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Owens-Jasey C, Chen J, Xu R, Angier H, Huebschmann AG, Ito Fukunaga M, Chaiyachati KH, Rendle KA, Robien K, DiMartino L, Amante DJ, Faro JM, Kepper MM, Ramsey AT, Bressman E, Gold R. Implementation of Health IT for Cancer Screening in US Primary Care: Scoping Review. JMIR Cancer 2024; 10:e49002. [PMID: 38687595 PMCID: PMC11094604 DOI: 10.2196/49002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/29/2023] [Accepted: 03/04/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND A substantial percentage of the US population is not up to date on guideline-recommended cancer screenings. Identifying interventions that effectively improve screening rates would enhance the delivery of such screening. Interventions involving health IT (HIT) show promise, but much remains unknown about how HIT is optimized to support cancer screening in primary care. OBJECTIVE This scoping review aims to identify (1) HIT-based interventions that effectively support guideline concordance in breast, cervical, and colorectal cancer screening provision and follow-up in the primary care setting and (2) barriers or facilitators to the implementation of effective HIT in this setting. METHODS Following scoping review guidelines, we searched MEDLINE, CINAHL Plus, Web of Science, and IEEE Xplore databases for US-based studies from 2015 to 2021 that featured HIT targeting breast, colorectal, and cervical cancer screening in primary care. Studies were dual screened using a review criteria checklist. Data extraction was guided by the following implementation science frameworks: the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework; the Expert Recommendations for Implementing Change taxonomy; and implementation strategy reporting domains. It was also guided by the Integrated Technology Implementation Model that incorporates theories of both implementation science and technology adoption. Reporting was guided by PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). RESULTS A total of 101 studies met the inclusion criteria. Most studies (85/101, 84.2%) involved electronic health record-based HIT interventions. The most common HIT function was clinical decision support, primarily used for panel management or at the point of care. Most studies related to HIT targeting colorectal cancer screening (83/101, 82.2%), followed by studies related to breast cancer screening (28/101, 27.7%), and cervical cancer screening (19/101, 18.8%). Improvements in cancer screening were associated with HIT-based interventions in most studies (36/54, 67% of colorectal cancer-relevant studies; 9/14, 64% of breast cancer-relevant studies; and 7/10, 70% of cervical cancer-relevant studies). Most studies (79/101, 78.2%) reported on the reach of certain interventions, while 17.8% (18/101) of the included studies reported on the adoption or maintenance. Reported barriers and facilitators to HIT adoption primarily related to inner context factors of primary care settings (eg, staffing and organizational policies that support or hinder HIT adoption). Implementation strategies for HIT adoption were reported in 23.8% (24/101) of the included studies. CONCLUSIONS There are substantial evidence gaps regarding the effectiveness of HIT-based interventions, especially those targeting guideline-concordant breast and colorectal cancer screening in primary care. Even less is known about how to enhance the adoption of technologies that have been proven effective in supporting breast, colorectal, or cervical cancer screening. Research is needed to ensure that the potential benefits of effective HIT-based interventions equitably reach diverse primary care populations.
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Affiliation(s)
- Constance Owens-Jasey
- BRIDGE-C2 Implementation Science Center in Cancer Control, Oregon Health & Science University, Portland, OR, United States
- Department of Health Administration and Policy, College of Public Health, George Mason University, Fairfax, VA, United States
- OCHIN, Inc, Portland, OR, United States
| | - Jinying Chen
- Department of Preventive Medicine and Epidemiology, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
- Data Science Core, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, United States
- iDAPT Implementation Science Center for Cancer Control, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Ran Xu
- Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Amy G Huebschmann
- Adult and Child Center for Outcomes Research and Delivery Science, Ludeman Family Center for Women's Health Research, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - Mayuko Ito Fukunaga
- Department of Medicine, UMass Chan Medical School, Worcester, MA, United States
| | - Krisda H Chaiyachati
- Penn Implementation Science Center in Cancer Control, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
- Verily Life Sciences, South San Francisco, CA, United States
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
| | - Katharine A Rendle
- Penn Implementation Science Center in Cancer Control, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kim Robien
- Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Lisa DiMartino
- RTI International, Research Triangle Park, NC, United States
- UT Southwestern Medical Center, University of Texas, Dallas, TX, United States
| | - Daniel J Amante
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, United States
| | - Jamie M Faro
- Department of Population and Quantitative Health Sciences, UMass Chan Medical School, Worcester, MA, United States
| | - Maura M Kepper
- Brown School, Washington University, St. Louis, MO, United States
| | - Alex T Ramsey
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, United States
| | - Eric Bressman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rachel Gold
- BRIDGE-C2 Implementation Science Center in Cancer Control, Oregon Health & Science University, Portland, OR, United States
- OCHIN, Inc, Portland, OR, United States
- Kaiser Permanente Center for Health Research, Portland, OR, United States
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2
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Atlas SJ, Tosteson ANA, Wright A, Orav EJ, Burdick TE, Zhao W, Hort SJ, Wint AJ, Smith RE, Chang FY, Aman DG, Thillaiyapillai M, Diamond CJ, Zhou L, Haas JS. A Multilevel Primary Care Intervention to Improve Follow-Up of Overdue Abnormal Cancer Screening Test Results: A Cluster Randomized Clinical Trial. JAMA 2023; 330:1348-1358. [PMID: 37815566 PMCID: PMC10565610 DOI: 10.1001/jama.2023.18755] [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: 04/19/2023] [Accepted: 08/31/2023] [Indexed: 10/11/2023]
Abstract
Importance Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results. Objective To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results. Design, Setting, and Participants Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021. Intervention Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment. Main Outcomes and Measures The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk. Results Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result. Conclusions and Relevance A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer. Trial Registration ClinicalTrials.gov Identifier: NCT03979495.
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Affiliation(s)
- Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Anna N. A. Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth Health and Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Timothy E. Burdick
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
- Department of Biomedical Data Science, Dartmouth Health, Lebanon, New Hampshire
| | - Wenyan Zhao
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Shoshana J. Hort
- Department of Medicine, Dartmouth Health, Lebanon, New Hampshire
- SYNERGY Research Informatics, Dartmouth Health, Lebanon, New Hampshire
| | - Amy J. Wint
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Rebecca E. Smith
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Frank Y. Chang
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - David G. Aman
- Research Computing, Dartmouth College, Lebanon, New Hampshire
| | | | - Courtney J. Diamond
- Department of Biomedical Informatics, Irving Medical Center, Columbia University, New York, New York
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer S. Haas
- Division of General Internal Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
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Schoenborn NL, Pollack CE, Boyd CM. When should electronic medical records reminders for cancer screening stop?-Results from a national physician survey. J Am Geriatr Soc 2023; 71:2878-2885. [PMID: 37224393 DOI: 10.1111/jgs.18412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/12/2023] [Accepted: 04/20/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Many older adults are screened for breast and colorectal cancers beyond guideline recommended thresholds. Electronic medical record (EMR) reminders are commonly used to prompt cancer screening. Behavioral economics theory suggests that changing the default settings for these reminders can be effective to reduce over-screening. We examined physician perspectives about acceptable thresholds for stopping EMR cancer screening reminders. METHODS In a national survey of 1200 primary care physicians (PCP) and 600 gynecologists randomly selected from the AMA Masterfile, we asked physicians to choose whether EMR reminders for cancer screening should stop based on a list of criteria that included age, life expectancy, specific serious illnesses, and functional limitations. Physicians could choose multiple responses. PCPs were randomized to questions about breast or colorectal cancer screening. RESULTS A total of 592 physicians participated (adjusted response rate 54.1%). 54.6% chose age and 71.8% chose life expectancy as criteria for stopping EMR reminders; only 30.6% chose functional limitations. Regarding age thresholds, 52.4% chose ages ≤75, 42.0% chose a threshold between 75 and 85, 5.6% would not stop reminders even at age 85. Regarding life expectancy thresholds, 32.0% chose ≥10 years, 53.1% chose a threshold between 5 and 9 years, 14.9% would not stop reminders even when life expectancy is <5 years. CONCLUSIONS We found that many physicians would continue EMR reminders for cancer screening even in light of older age, limited life expectancy, and functional limitations. This may reflect reluctance to stop cancer screening and/or reluctance to stop EMR reminders so that physicians can retain control to decide for individual patients, for example, to assess patient preference and ability to tolerate treatment. There was consensus for stopping EMR reminders at ages 85+ and <5-year life expectancy. Interventions that seek to reduce over-screening by suppressing EMR reminders may be important for these groups but may have limited physician buy-in outside these thresholds.
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Affiliation(s)
- Nancy L Schoenborn
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Craig E Pollack
- School of Public Health, Department of Health Policy and Management, Johns Hopkins University Bloomberg, Baltimore, Maryland, USA
| | - Cynthia M Boyd
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Xu WY, Raver E, Jung J, Li Y, Thai G, Lee S. Rural-urban disparities in preventive breast and cervical cancer screening among women with early-onset dementia. BMC Womens Health 2023; 23:255. [PMID: 37170251 PMCID: PMC10176945 DOI: 10.1186/s12905-023-02301-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/22/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND The early onset of Alzheimer's disease and related dementias (ADRD) before age 65 can introduce life and health care complications. Preserving an early-onset ADRD patient's daily functioning longer and delaying declines in health from non-ADRD conditions become important preventive goals. This study examined the differences in utilization of preventive cancer screenings between patients with and without early-onset ADRD, and compared utilization of the screenings in rural versus urban areas among women with early-onset ADRD in the United States. METHODS We conducted a cross-sectional study of women aged 40 to 64 years eligible for mammogram and cervical cancer screenings using commercial insurance claims from 2012 to 2018. We measured the use of biennial mammogram among women 50 to 64 years old, and the use of triennial Pap smear test among women 40 to 64 years old. We used inverse probability weighted logistic regressions to estimate the odds of receiving preventive cancer screenings by the presence of early-onset ADRD or cognitive impairments (CI). We used multivariable logistic regressions to estimate the odds of receiving preventive cancer screenings by rural or urban residence among women with early-onset ADRD/CI. RESULTS Among 6,349,308 women in the breast cancer screening sample (mean [SD] age, 56.52 [4.03] years), 36,131 had early-onset ADRD/CI (mean [SD] age, 57.99 [3.98] years). Among 6,583,088 women in the cervical cancer screening sample (mean [SD] age, 52.37 [6.81] years), 30,919 had early-onset ADRD/CI (mean [SD] age, 55.79 [6.22] years). Having early-onset ADRD/CI was associated with lower utilization of mammogram (OR: 0.92, 95% CI: 0.90-0.95). No significant difference was observed in Pap smear screening (OR: 0.99, 95% CI: 0.96-1.02) between patients with and without early-onset ADRD/CI. Among patients with early-onset ADRD/CI, those in rural areas were less likely than those in urban areas to have mammograms (OR: 0.91, 95% CI: 0.85-0.97) and Pap smears (OR: 0.65, 95% CI: 0.61-0.71). CONCLUSIONS The observed pattern of rural-urban differences in cancer screening in our study emphasizes the need for efforts to promote evidence-based, individualized decision-making processes in the early-onset ADRD population.
