard and Madlyn Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA. Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
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Bakhai S, Ahluwalia G, Nallapeta N, Mangat A, Reynolds JL. Faecal immunochemical testing implementation to increase colorectal cancer screening in primary care. BMJ Open Qual 2018; 7:e000400. [PMID: 30397662 PMCID: PMC6203033 DOI: 10.1136/bmjoq-2018-000400] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 08/14/2018] [Accepted: 09/22/2018] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer (CRC) is the second leading cause of cancer death in USA, and CRC screening remains suboptimal. The aim of this quality improvement was to increase CRC screening in the internal medicine clinic (IMC) patients, between the ages of 50–75 years, from a baseline rate of 50%–70% over 12 months with the introduction of faecal immunochemical test (FIT) testing. We used the Plan–Do–Study–Act (PDSA) method and performed a root cause analysis to identify barriers to acceptance of CRC screening. The quality improvement team created a driver diagram to identify and prioritise change ideas. We developed a process flow map to optimise opportunities to improve CRC screening. We performed eight PDSA cycles. The major components of interventions included: (1) leveraging health information technology; (2) optimising team work, (3) education to patient, physicians and IMC staff, (4) use of patient navigator for tracking FIT completion and (5) interactive workshops for the staff and physicians to learn motivational interview techniques. The outcome measure included CRC screening rates with either FIT or colonoscopy. The process measures included FIT order and completion rates. Data were analysed using a statistical process control and run charts. Four hundred and seven patients visiting the IMC were offered FIT, and 252 (62%) completed the test. Twenty-two (8.7%) of patients were FIT positive, 14 of those (63.6%) underwent a subsequent diagnostic colonoscopy. We achieved 75% CRC screening with FIT or colonoscopy within 12 months and exceeded our goal. Successful strategies included engaging the leadership, the front-line staff and a highly effective multidisciplinary team. For average-risk patients, FIT was the preferred method of screening. We were able to sustain a CRC screening rate of 75% during the 6-month postproject period. Sustainable annual FIT is required for successful CRC screening.
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Affiliation(s)
- Smita Bakhai
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Gaurav Ahluwalia
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Naren Nallapeta
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Amanpreet Mangat
- Department of Internal Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
| | - Jessica L Reynolds
- Department of Medicine, University at Buffalo, The State University of New York, Buffalo, New York, USA
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A Multi-Level Fit-Based Quality Improvement Initiative to Improve Colorectal Cancer Screening in a Managed Care Population. Clin Transl Gastroenterol 2018; 9:177. [PMID: 30177700 PMCID: PMC6120887 DOI: 10.1038/s41424-018-0046-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 07/19/2018] [Indexed: 12/28/2022] Open
Abstract
Introduction Colorectal cancer (CRC) is a common but largely preventable disease with suboptimal screening rates despite national guidelines to screen individuals age 50–75. Single-component interventions aimed to improve screening uptake only modestly improve rates; data suggest that multi-modal approaches may be more effective. Methods We designed, implemented, and evaluated the impact of a multi-modal intervention on CRC screening uptake among unscreened patients in a large managed care population. Patient-level components included a mailed letter with education about screening options and pre-colonoscopy telephone counseling. For providers, we facilitated communication of screening test results and work-flow for abnormal results. System-level modifications included establishment of a patient navigator, expedited work-up for abnormal results, and stream-lined colonoscopy scheduling. We measured the rate of screening uptake overall, screening uptake by modality, change in the proportion of the population screened, and positive fecal immunochemical test (FIT) follow-up rates in the 1-year study period. Results There were 5093 patients in the intervention cohort. Of these, 33.2% participated in FIT or colonoscopy screening within 1 year of the mailing. A total of 1078 (21.2%) participants completed a FIT and 611 (12.0%) completed a screening colonoscopy. The screening rate in the managed care population increased from 65.1 to 76.6%. Fifty-nine patients (5.5%) had a positive FIT, of which 30 (50.8%) completed a diagnostic colonoscopy. Conclusion Multi-modal interventions can result in substantial improvement in CRC screening uptake in large and diverse managed care populations. Translational Impact Health systems should shift their focus from single-level to multi-level interventions when addressing barriers to CRC screening.
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