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Affiliation(s)
- Wendy Y Xu
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave., 200-D Cunz Hall, Columbus, OH, 43210, USA.
| | - Eli Raver
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave., 200-D Cunz Hall, Columbus, OH, 43210, USA
| | - Jeah Jung
- Department of Health Administration and Policy, College of Public Health, George Mason University, Fairfax, USA
| | - Yiting Li
- Division of Health Services Management and Policy, College of Public Health, The Ohio State University, 1841 Neil Ave., 200-D Cunz Hall, Columbus, OH, 43210, USA
| | - Gaby Thai
- Department of Neurology, School of Medicine, University of California, Irvine, USA
| | - Sunmin Lee
- Department of Medicine, School of Medicine & Chao Family Comprehensive Cancer Center, University of California, Irvine, USA
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Martinez MC, Stults CD, Li J. Provider and patient perspectives to improve lung cancer screening with low-dose computed tomography 5 years after Medicare coverage: a qualitative study. BMC PRIMARY CARE 2022; 23:332. [PMID: 36539693 PMCID: PMC9768892 DOI: 10.1186/s12875-022-01925-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022]
Abstract
Lung cancer remains the leading cause of cancer-related deaths for both men and women in the U.S., yet uptake of preventive cancer screening for people with a heavy smoking history remains low. This qualitative interview study of patients and providers from a large ambulatory healthcare system in northern and central California reevaluated perceptions of lung cancer screening with low-dose computed tomography (LCS-LDCT) 5 years after Medicare coverage. We hypothesized that initial attitudes and barriers within the LCS-LDCT discussion and process have likely persisted with little change since Medicare coverage and we sought to understand how these attitudes continue to impact effective implementation and uptake of screening with the goal of identifying opportunities for improvement. Between 2019 and 2020, interviews were conducted with 10 primary care physicians and 30 patients using semi-structured interview guides. Providers and patients expressed that they were both aware and supportive of LCS-LDCT, a change from earlier studies, but continued to report little to no shared decision making nor use of a decision aid despite being Medicare requirements. Creation and incorporation of a single-page, graphic heavy decision aid may help address many of the persistent barriers around implementation for both providers and patients. Given recently expanded guidelines from the U.S. Preventive Services Task Force for LCS-LDCT screening and their coverage by Medicare, it is important for healthcare systems to understand provider and patient perceptions to further improve the implementation of LCS-LDCT to ultimately reduce lung cancer mortality.
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Affiliation(s)
- Meghan C. Martinez
- grid.416759.80000 0004 0460 3124Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, 795 El Camino Real, Ames Building, Palo Alto, CA 94301 USA
| | - Cheryl D. Stults
- grid.416759.80000 0004 0460 3124Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, 795 El Camino Real, Ames Building, Palo Alto, CA 94301 USA
| | - Jiang Li
- grid.416759.80000 0004 0460 3124Center for Health Systems Research, Palo Alto Medical Foundation Research Institute, Sutter Health, 795 El Camino Real, Ames Building, Palo Alto, CA 94301 USA
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Atlas SJ, Tosteson ANA, Burdick TE, Wright A, Breslau ES, Dang TH, Wint AJ, Smith RE, Harris KA, Zhou L, Haas JS. Primary Care Practitioner Perceptions on the Follow-up of Abnormal Cancer Screening Test Results. JAMA Netw Open 2022; 5:e2234194. [PMID: 36173627 PMCID: PMC9523497 DOI: 10.1001/jamanetworkopen.2022.34194] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/12/2022] [Indexed: 01/12/2023] Open
Abstract
Importance Health care systems focus on delivering routine cancer screening to eligible individuals, yet little is known about the perceptions of primary care practitioners (PCPs) about barriers to timely follow-up of abnormal results. Objective To describe PCP perceptions about factors associated with the follow-up of abnormal breast, cervical, colorectal, and lung cancer screening test results. Design, Setting, and Participants Survey study of PCPs from 3 primary care practice networks in New England between February and October 2020, prior to participating in a randomized clinical trial to improve follow-up of abnormal cancer screening test results. Participants were physicians and advanced practice clinicians from participating practices. Main Outcomes and Measures Self-reported process, attitudes, knowledge, and satisfaction about the follow-up of abnormal cancer screening test results. Results Overall, 275 (56.7%) PCPs completed the survey (range by site, 34.9%-71.9%) with more female PCPs (61.8% [170 of 275]) and general internists (73.1% [201 of 275]); overall, 28,7% (79 of 275) were aged 40 to 49 years. Most PCPs felt responsible for managing abnormal cancer screening test results with the specific cancer type being the best factor (range, 63.6% [175 of 275] for breast to 81.1% [223 of 275] for lung; P < .001). The PCPs reported limited support for following up on overdue abnormal cancer screening test results. Standard processes such as automated reports, reminder letters, or outreach workers were infrequently reported. Major barriers to follow-up of abnormal cancer screening test results across all cancer types included limited electronic health record tools (range, 28.5% [75 of 263]-36.5%[96 of 263]), whereas 50% of PCPs felt that there were major social barriers to receiving care for abnormal cancer screening test results for colorectal cancer. Fewer than half reported being very satisfied with the process of managing abnormal cancer screening test results, with satisfaction being greatest for breast cancer (46.9% [127 of 271]) and lowest for cervical (21.8% [59 of 271]) and lung cancer (22.4% [60 of 268]). Conclusions and Relevance In this survey study of PCPs, important deficiencies in systems for managing abnormal cancer screening test results were reported. These findings suggest a need for comprehensive organ-agnostic systems to promote timely follow-up of abnormal cancer screening results using a primary care-focused approach across the range of cancer screening tests.
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Affiliation(s)
- Steven J. Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Anna N. A. Tosteson
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
- Dartmouth Cancer Center, Dartmouth Health and Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Timothy E. Burdick
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
- Department of Community and Family Medicine, Dartmouth Health, Lebanon, New Hampshire
| | - Adam Wright
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erica S. Breslau
- Division of Cancer Prevention and Control, National Cancer Institute, Rockville, Maryland
| | - Tin H. Dang
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amy J. Wint
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Rebecca E. Smith
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Kimberly A. Harris
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Li Zhou
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer S. Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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Geographic distribution of colonoscopy providers in the United States: An analysis of medicare claims data. Surg Endosc 2022; 36:7673-7678. [PMID: 35729404 DOI: 10.1007/s00464-022-09083-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 01/25/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Screening colonoscopy is one of the few procedures that can prevent cancer. While the majority of colonoscopies in the USA are performed by gastroenterologists, general surgeons play a key role in at-risk, rural populations. The aim of this study was to examine geographic practice patterns in colonoscopy using a nationwide Medicare claims database. METHODS AND PROCEDURES The 2017 Medicare Provider Utilization and Payment database was used to identify physicians performing colonoscopy. Providers were classified as gastroenterologists, surgeons, ambulatory surgical centers (ASCs), or other. Rural-Urban Commuting Area classification at the zip code level was used to determine whether the practice location for an individual provider was in a rural area/small town (< 10,000 people), micropolitan area (10-50,000 people), or metropolitan area (> 50,000 people). RESULTS Claims data from 3,861,187 colonoscopy procedures on Medicare patients were included. The majority of procedures were performed by gastroenterologists (57.2%) and ASCs (32.1%). Surgeons performed 6.8% of cases overall. When examined at a zip code level, surgeons performed 51.6% of procedures in small towns/rural areas and 21.7% of procedures in micropolitan areas. Individual surgeons performed fewer annual procedures as compared to gastroenterologists (median 51 vs. 187, p < 0.001). CONCLUSIONS Surgeons perform the majority of colonoscopies in rural zip codes on Medicare patients. High-quality, surgical training in endoscopy is essential to ensure access to colonoscopy for patients outside of major metropolitan areas.
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Thiel de Bocanegra H, Dehlendorf C, Kuppermann M, Vangala SS, Moscicki AB. Impact of an educational tool on young women's knowledge of cervical cancer screening recommendations. Cancer Causes Control 2022; 33:813-821. [PMID: 35312891 PMCID: PMC9085671 DOI: 10.1007/s10552-022-01569-8] [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: 10/10/2020] [Accepted: 03/03/2022] [Indexed: 10/27/2022]
Abstract
PURPOSE Current cervical cancer screening guidelines recommend 3-year screening intervals, in contrast to the previous recommendation of annual screening, to prevent over screening and overtreatment. We evaluated the impact of viewing a tablet-based educational tool prior to seeing a clinician on young women's knowledge and understanding of cervical cancer screening, HPV vaccination follow-up of abnormal pap smears, and comfort in communicating with their providers. METHODS This cross-sectional study was part of a cluster-randomized study of fourteen primary care clinics from January 2015 to December 2016. We developed the cervical cancer education tool in English and Spanish using a community-based approach that included formative work and cognitive interviewing. Clinics were randomized to use the intervention (tablet-based patient education tool) or to participate as a control group. We administered surveys to a convenience sample of 229 English- or Spanish-speaking women aged 19 to 35 years in these clinics. We used descriptive analyses and logistic regression models with cluster-robust standard errors to compare differences among the two groups. RESULTS Compared to women seen in control clinics, women seen in intervention clinics demonstrated greater knowledge regarding human papilloma virus (HPV (p = 0.004) and understanding (p < 0.001) of cervical cancer screening. Comfort in communicating with providers was not statistically different (p = 0.053). Women in the intervention group felt that the tool helped them understand that an abnormal Pap smear does not require immediate treatment (61.5%). CONCLUSION Innovative online patient education that is offered prior to patients' interaction with their clinicians can improve their knowledge about cervical cancer prevention and treatment.
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Affiliation(s)
- Heike Thiel de Bocanegra
- Department of Obstetrics and Gynecology, School of Medicine, University of California, Irvine, 333 City Boulevard West, Suite 1400, Orange, CA, 92868, USA.
| | - Christine Dehlendorf
- Department of Family & Community Medicine, School of Medicine, University of California, San Francisco, San Francisco, USA.,Department of Obstetrics, Gynecology & Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, USA.,Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, USA
| | - Miriam Kuppermann
- Department of Obstetrics, Gynecology & Reproductive Sciences, School of Medicine, University of California, San Francisco, San Francisco, USA.,Department of Epidemiology & Biostatistics, School of Medicine, University of California, San Francisco, San Francisco, USA
| | - Sitaram S Vangala
- Department of Medicine Statistics Core, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Anna-Barbara Moscicki
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
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Maxwell AE, DeGroff A, Hohl SD, Sharma KP, Sun J, Escoffery C, Hannon PA. Evaluating Uptake of Evidence-Based Interventions in 355 Clinics Partnering With the Colorectal Cancer Control Program, 2015-2018. Prev Chronic Dis 2022; 19:E26. [PMID: 35588522 PMCID: PMC9165474 DOI: 10.5888/pcd19.210258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE AND OBJECTIVES Colorectal cancer screening rates remain suboptimal in the US. The Colorectal Cancer Control Program (CRCCP) of the Centers for Disease Control and Prevention (CDC) seeks to increase screening in health system clinics through implementation of evidence-based interventions (EBIs) and supporting activities (SAs). This program provided an opportunity to assess the uptake of EBIs and SAs in 355 clinics that participated from 2015 to 2018. INTERVENTION APPROACH The 30 funded awardees of CRCCP partnered with clinics to implement at least 2 of 4 EBIs that CDC prioritized (patient reminders, provider reminders, reducing structural barriers, provider assessment and feedback) and 4 optional strategies that CDC identified as SAs (small media, professional development and provider education, patient navigation, and community health workers). EVALUATION METHODS Clinics completed 3 annual surveys to report uptake, implementation, and integration and perceived sustainability of the priority EBIs and SAs. RESULTS In our sample of 355 clinics, uptake of 4 EBIs and 2 SAs significantly increased over time. By year 3, 82% of clinics implemented patient reminder systems, 88% implemented provider reminder systems, 82% implemented provider assessment and feedback, 76% implemented activities to reduce structural barriers, 51% implemented provider education, and 84% used small media. Most clinics that implemented these strategies (>90%) considered them fully integrated into the health system or clinic operations and sustainable by year 3. Fewer clinics used patient navigation (30%) and community health workers (19%), with no increase over the years of the study. IMPLICATIONS FOR PUBLIC HEALTH Clinics participating in the CRCCP reported high uptake and perceived sustainability of EBIs that can be integrated into electronic medical record systems but limited uptake of patient navigation and community health workers, which are uniquely suited to reduce cancer disparities. Future research should determine how to promote uptake and assess cost-effectiveness of CRCCP interventions.
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Affiliation(s)
- Annette E Maxwell
- University of California Los Angeles, Los Angeles, California.,Department of Health Policy and Management, University of California, Los Angeles, 650 Charles Young Dr South, A2-125 CHS, Box 956900, Los Angeles, CA 90095-6900. E-mail:
| | - Amy DeGroff
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | | | - Juzhong Sun
- Centers for Disease Control and Prevention, Atlanta, Georgia
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10
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Haas JS, Cheng D, Yu L, Atlas SJ, Clark C, Feldman S, Silver MI, Kamineni A, Chubak J, Pocobelli G, Tiro JA, Kobrin SC. Variation in the receipt of human papilloma virus co-testing for cervical screening: Individual, provider, facility and healthcare system characteristics. Prev Med 2022; 154:106871. [PMID: 34762966 PMCID: PMC8724456 DOI: 10.1016/j.ypmed.2021.106871] [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] [Received: 06/19/2021] [Revised: 10/18/2021] [Accepted: 11/04/2021] [Indexed: 01/03/2023]
Abstract
Since 2012, cervical cancer screening guidelines allow for choice of screening test for women age 30-65 years (i.e., Pap every 3 years or Pap with human papillomavirus co-testing every 5 years). Intended to give patients and providers options, this flexibility reflects a trend in the growing complexity of screening guidelines. Our objective was to characterize variation in cervical screening at the individual, provider, clinic/facility, and healthcare system levels. The analysis included 296,924 individuals receiving screening from 3626 providers at 136 clinics/facilities in three healthcare systems, 2010 to 2017. Main outcome was receipt of co-testing vs. Pap alone. Co-testing was more common in one healthcare system before the 2012 guidelines (adjusted odds ratio (AOR) of co-testing at the other systems relative to this system 0.00 and 0.50) but was increasingly implemented over time in a second with declining uptake in the third (2017: AORs shifted to 7.32 and 0.01). Despite system-level differences, there was greater heterogeneity in receipt of co-testing associated with providers than clinics/facilities. In the three healthcare systems, providers in the highest quartile of co-testing use had an 8.35, 8.81, and 25.05-times greater odds of providing a co-test to women with the same characteristics relative to the lowest quartile. Similarly, clinics/ facilities in the highest quartile of co-testing use had a 4.20, 3.14, and 6.56-times greater odds of providing a co-test relative to the lowest quartile. Variation in screening test use is associated with health system, provider, and clinic/facility levels even after accounting for patient characteristics.
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Affiliation(s)
- Jennifer S Haas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David Cheng
- Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Liyang Yu
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Steven J Atlas
- Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Cheryl Clark
- Division of General Internal Medicine & Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Sarah Feldman
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Michelle I Silver
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, Saint Louis, MO, United States of America
| | - Aruna Kamineni
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Jessica Chubak
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Gaia Pocobelli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States of America
| | - Jasmin A Tiro
- Department of Population & Data Sciences and Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Sarah C Kobrin
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, United States of America
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11
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Austin JD, Agovino M, Rodriguez CB, Terry MB, Shelton RC, Wei Y, Desperito E, Schmitt KM, Kukafka R, Tehranifar P. Breast Density Awareness and Knowledge in a Mammography Screening Cohort of Predominantly Hispanic Women: Does Breast Density Notification Matter? Cancer Epidemiol Biomarkers Prev 2021; 30:1913-1920. [PMID: 34348958 DOI: 10.1158/1055-9965.epi-21-0172] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/10/2021] [Accepted: 07/29/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND New York State law mandates that women with dense breasts receive a written notification of their breast density (BD) and its implications, but data on the impact of dense breast notification (DBN) on BD awareness and knowledge in diverse populations remain limited. METHODS Between 2016 and 2018, we collected survey and mammographic data from 666 women undergoing screening mammography in New York City (ages 40-60, 80% Hispanic, 69% Spanish-speaking) to examine the impact of prior DBN on BD awareness by sociodemographic and breast cancer risk factors, and describe BD knowledge by sources of information. RESULTS Only 24.8% of the overall sample and 34.9% of women receiving DBN had BD awareness. In multivariable models adjusting for DBN, awareness was significantly lower in women who were Spanish-speaking [OR, 0.16; 95% confidence interval (CI), 0.09-0.30 vs. English speakers], were foreign-born (OR, 0.31; 95% CI, 0.16-0.58 vs. U.S.-born), and had lower educational attainment (e.g., high school degree or less; OR, 0.14; 95% CI, 0.08-0.26 vs. college or higher degree). Women receiving DBN were more likely to be aware of BD (OR, 2.61; 95% CI, 1.59-4.27) but not more knowledgeable about the impact of BD on breast cancer risk and detection. However, women reporting additional communication about their BD showed greater knowledge in these areas. CONCLUSIONS DBN increases BD awareness disproportionately across sociodemographic groups. IMPACT Efforts to improve communication of DBN must focus on addressing barriers in lower socioeconomic and racially and ethnically diverse women, including educational and language barriers.
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Affiliation(s)
- Jessica D Austin
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York
| | - Mariangela Agovino
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Carmen B Rodriguez
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Mary Beth Terry
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Rachel C Shelton
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
| | - Ying Wei
- Department of Biostatistics, Columbia University Mailman School of Public Health, New York, New York
| | - Elise Desperito
- Department of Radiology, Columbia University Irving Medical Center, New York, New York
| | - Karen M Schmitt
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Division of Academics, Columbia University School of Nursing, New York, New York
| | - Rita Kukafka
- Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, New York.,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York.,Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Parisa Tehranifar
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York. .,Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, New York
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12
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Pengpid S, Zhang C, Peltzer K. The Prevalence and Associated Factors of Cancer Screening Uptake Among a National Population-Based Sample of Adults in Marshall Islands. Cancer Control 2021; 28:1073274821997497. [PMID: 33890501 PMCID: PMC8204481 DOI: 10.1177/1073274821997497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: The study aimed to estimate the prevalence and associated factors of cancer screening among men and women in the general population in Marshall Islands. Methods: The national cross-sectional sub-study population consisted of 2,813 persons aged 21-75 years (Median = 37.4 years) from the “2017/2018 Marshall Islands STEPS survey”. Information about cancer screening uptake included Pap smear or Vaginal Inspection with Acetic Acid (=VIA), clinical breast examination, mammography, faecal occult blood test (FOBT), and colonoscopy. Results: The prevalence of past 2 years mammography screening was 21.7% among women aged 50-74 years, past year CBE 15.9% among women aged 40 years and older, past 3 years Pap smear or VIA 32.6% among women 21-65 years, past year FOBT 21.8% among women and 22.3% among men aged 50-75 years, and past 10 years colonoscopy 9.1% among women and 7.3% among men aged 50-75 years. In adjusted logistic regression, cholesterol screening (AOR: 1.91, 95% CI: 1.07-3.41) was associated with past 2 years mammography screening among women aged 50-74 years. Blood pressure screening (AOR: 2.39, 95% CI: 1.71-3.35), glucose screening (AOR: 1.59, 95% CI: 1.13-2.23), dental visit in the past year (AOR: 1.51, 95% CI: 1.17, 1.96), binge drinking (AOR: 1.88, 95% CI: 1.07-3.30), and 2-3 servings of fruit and vegetable consumption a day (AOR: 1.42, 95% CI: 1.03-1.95) were positively and high physical activity (30 days a month) (AOR: 0.56, 95% CI: 0.41-0.76) was negatively associated with Pap smear or VIA screening among women aged 21-65 years. Higher education (AOR: 2.58, 95% CI: 1.02-6.58), and cholesterol screening (AOR: 2.87, 95% CI: 1.48-5.59), were positively and current smoking (AOR: 0.09, 95% CI: 0.01-0.65) was negatively associated with past 10 years colonoscopy uptake among 50-75 year-olds. Conclusion: The study showed a low cancer screening uptake, and several factors were identified that can assist in promoting cancer screening in Marshall Islands.
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Affiliation(s)
- Supa Pengpid
- ASEAN Institute for Health Development, 26685Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand
| | - Chao Zhang
- Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa.,Department of Bone and Soft Tissue Tumors, 74675Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Karl Peltzer
- Department of Psychology, 37702University of the Free State, Bloemfontein, South Africa
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13
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Disparities in cancer screening in people with mental illness across the world versus the general population: prevalence and comparative meta-analysis including 4 717 839 people. Lancet Psychiatry 2020; 7:52-63. [PMID: 31787585 DOI: 10.1016/s2215-0366(19)30414-6] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 10/03/2019] [Accepted: 10/03/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Since people with mental illness are more likely to die from cancer, we assessed whether people with mental illness undergo less cancer screening compared with the general population. METHODS In this systematic review and meta-analysis, we searched PubMed and PsycINFO, without a language restriction, and hand-searched the reference lists of included studies and previous reviews for observational studies from database inception until May 5, 2019. We included all published studies focusing on any type of cancer screening in patients with mental illness; and studies that reported prevalence of cancer screening in patients, or comparative measures between patients and the general population. The primary outcome was odds ratio (OR) of cancer screening in people with mental illness versus the general population. The Newcastle-Ottawa Scale was used to assess study quality and I2 to assess study heterogeneity. This study is registered with PROSPERO, CRD42018114781. FINDINGS 47 publications provided data from 46 samples including 4 717 839 individuals (501 559 patients with mental illness, and 4 216 280 controls), of whom 69·85% were women, for screening for breast cancer (k=35; 296 699 individuals with mental illness, 1 023 288 in the general population), cervical cancer (k=29; 295 688 with mental illness, 3 540 408 in general population), colorectal cancer (k=12; 153 283 with mental illness, 2 228 966 in general population), lung and gastric cancer (both k=1; 420 with mental illness, none in general population), ovarian cancer (k=1; 37 with mental illness, none in general population), and prostate cancer (k=6; 52 803 with mental illness, 2 038 916 in general population). Median quality of the included studies was high at 7 (IQR 6-8). Screening was significantly less frequent in people with any mental disease compared with the general population for any cancer (k=37; OR 0·76 [95% CI 0·72-0·79]; I2=98·53% with publication bias of Egger's p value=0·025), breast cancer (k=27; 0·65 [0·60-0·71]; I2=97·58% and no publication bias), cervical cancer (k=23; 0·89 [0·84-0·95]; I2=98·47% and no publication bias), and prostate cancer (k=4; 0·78 [0·70-0·86]; I2=79·68% and no publication bias), but not for colorectal cancer (k=8; 1·02 [0·90-1·15]; I2=97·84% and no publication bias). INTERPRETATION Despite the increased mortality from cancer in people with mental illness, this population receives less cancer screening compared with that of the general population. Specific approaches should be developed to assist people with mental illness to undergo appropriate cancer screening, especially women with schizophrenia. FUNDING None.
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14
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Puzhko S, Gagnon J, Simard J, Knoppers BM, Siedlikowski S, Bartlett G. Health professionals' perspectives on breast cancer risk stratification: understanding evaluation of risk versus screening for disease. Public Health Rev 2019; 40:2. [PMID: 30858992 PMCID: PMC6394012 DOI: 10.1186/s40985-019-0111-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 02/12/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Younger women at higher-than-population-average risk for breast cancer may benefit from starting screening earlier than presently recommended by the guidelines. The Personalized Risk Stratification for Prevention and Early Detection of Breast Cancer (PERSPECTIVE) approach aims to improve the prevention of breast cancer through differential screening recommendations based on a personal risk estimate. In our study, we used deliberative stakeholder consultations to engage health professionals in an in-depth dialog to explore the feasibility of the proposed implementation strategies for this new personalized breast cancer screening approach. METHODS Deliberative stakeholder consultation is a qualitative descriptive study design used to engage health professionals in the discussion, while the mediators play a more passive role. A purposeful sample of 11 health professionals (family physicians and genetic counselors) working in Montreal was used. The deliberations were organized in two phases, including small group deliberations according to the deliberants' health profession and a mixed group deliberation combining participants from the small groups. Inductive thematic content analysis was performed on the transcripts by two coders to create the deliberative and analytic outputs. Quality of deliberations was assessed quantitatively using the de Vries method and qualitatively using participant observation. RESULTS One of our key findings was that health professionals lacked understanding of the two steps of the screening approach: risk stratification "screening," which is an evaluation for the level of risk and screening for disease. As part of this confusion, the main topic of concern was a justification of program implementation as a population-wide screening, based on their uncertainty that it will be beneficial for women with near-population risks. Despite the noted difficulties concerning implementation, health professionals acknowledged the substantial benefits of the proposed PERSPECTIVE program. CONCLUSIONS Our study was the first to evaluate the perspectives of health professionals on the implementation and benefits of a new program for breast cancer risk stratification with the purpose of personalizing screening for disease. This new multi-step approach to screening requires more clarity in communication with health professionals. To implement and maintain effective screening, engagement of family physicians with other health professionals or even development of a centralized public health system may be needed.
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Affiliation(s)
- Svetlana Puzhko
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
| | - Justin Gagnon
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
| | - Jacques Simard
- 2Genomics Center, CHU de Québec-Université Laval Research Center, Room R4-4787, 2705 Laurier Blvd, Québec, Québec G1V 4G2 Canada
- 4Department of Molecular Medicine, Faculty of Medicine, Université Laval, Québec, Canada
| | - Bartha Maria Knoppers
- 3Genome Quebec Innovation Centre of Genomics and Policy, Department of Human Genetics, Faculty of Medicine, McGill University, 3640 University Street, Room W-315, 740 Dr. Penfield Ave, 5214, Montréal, Québec H3A 0C7OG1 Canada
| | - Sophia Siedlikowski
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
| | - Gillian Bartlett
- 1Department of Family Medicine, Faculty of Medicine, McGill University, 5858 Chemin de la Côte-des-Neiges, Suite 300, Montréal, Québec H3S 1Z1 Canada
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15
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Gunn CM, Fitzpatrick A, Waugh S, Carrera M, Kressin NR, Paasche-Orlow MK, Battaglia TA. A Qualitative Study of Spanish-Speakers' Experience with Dense Breast Notifications in a Massachusetts Safety-Net Hospital. J Gen Intern Med 2019; 34:198-205. [PMID: 30350031 PMCID: PMC6374252 DOI: 10.1007/s11606-018-4709-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 09/04/2018] [Accepted: 10/01/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Legislation requiring mammography facilities to notify women if they have dense breast tissue found on mammography has been enacted in 34 US states. The impact of dense breast notifications (DBNs) on women with limited English proficiency (LEP) is unknown. OBJECTIVE This study sought to understand Spanish-speaking women's experience receiving DBNs in a Massachusetts safety-net hospital. DESIGN Eligible women completed one audio-recorded, semi-structured interview via telephone with a native Spanish-speaking research assistant trained in qualitative methods. Interviews were professionally transcribed verbatim and translated. The translation was verified by a third reviewer to ensure fidelity with audio recordings. PARTICIPANTS Nineteen Spanish-speaking women ages 40-74 who received mammography with a normal result and recalled receiving a DBN. APPROACH Using the verified English transcripts, we conducted a content analysis to identify women's perceptions and actions related to receiving the notification. A structured codebook was developed. Transcripts were independently coded and assessed for agreement with a modification of Cohen's kappa. Content codes were grouped to build themes related to women's perceptions and actions after receiving a DBN. KEY RESULTS Nineteen Spanish-speaking women completed interviews. Nine reported not receiving the notification in their native language. Four key themes emerged: (1) The novelty of breast density contributed to notification-induced confusion; (2) women misinterpreted key messages in the notification; (3) varied actions were taken to seek further information; and (4) women held unrealized expectations and preferences for follow-up. CONCLUSIONS Not having previous knowledge of breast density and receiving notifications in English contributed to confusion about its meaning and inaccurate interpretations of key messages by Spanish speakers. Tools that promote understanding should be leveraged in seeking equity in risk-based breast cancer screening for women with dense breasts.
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Affiliation(s)
- Christine M Gunn
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA. .,Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, MA, USA.
| | - Amy Fitzpatrick
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
| | - Sarah Waugh
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
| | - Michelle Carrera
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
| | - Nancy R Kressin
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, MA, USA.,Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, Boston, MA, USA
| | - Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine, School of Medicine, Boston University, 801 Massachusetts Avenue, First Floor, Women's Health, Boston, MA, 02118, USA
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16
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Kristiansen BK, Andersen B, Bro F, Svanholm H, Vedsted P. Direct notification of cervical cytology results to women improves follow-up in cervical cancer screening - A cluster-randomised trial. Prev Med Rep 2018; 13:118-125. [PMID: 30568870 PMCID: PMC6296289 DOI: 10.1016/j.pmedr.2018.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/23/2018] [Accepted: 11/22/2018] [Indexed: 11/27/2022] Open
Abstract
Up to half of all women do not receive follow-up as recommended after cervical cytology testing and are thus at increased risk of dysplasia progression. Women from lower social positions are at increased risk of not receiving follow-up. Sample takers, often general practitioners, convey results to women, but communication problems constitute a challenge. We aimed to investigate the effect of direct notification of cervical cytology results on follow-up rates. In a 1:1 cluster-randomised controlled trial, we assessed if having the pathology department convey cervical cytology results directly to the investigated women improved timely follow-up, compared with conveying the results via the general practitioner as usual. All women with a cervical cytology performed in a general practice in the Central Denmark Region (2013-2014) and receiving follow-up recommendation were included (n = 11,833). The proportion of women without timely follow-up was lower in the group with direct notifications than in the control group of women receiving usual care, regardless of age, educational status, cohabitation status and ethnicity. Among the women with the most severe cervical cytology diagnoses who are recommended gynaecological follow-up within 3 months, the percentage without timely follow-up was 15.1% in the intervention group and 19.5% in the control group (prevalence difference: -0.04 (95%CI: -0.07; -0.02)). Improved timely follow-up was also observed for women with a recommendation to have follow-up performed at 3 and 12 months. Cervical cytology results conveyed directly by letter to women increased the proportion of women with timely follow-up without raising inequality in follow-up measured by social position. Trial registration: ClinicalTrials.gov (TRN: NCT02002468) 29 November 2013.
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Key Words
- AGC, Atypical Glandular Cells
- AIS, adenocarcinoma in situ
- ASC-H, atypical squamous cells cannot exclude HSIL
- ASC-US, Atypical Squamous Cells of Undetermined Significance
- CCU, cancer of the cervix uteri
- CDR, Central Denmark Region
- DPDB, Danish National Pathology Registry and Data Bank
- Early detection of cancer
- GP, general practitioner
- General practice
- HSIL, High-grade Squamous Intraepithelial Lesion
- ICC, intra-cluster correlation coefficient
- LSIL, Low-grade Squamous Intraepithelial Lesion
- Mass screening
- PD, prevalence differences
- PR, prevalence ratio
- Quality of health care
- SNOMED, Systematized Nomenclature of Medicine
- Socioeconomic factors
- Uterine cervical dysplasia
- hrHPV-pos., high-risk Human Papilloma Virus positive
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Affiliation(s)
- Bettina Kjær Kristiansen
- Research Unit for General Practice, Department of Public Health, Aarhus University, 8000 Aarhus, Denmark.,Department for Public Health Programmes, Randers Regional Hospital, 8930 Randers, Denmark
| | - Berit Andersen
- Department for Public Health Programmes, Randers Regional Hospital, 8930 Randers, Denmark
| | - Flemming Bro
- Research Unit for General Practice, Department of Public Health, Aarhus University, 8000 Aarhus, Denmark
| | - Hans Svanholm
- Department of Pathology, Randers Regional Hospital, 8930 Randers, Denmark
| | - Peter Vedsted
- Research Centre for Cancer Diagnosis in Primary Care (CaP), Department of Public Health, Aarhus University, 8000 Aarhus, Denmark
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Yabroff KR, Zhao J, Zheng Z, Rai A, Han X. Medical Financial Hardship among Cancer Survivors in the United States: What Do We Know? What Do We Need to Know? Cancer Epidemiol Biomarkers Prev 2018; 27:1389-1397. [DOI: 10.1158/1055-9965.epi-18-0617] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 07/19/2018] [Accepted: 09/07/2018] [Indexed: 11/16/2022] Open
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18
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Onega T, Tosteson TD, Weiss J, Haas JS, Goodrich M, DiFlorio R, Brackett C, Clark C, Harris K, Tosteson ANA. Multi-level Influences on Breast Cancer Screening in Primary Care. J Gen Intern Med 2018; 33:1729-1737. [PMID: 30076569 PMCID: PMC6153219 DOI: 10.1007/s11606-018-4560-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 04/24/2018] [Accepted: 06/28/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Use of breast cancer screening is influenced by factors associated with patients, primary care providers, practices, and health systems. OBJECTIVE We examined the relative effects of these nested levels on four breast cancer screening metrics. DESIGN A web-based survey was completed at 15 primary care practices within two health systems representing 306 primary care providers (PCPs) serving 46,944 women with a primary care visit between 1/2011-9/2014. Analyses occurred between 1/2017 and 5/2017. MAIN MEASURES Across four nested levels (patient, PCP, primary care practice, and health system), frequency distributions and adjusted rates of primary care practice characteristics and survey results for four breast screening metrics (percent screened overall, and percent screened age 40-49, 50-74, and 75+) were reported. We used hierarchical multi-level mixed and random effects analysis to assess the relative influences of PCP, primary care practice, and health system on the breast screening metrics. KEY RESULTS Overall, the proportion of women undergoing breast cancer screening was 73.1% (73.4% for ages 40-49, 76.5% for 50-74, and 51.1% for 75+). Patient ethnicity and number of primary care visits were strongly associated with screening rates. After adjusting for woman-level factors, 24% of the overall variation among PCPs was attributable to the primary care practice level, 35% to the health system level, and 41% to the residual variation among PCPs within practice. No specific provider-level characteristics were found to be statistically significant determinants of screening rates. CONCLUSIONS After accounting for woman-level characteristics, the remaining variation in breast cancer screening was largely due to provider and health system variation.
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Affiliation(s)
- Tracy Onega
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Tor D Tosteson
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Julie Weiss
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
| | - Jennifer S Haas
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Martha Goodrich
- Department of Biomedical Data Science, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA. .,Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.
| | - Roberta DiFlorio
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Charles Brackett
- Department of General Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Cheryl Clark
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Kimberly Harris
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
| | - Anna N A Tosteson
- Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA
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19
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de Moor JS, Cohen RA, Shapiro JA, Nadel MR, Sabatino SA, Robin Yabroff K, Fedewa S, Lee R, Paul Doria-Rose V, Altice C, Klabunde CN. Colorectal cancer screening in the United States: Trends from 2008 to 2015 and variation by health insurance coverage. Prev Med 2018; 112:199-206. [PMID: 29729288 PMCID: PMC6202023 DOI: 10.1016/j.ypmed.2018.05.001] [Citation(s) in RCA: 101] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 04/09/2018] [Accepted: 05/02/2018] [Indexed: 01/03/2023]
Abstract
Regular colorectal cancer (CRC) screening is recommended for reducing CRC incidence and mortality. This paper provides an updated analysis of CRC screening in the United States (US) and examines CRC screening by several features of health insurance coverage. Recommendation-consistent CRC screening was calculated for adults aged 50-75 in 2008, 2010, 2013 and 2015 using data from the National Health Interview Survey. CRC screening prevalence in 2015 was described overall and by sociodemographic subgroups. CRC screening by health insurance coverage was further examined using multivariable logistic regression, stratified by age (50-64 years and 65-75 years) and adjusted for age, race/ethnicity, sex, education, income, time in US, and comorbid conditions. Recommendation-consistent screening increased from 51.6% in 2008 to 58.3% in 2010 (p < 0.001). Use plateaued from 2010 to 2013 but increased to 61.3% in 2015 (p < 0.001). In 2015, adults aged 50-64 years with traditional employer-sponsored private insurance were more likely to be screened (62.2%) than those with traditional private direct purchase plans (50.9%) and the uninsured (24.8%) (p < 0.01, respectively). After multivariable adjustment, differences between traditional employer-sponsored private insurance and the uninsured remained statistically significant. Adults aged 65-75 with Medicare and private insurance were more likely to be screened (76.3%) than those with Medicare, no supplemental insurance (68.8%) or Medicare and Medicaid (65.2%) (p < 0.001). After multivariable adjustment, the differences between Medicare and private insurance and Medicare no supplemental insurance remained statistically significant. CRC screening rates have increased over time, but certain segments of the population, especially the uninsured, continue to screen below recommended levels.
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Affiliation(s)
- Janet S de Moor
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, United States.
| | - Robin A Cohen
- Division of Health Interview Statistics, National Center for Health Statistics, Hyattsville, MD, United States
| | - Jean A Shapiro
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Marion R Nadel
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Susan A Sabatino
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - K Robin Yabroff
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, United States
| | - Stacey Fedewa
- Surveillance and Health Services Research Program, American Cancer Society, Atlanta, GA, United States
| | - Richard Lee
- Information Management Services, Inc., Calverton, MD, United States
| | - V Paul Doria-Rose
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, United States
| | - Cheryl Altice
- Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, United States
| | - Carrie N Klabunde
- Office of Disease Prevention, National Institutes of Health, Bethesda, MD, United States
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20
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Kistler CE, Vu M, Sutkowi-Hemstreet A, Gizlice Z, Harris RP, Brewer NT, Lewis CL, Dolor RJ, Barclay C, Sheridan SL. Exploring factors that might influence primary-care provider discussion of and recommendation for prostate and colon cancer screening. Int J Gen Med 2018; 11:179-190. [PMID: 29844698 PMCID: PMC5962312 DOI: 10.2147/ijgm.s153887] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Primary-care providers may contribute to the use of low-value cancer screening. Objective We sought to examine circumstances under which primary-care providers would discuss and recommend two types of cancer screening services across a spectrum of net benefit and other factors known to influence screening. Patients and methods This was a cross sectional survey of 126 primary-care providers in 24 primary-care clinics in the US. Participants completed surveys with two hypothetical screening scenarios for prostate or colorectal cancer (CRC). Patients in the scenarios varied by age and screening-request status. For each scenario, providers indicated whether they would discuss and recommend screening. Providers also reported on their screening attitudes and the influence of other factors known to affect screening (short patient visits, worry about lawsuits, clinical reminders/performance measures, and screening guidelines). We examined associations between providers’ attitudes and their screening recommendations for hypothetical 90-year-olds (the lowest-value screening). Results Providers reported they would discuss cancer screening more often than they would recommend it (P<0.001). More providers would discuss and recommend screening for CRC than prostate cancer (P<0.001), for younger than older patients (P<0.001), and when the patient requested it than when not (P<0.001). For a 90-year-old patient, every point increase in cancer-specific screening attitude increased the likelihood of a screening recommendation (30% for prostate cancer and 30% for CRC). Discussion While most providers’ reported practice patterns aligned with net benefit, some providers would discuss and recommend low-value cancer screening, particularly when faced with a patient request. Conclusion More work appears to be needed to help providers to discuss and recommend screening that aligns with value.
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Affiliation(s)
| | - Maihan Vu
- Center for Health Promotion and Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Ziya Gizlice
- Biostatistical Support Unit, Center for Health Promotion and Disease Prevention
| | | | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Carmen L Lewis
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Rowena J Dolor
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
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21
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Syse A, Soneji SS, Andrew AS, Tretli S, Baili P, Bynum JPW. Short-term survival after colorectal cancer in a screened versus unscreened population. Scand J Public Health 2018; 47:528-537. [PMID: 29360010 DOI: 10.1177/1403494817744394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aims: United States' (US) colorectal cancer (CRC) screening and treatment practices seek to reduce mortality. We examined the survival of US patients compared with patients in the virtually unscreened Norwegian population. Methods: We compared short-term survival after CRC between the US and Norway using relative survival (RS) and excess mortality (EMR) analyses. The CRC patients were aged 50 and older diagnosed in the US (Surveillance, Epidemiology and End Results registry, 2004, N=9511) and in Norway (Cancer Registry of Norway, 2003-2005, N=8256). Results: Death occurred within three years for 39% of the CRC patients. Stage distributions were more favorable for US patients. Stage-specific survival was similar for localized and regional cancers, but more favorable for US distant cancers. In multivariate models of patient, tumor and treatment characteristics, patients (especially below age 80) in the US experienced longer survival (EMR 0.9, CI 0.8-0.9). Stage-specific analyses showed, however, that survival for localized cancers was relatively shorter in the US than in Norway (EMR 1.4, CI 1.1-1.8), but longer for distant cancers (EMR 0.8, CI 0.7-0.8). Conclusions: The enhanced survival for US CRC patients likely reflects a screening-related earlier diagnostic stage distribution, as well as prioritized life extension for patients with metastatic cancers, reflecting vastly different health care systems in the two countries. CRC screening is currently under consideration in Norway. For survival outcomes, the current findings do not discourage such an implementation. Other screening-related aspects such as feasibility and cost-benefit are, however, also relevant and warrant further research within a socialized health system.
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Affiliation(s)
| | | | | | | | - Paolo Baili
- 4 Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Lombardia, Italy
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22
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MacLaughlin KL, Kessler ME, Komandur Elayavilli R, Hickey BC, Scheitel MR, Wagholikar KB, Liu H, Kremers WK, Chaudhry R. Impact of Patient Reminders on Papanicolaou Test Completion for High-Risk Patients Identified by a Clinical Decision Support System. J Womens Health (Larchmt) 2018; 27:569-574. [PMID: 29297754 PMCID: PMC5953769 DOI: 10.1089/jwh.2017.6667] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: A clinical decision support system (CDSS) for cervical cancer screening identifies patients due for routine cervical cancer screening. Yet, high-risk patients who require more frequent screening or earlier follow-up to address past abnormal results are not identified. We aimed to assess the effect of a complex CDSS, incorporating national guidelines for high-risk patient screening and abnormal result management, its implementation to identify patients overdue for testing, and the outcome of sending a targeted recommendation for follow-up. Materials and Methods: At three primary care clinics affiliated with an academic medical center, a reminder recommending an appointment for Papanicolaou (Pap) testing or Pap and human papillomavirus cotesting was sent to high-risk women aged 18 through 65 years (intervention group) identified by CDSS as overdue for testing. Historical control patients, who did not receive a reminder, were identified by CDSS 1 year before the date when reminders were sent to the intervention group. Test completion rates were compared between the intervention and control groups through a generalized estimating equation extension. Results: Across the three sites, the average completion rate of recommended follow-up testing was significantly higher in the intervention group at 23.7% (61/257) than the completion rate at 3.3% (17/516) in the control group (p < 0.001). Conclusions: A CDSS with enhanced capabilities to identify high-risk women due for cervical cancer testing beyond routine screening intervals, with subsequent patient notification, has the potential to decrease cervical precancer and cancer by improving adherence to guideline-compliant follow-up and needed treatment.
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Affiliation(s)
| | - Maya E Kessler
- 2 Division of Primary Care Internal Medicine, Mayo Clinic , Rochester, Minnesota
| | | | - Branden C Hickey
- 4 Knowledge and Delivery Center, Mayo Clinic , Rochester, Minnesota
| | | | | | - Hongfang Liu
- 3 Division of Biomedical Statistics and Informatics, Mayo Clinic , Rochester, Minnesota
| | - Walter K Kremers
- 3 Division of Biomedical Statistics and Informatics, Mayo Clinic , Rochester, Minnesota
| | - Rajeev Chaudhry
- 2 Division of Primary Care Internal Medicine, Mayo Clinic , Rochester, Minnesota
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23
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Nicolau AIO, Lima TM, Vasconcelos CTM, Carvalho FHC, Aquino PDS, Pinheiro AKB. Telephone interventions in adherence to receiving the Pap test report: a randomized clinical trial. Rev Lat Am Enfermagem 2017; 25:e2948. [PMID: 29211194 PMCID: PMC5738872 DOI: 10.1590/1518-8345.1845.2948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 08/01/2017] [Indexed: 05/29/2023] Open
Abstract
Objective: to test the efficacy of the behavioral and educational interventions undertaken by
telephone, for women’s attendance at the consultation to receive the Pap test
report. Method: a randomized clinical trial, with a sample randomized in three groups: telephone
call - educational (n=171), telephone call - reminder (n=171) and comparison
(n=169). The inclusion criteria were to be of legal age, to have become sexually
active, to undertake the preventive examination during the study and to have a
mobile or fixed telephone. The educational group received a telephone call
involving a script based in the motivational interview and in the Brazilian
guidelines. The behavioral group received a telephone call involving a reminder
about the consultation. The comparison group received a card with details of when
to return for a consultation regarding the results. Results: the women who received one of the interventions had a non-return rate of 7.3% and
an increase of 39% (RR CI95%: 1.24-1.55) in the protection against this outcome.
In the individual analysis of the interventions, it was evidenced that both are
efficacious, as the telephone call - reminder reduces the woman’s failure to
return to the service by 40% (RR CI95%: 1.25-1.57), while the telephone call -
educational does so by 37% (RR CI95%: 1.22-1.54). The rates of non-return were of
6.5% and 8.2%, respectively, as against 33.1% in the comparison group. Conclusion: the interventions tested showed greater efficacy in the educational and behavioral
contexts, in relation to the normal attendance, as they motivated the women to
return to the service to receive the Pap test report. Clinical trial register:
RBR-w3vnc.
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Affiliation(s)
| | - Thaís Marques Lima
- PhD, Assistant Professor, Via Corpvs, Centro Universitário Estácio do Ceará, Fortaleza, CE, Brasil
| | | | | | - Priscila de Souza Aquino
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal do Ceará, Fortaleza, CE, Brasil
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Nguyen KH, Pasick RJ, Stewart SL, Kerlikowske K, Karliner LS. Disparities in abnormal mammogram follow-up time for Asian women compared with non-Hispanic white women and between Asian ethnic groups. Cancer 2017; 123:3468-3475. [PMID: 28603859 PMCID: PMC5648644 DOI: 10.1002/cncr.30756] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/20/2017] [Accepted: 03/30/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Delays in abnormal mammogram follow-up contribute to poor outcomes. In the current study, the authors examined differences in abnormal screening mammogram follow-up between non-Hispanic white (NHW) and Asian women. METHODS The authors used a prospective cohort of NHW and Asian women with a Breast Imaging, Reporting and Data System (BI-RADS) abnormal result of category 0 or 3-plus in the San Francisco Mammography Registry between 2000 and 2010. Kaplan-Meier estimation for the median number of days to follow-up with a diagnostic radiologic test was performed, and the authors compared the percentage of women with follow-up at 30 days, 60 days, and 90 days and no follow-up at 1 year for Asian women overall (and Asian ethnic groups) and NHW women. In addition, the authors assessed the relationship between race/ethnicity and time to follow-up with adjusted Cox proportional hazards models. RESULTS Among Asian women, Vietnamese and Filipina women had the longest, and Japanese women the shortest, median follow-up (32 days, 28 days, and 19 days, respectively) compared with NHW women (15 days). The percentage of women receiving follow-up at 30 days was lower for Asians versus NHWs (57% vs 77%; P<.0001), and these disparities persisted at 60 days and 90 days for all Asian ethnic groups except Japanese. Asian women had a reduced hazard of follow-up compared with NHW women (adjusted hazard ratio, 0.70; 95% confidence interval, 0.69-0.72). Asian women also had a higher rate of receiving no follow-up compared with NHW women (15% vs 10%; P<.001); among Asian ethnic groups, Filipinas were found to have the highest percentage of women with no follow-up (18.1%). CONCLUSIONS Asian women, particularly Filipina and Vietnamese women, were less likely than NHW women to receive timely follow-up after an abnormal screening mammogram. Research should disaggregate Asian ethnicity to better understand and address barriers to effective cancer prevention. Cancer 2017;123:3468-75. © 2017 American Cancer Society.
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Affiliation(s)
- Kim H Nguyen
- Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Rena J Pasick
- Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, California
| | - Susan L Stewart
- Division of Biostatistics, Department of Public Health Sciences, University of California at Davis, Davis, California
| | - Karla Kerlikowske
- General Internal Medicine Section, San Francisco Veteran Affairs Medical Center, San Francisco, California
- Department of Epidemiology, University of California at San Francisco, San Francisco, California
- Department of Biostatistics, University of California at San Francisco, San Francisco, California
| | - Leah S Karliner
- Division of General Internal Medicine, Department of Medicine, University of California at San Francisco, San Francisco, California
- Multiethnic Health Equity Research Center, University of California at San Francisco, San Francisco, California
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Impact of GP reminders on follow-up of abnormal cervical cytology: a before-after study in Danish general practice. Br J Gen Pract 2017; 67:e580-e587. [PMID: 28716995 DOI: 10.3399/bjgp17x691913] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 04/12/2017] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Dysplasia may progress because of a loss to follow-up after an abnormal cervical cytology. Approximately 18% of Danish women postpone the recommended follow-up, which depends on the cytology results. AIM To investigate if a reminder to the GP about missed follow-up could reduce the proportion of women who fail to act on a recommended follow-up, and to analyse the effect on sociodemographic and general practice variations. DESIGN AND SETTING A national electronic GP reminder system was launched in Denmark in 2012 to target missed follow-up after screening, opportunistic testing, or surveillance indication. The authors compared follow-up proportions in a national observational before-after study. METHOD From national registries, 1.5 million cervical cytologies (from 2009 to 2013) were eligible for inclusion. Approximately 10% had a recommendation for follow-up. The proportion of cervical cytologies without follow-up was calculated at different time points. Results were stratified by follow-up recommendations and sociodemographic characteristics, and changes in practice variation for follow-up were analysed. RESULTS Fewer women with a recommendation for follow-up missed follow-up 6 months after a GP reminder. Follow-up improved in all investigated sociodemographic groups (age, ethnicity, education, and cohabitation status). Interaction was found for age and cohabitation status. Variation between practices in loss to follow-up was significantly reduced. CONCLUSION An electronic GP reminder system showed potential to improve the quality of cervical cancer screening through reduced loss to follow-up.
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26
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Petrik AF, Green BB, Vollmer WM, Le T, Bachman B, Keast E, Rivelli J, Coronado GD. The validation of electronic health records in accurately identifying patients eligible for colorectal cancer screening in safety net clinics. Fam Pract 2016; 33:639-643. [PMID: 27471224 PMCID: PMC5161488 DOI: 10.1093/fampra/cmw065] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND While electronic health records (EHRs) play a key role in increasing colorectal cancer (CRC) screening by identifying individuals who are overdue, important shortfalls remain. OBJECTIVES As part of the Strategies and Opportunities to STOP Colon Cancer (STOP CRC) study, we assessed the accuracy of EHR codes in identifying patients eligible for CRC screening. METHODS We selected a stratified random sample of 800 study participants from 26 participating clinics, in the Pacific Northwest region of the USA. We compared data obtained through codes in the EHR to conduct a manual chart audit. A trained chart abstractor completed the abstraction of eligible and ineligible patients. RESULTS Of 520 individuals in need of CRC screening, identified via the EHR, 459 were confirmed through chart review (positive predictive value = 88%). Of 280 individuals flagged as up-to-date in their screening per EHR data, 269 were confirmed through chart review (negative predictive value = 96%). Among the 61 patients incorrectly classified as eligible, 83.6% of disagreements were due to evidence of a prior colonoscopy or referral that was not captured in recognizable fields in the EHR. CONCLUSIONS Our findings highlight importance of better capture of past screening events in the EHR. While the need for better population-based data is not unique to CRC screening, it provides an important example of the use of population-based data not only for tracking care, but also for delivering interventions.
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Affiliation(s)
- Amanda F Petrik
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR,
| | | | - William M Vollmer
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | - Barbara Bachman
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Erin Keast
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Jennifer Rivelli
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Gloria D Coronado
- The Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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27
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Barnett KS, Shoben AB, McRee AL, Reiter PL, Paskett ED, Katz ML. Human papillomavirus vaccine and Pap tests on college campuses: How do historically black colleges and universities (HBCUs) measure up? JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2016; 64:613-618. [PMID: 27455193 DOI: 10.1080/07448481.2016.1213731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE The availability of cervical cancer prevention services at college health centers was compared between historically black colleges and universities (HBCUs) and non-HBCUs. METHODS Four-year, non-primarily distant learning colleges, matching HBCUs with randomly selected non-HBCUs within the same states (N = 136) were examined. Data were collected (2014-2015 academic year) on the availability of human papillomavirus (HPV) vaccine and Pap tests at college health centers. HBCUs were compared with non-HBCUs using conditional logistic regression, and correlates of offering these services were identified. RESULTS Many institutions did not offer HPV vaccine or Pap tests. Fewer HBCUs offered HPV vaccine (18% vs 53%) and Pap tests (50% vs 76%) compared with non-HBCUs. In multivariable analyses, HBCUs remained less likely than non-HBCUs to offer HPV vaccine (odds ratio [OR] = 0.07, 95% confidence interval [CI]: 0.02-0.26) and Pap tests (OR = 0.19, 95% CI: 0.06-0.61). CONCLUSIONS Greater effort is needed to make cervical cancer prevention services available at colleges, especially at HBCUs.
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Affiliation(s)
- Kierra S Barnett
- a Division of Health Behavior and Health Promotion , College of Public Health, The Ohio State University , Columbus , Ohio , USA
| | - Abigail B Shoben
- b Division of Biostatistics , College of Public Health, The Ohio State University , Columbus , Ohio , USA
- c Comprehensive Cancer Center , The Ohio State University , Columbus , Ohio , USA
| | - Annie-Laurie McRee
- d Division of General Pediatrics and Adolescent Health, Department of Pediatrics , University of Minnesota , Minneapolis , Minnesota , USA
| | - Paul L Reiter
- c Comprehensive Cancer Center , The Ohio State University , Columbus , Ohio , USA
- e Division of Cancer Prevention and Control, Department of Medicine , College of Medicine, The Ohio State University , Columbus , Ohio , USA
| | - Electra D Paskett
- c Comprehensive Cancer Center , The Ohio State University , Columbus , Ohio , USA
- e Division of Cancer Prevention and Control, Department of Medicine , College of Medicine, The Ohio State University , Columbus , Ohio , USA
| | - Mira L Katz
- a Division of Health Behavior and Health Promotion , College of Public Health, The Ohio State University , Columbus , Ohio , USA
- c Comprehensive Cancer Center , The Ohio State University , Columbus , Ohio , USA
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28
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Schapira MM, Sprague BL, Klabunde CN, Tosteson ANA, Bitton A, Chen JS, Beaber EF, Onega T, MacLean CD, Harris K, Howe K, Pearson L, Feldman S, Brawarsky P, Haas JS. Inadequate Systems to Support Breast and Cervical Cancer Screening in Primary Care Practice. J Gen Intern Med 2016; 31:1148-55. [PMID: 27251058 PMCID: PMC5023599 DOI: 10.1007/s11606-016-3726-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 03/25/2016] [Accepted: 04/22/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND Despite substantial resources devoted to cancer screening nationally, the availability of clinical practice-based systems to support screening guidelines is not known. OBJECTIVE To characterize the prevalence and correlates of practice-based systems to support breast and cervical cancer screening, with a focus on the patient-centered medical home (PCMH). DESIGN Web and mail survey of primary care providers conducted in 2014. The survey assessed provider (gender, training) and facility (size, specialty training, physician report of National Committee for Quality Assurance (NCQA) PCMH recognition, and practice affiliation) characteristics. A hierarchical multivariate analysis clustered by clinical practice was conducted to evaluate characteristics associated with the adoption of practice-based systems and technology to support guideline-adherent screening. PARTICIPANTS Primary care physicians in family medicine, general internal medicine, and obstetrics and gynecology, and nurse practitioners or physician assistants from four clinical care networks affiliated with PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium research centers. MAIN MEASURES The prevalence of routine breast cancer risk assessment, electronic health record (EHR) decision support, comparative performance reports, and panel reports of patients due for routine screening and follow-up. KEY RESULTS There were 385 participants (57.6 % of eligible). Forty-seven percent (47.0 %) of providers reported NCQA recognition as a PCMH. Less than half reported EHR decision support for breast (48.8 %) or cervical cancer (46.2 %) screening. A minority received comparative performance reports for breast (26.2 %) or cervical (19.7 %) cancer screening, automated reports of patients overdue for breast (18.7 %) or cervical (16.4 %) cancer screening, or follow-up of abnormal breast (18.1 %) or cervical (17.6 %) cancer screening tests. In multivariate analysis, reported NCQA recognition as a PCMH was associated with greater use of comparative performance reports of guideline-adherent breast (OR 3.23, 95 % CI 1.58-6.61) or cervical (OR 2.56, 95 % CI 1.32-4.96) cancer screening and automated reports of patients overdue for breast (OR 2.19, 95 % CI 1.15-41.7) or cervical (OR. 2.56, 95 % CI 1.26-5.26) cancer screening. CONCLUSIONS Providers lack systems to support breast and cervical cancer screening. Practice transformation toward a PCMH may support the adoption of systems to achieve guideline-adherent cancer screening in primary care settings.
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Affiliation(s)
- Marilyn M Schapira
- University of Pennsylvania and the Philadelphia VA Medical Center, 1110 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104, USA.
| | | | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Asaf Bitton
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | - Jane S Chen
- Brigham and Women's Hospital, Boston, MA, USA
| | | | - Tracy Onega
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | | | | | | | - Loretta Pearson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Sarah Feldman
- Harvard Medical School, Boston, MA, USA.,Brigham and Women's Hospital, Boston, MA, USA
| | | | - Jennifer S Haas
- Division of General Internal Medicine and Primary Care, Brigham and Woman's Hospital, Boston, MA, USA
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Klabunde CN, Zheng Y, Quinn VP, Beaber EF, Rutter CM, Halm EA, Chubak J, Doubeni CA, Haas JS, Kamineni A, Schapira MM, Vacek PM, Garcia MP, Corley DA. Influence of Age and Comorbidity on Colorectal Cancer Screening in the Elderly. Am J Prev Med 2016; 51:e67-75. [PMID: 27344108 PMCID: PMC4992638 DOI: 10.1016/j.amepre.2016.04.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 04/15/2016] [Accepted: 04/15/2016] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Expert recommendations differ for colorectal cancer screening in the elderly. Recent studies suggest that healthy adults aged >75 years may benefit from screening. This study examined screening use and follow-up, and how they varied by health status within age strata, among a large cohort of elderly individuals in community settings. METHODS A population-based, longitudinal cohort study was conducted among health plan members aged 65-89 years enrolled during 2011-2012 in three integrated healthcare systems participating in the Population-Based Research Optimizing Screening through Personalized Regimens consortium. Comorbidity measurements used the Charlson index. Analyses, conducted in 2015, comprised descriptive statistics and multivariable modeling that estimated age by comorbidity-specific percentages of patients for two outcomes: colorectal cancer screening uptake and follow-up of abnormal fecal blood tests. RESULTS Among 846,267 patients, 72% were up-to-date with colorectal cancer screening. Of patients with a positive fecal blood test, 65% received follow-up colonoscopy within 3 months. Likelihood of being up-to-date and receiving timely follow-up was significantly lower for patients aged ≥76 years than their younger counterparts (p<0.001). Comorbidity was less influential than age and more strongly related to timely follow-up than being up-to-date. In all age groups, considerable numbers of patients with no/low comorbidity were not up-to-date or did not receive timely follow-up. CONCLUSIONS In three integrated healthcare systems, many older, relatively healthy patients were not screening up-to-date, and some relatively young, healthy patients did not receive timely follow-up. Findings suggest a need for re-evaluating age-based screening guidelines and improving screening completion among the elderly.
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Affiliation(s)
- Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, NIH, Rockville, Maryland.
| | - Yingye Zheng
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Virginia P Quinn
- Kaiser Permanente Southern California, Research and Evaluation, Pasadena, California
| | - Elisabeth F Beaber
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Ethan A Halm
- Departments of Internal Medicine and Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Chyke A Doubeni
- Department of Family Medicine and Community Health and Department of Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer S Haas
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Marilyn M Schapira
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania and the Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Pamela M Vacek
- Medical Biostatistics Unit, University of Vermont College of Medicine, Burlington, Vermont
| | - Michael P Garcia
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
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Murphy J, Mollica M. All Hands on Deck: Nurses and Cancer Care Delivery in Women's Health. Front Oncol 2016; 6:174. [PMID: 27500124 PMCID: PMC4956645 DOI: 10.3389/fonc.2016.00174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 07/07/2016] [Indexed: 12/04/2022] Open
Affiliation(s)
- Jeanne Murphy
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, Rockville, MD, USA
| | - Michelle Mollica
- Cancer Prevention Fellowship Program, Division of Cancer Prevention, National Cancer Institute, Rockville, MD, USA
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Bowles EJA, Gao H, Brandzel S, Bradford SC, Buist DSM. Comparative effectiveness of two outreach strategies for cervical cancer screening. Prev Med 2016; 86:19-27. [PMID: 26820221 PMCID: PMC4902104 DOI: 10.1016/j.ypmed.2016.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 01/04/2016] [Accepted: 01/18/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Test-specific reminder letters can improve cancer screening adherence. Little is known about the effectiveness of a reminder system that targets the whole person by including multiple screening recommendations per letter. METHODS We compared the effectiveness of a Pap-specific reminder letter sent 27months after a woman's last Pap, to a reminder letter that included up to seven preventive service recommendations sent before a woman's birthday ("birthday letter") on Pap smear adherence from a natural experiment occurring in routine clinical care. Participants included 82,016 women from Washington State who received 72,615 Pap-specific letters between 2003 and 2007 and 100,218 birthday letters between 2009 and 2012. We defined adherence as having a Pap test within a six month window around the Pap test due date. Using logistic regression, we calculated adjusted odds ratios (OR) for adherence with 95% confidence intervals (CI) following the birthday letter with 1-2 recommendations, 3-5 recommendations, and 6-7 recommendations compared to the Pap-specific letter. All analyses were stratified by whether a woman was up-to-date or overdue for screening at the time she received a letter. RESULTS Adjusted ORs showed reduced adherence following the birthday letter compared with the Pap-specific letter for up-to-date women whether the letter had 1-2 recommendations (OR=0.37, 95%CI=0.36-0.39), 3-5 recommendations (OR=0.44, 95%CI=0.42-0.45), or 6-7 recommendations (OR=0.36, 95%CI=0.32-0.40). We noted no difference in Pap-test adherence between letter types for overdue women. CONCLUSIONS In conclusion, for women regularly adherent to screening, an annual birthday letter containing reminders for multiple preventive services was less effective at promoting cervical cancer screening compared with a Pap-specific letter.
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Affiliation(s)
- Erin J Aiello Bowles
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
| | - Hongyuan Gao
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
| | - Susan Brandzel
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
| | - Susan Carol Bradford
- Department of Clinical Improvement and Prevention, Group Health Cooperative, 201 16th Ave E, Seattle, WA 98112, USA
| | - Diana S M Buist
- Group Health Research Institute, Group Health Cooperative, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA
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Variation in Screening Abnormality Rates and Follow-Up of Breast, Cervical and Colorectal Cancer Screening within the PROSPR Consortium. J Gen Intern Med 2016; 31:372-9. [PMID: 26658934 PMCID: PMC4803707 DOI: 10.1007/s11606-015-3552-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Primary care providers and health systems have prominent roles in guiding effective cancer screening. OBJECTIVE To characterize variation in screening abnormality rates and timely initial follow-up for common cancer screening tests. DESIGN Population-based cohort undergoing screening in 2011, 2012, or 2013 at seven research centers comprising the National Cancer Institute-sponsored Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. PARTICIPANTS Adults undergoing mammography with or without digital breast tomosynthesis (n = 97,683 ages 40-75 years), fecal occult blood or fecal immunochemical tests (n = 759,553 ages 50-75 years), or Papanicolaou with or without human papillomavirus tests (n = 167,330 ages 21-65 years). INTERVENTION Breast, colorectal, or cervical cancer screening. MAIN MEASURES Abnormality rates per 1000 screens; percentage with timely initial follow-up (within 90 days, except 9-month window for BI-RADS 3). Primary care clinic-level variation in percentage with screening abnormality and percentage with timely initial follow-up. KEY RESULTS There were 10,248/97,683 (104.9 per 1000) abnormal breast cancer screens, 35,847/759,553 (47.2 per 1000) FOBT/FIT-positive colorectal cancer screens, and 13,266/167,330 (79.3 per 1000) abnormal cervical cancer screens. The percentage with timely follow-up was 93.2 to 96.7 % for breast centers, 46.8 to 68.7 % for colorectal centers, and 46.6 % for the cervical cancer screening center (low-grade squamous intraepithelial lesions or higher). The primary care clinic variation (25th to 75th percentile) was smaller for the percentage with an abnormal screen (breast, 8.5-10.3 %; colorectal, 3.0-4.8 %; cervical, 6.3-9.9 %) than for the percentage with follow-up within 90 days (breast, 90.2-95.8 %; colorectal, 43.4-52.0 %; cervical, 29.6-61.4 %). CONCLUSIONS Variation in both the rate of screening abnormalities and their initial follow-up was evident across organ sites and primary care clinics. This highlights an opportunity for improving the delivery of cancer screening through focused study of patient, provider, clinic, and health system characteristics associated with timely follow-up of screening abnormalities.
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Abstract
The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7% (95% CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9% (95% CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤ 1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤ 1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2% indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥ 89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed.
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Haas JS, Hill DA, Wellman RD, Hubbard RA, Lee CI, Wernli KJ, Stout NK, Tosteson ANA, Henderson LM, Alford-Teaster JA, Onega TL. Disparities in the use of screening magnetic resonance imaging of the breast in community practice by race, ethnicity, and socioeconomic status. Cancer 2016; 122:611-7. [PMID: 26709819 PMCID: PMC4742376 DOI: 10.1002/cncr.29805] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/09/2015] [Accepted: 10/29/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Uptake of breast magnetic resonance imaging (MRI) coupled with breast cancer risk assessment offers the opportunity to tailor the benefits and harms of screening strategies for women with differing cancer risks. Despite the potential benefits, there is also concern for worsening population-based health disparities. METHODS Among 316,172 women aged 35 to 69 years from 5 Breast Cancer Surveillance Consortium registries (2007-2012), the authors examined 617,723 negative screening mammograms and 1047 screening MRIs. They examined the relative risks (RRs) of MRI use by women with a <20% lifetime breast cancer risk and RR in the absence of MRI use by women with a ≥20% lifetime risk. RESULTS Among women with a <20% lifetime risk of breast cancer, non-Hispanic white women were found to be 62% more likely than nonwhite women to undergo an MRI (95% confidence interval, 1.32-1.98). Of these women, those with an educational level of some college or technical school were 43% more likely and those who had at least a college degree were 132% more likely to receive an MRI compared with those with a high school education or less. Among women with a ≥20% lifetime risk, there was no statistically significant difference noted with regard to the use of screening MRI by race or ethnicity, but high-risk women with a high school education or less were less likely to undergo screening MRI than women who had graduated from college (RR, 0.40; 95% confidence interval, 0.25-0.63). CONCLUSIONS Uptake of screening MRI of the breast into clinical practice has the potential to worsen population-based health disparities. Policies beyond health insurance coverage should ensure that the use of this screening modality reflects evidence-based guidelines.
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Affiliation(s)
- Jennifer S Haas
- Division of General Internal Medicine and Primary Care, Department of Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deirdre A Hill
- Department of Internal Medicine and Cancer Research Center and School of Medicine, University of New Mexico, Albuquerque, New Mexico
| | | | - Rebecca A Hubbard
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christoph I Lee
- Department of Radiology, University of Washington School of Medicine, Seattle, Washington
- Department of Health Services, University of Washington School of Public Health, Seattle, Washington
| | | | - Natasha K Stout
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Anna N A Tosteson
- Department of Medicine, Department of Community and Family Medicine, The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Louise M Henderson
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer A Alford-Teaster
- Department of Medicine, Department of Community and Family Medicine, The Dartmouth Institute, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Tracy L Onega
- Department of Biomedical Science, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Haas JS, Sprague BL, Klabunde CN, Tosteson ANA, Chen JS, Bitton A, Beaber EF, Onega T, Kim JJ, MacLean CD, Harris K, Yamartino P, Howe K, Pearson L, Feldman S, Brawarsky P, Schapira MM. Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines. J Gen Intern Med 2016; 31:52-9. [PMID: 26129780 PMCID: PMC4700005 DOI: 10.1007/s11606-015-3449-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers. OBJECTIVE To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening. DESIGN, SETTING, PARTICIPANTS In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %). MAIN MEASURES We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations. KEY RESULTS The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %). CONCLUSIONS Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential.
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Affiliation(s)
- Jennifer S Haas
- Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
| | | | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Jane S Chen
- Brigham and Women's Hospital, Boston, MA, USA
| | - Asaf Bitton
- Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Tracy Onega
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Jane J Kim
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | - Phillip Yamartino
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
| | | | - Loretta Pearson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Sarah Feldman
- Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Marilyn M Schapira
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
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Hill H, Johnson B, Jader L, Bal M, Wang W, Bansal S, Lewis JH. Quality Improvement Measures for Increasing the Colorectal Cancer Screening Rates at a Community Health Center. J Osteopath Med 2015; 115:e20-4. [PMID: 26618822 DOI: 10.7556/jaoa.2015.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Direct recommendation from health care professionals has been shown to generally increase colorectal cancer screening rates in the United States. However, data for rural, underserved communities are limited. OBJECTIVE To increase colorectal cancer screening rates at a rural community health center (CHC) by increasing health care professionals' awareness of patients' screening eligibility. METHODS Participants were health care professionals at a CHC treating patients eligible for colorectal cancer screening (defined as patients aged 50-74 years who visited the CHC between February 24, 2014, and March 15, 2014, and whose electronic medical records [EMRs] had no recording of colorectal cancer screening). For a 3-week period, these participants added electronic reminders to eligible patients' EMRs. Data reports for the screening rates of each participant, in addition to the overall CHC, were generated 4 weeks after the study period and compared with screening rates in 2013. RESULTS Five health care professionals volunteered to participate. No statistically significant difference was found in screening rates of participants compared with overall clinic rates between the 2013 (P=.639) and 2014 (P=.583) sample dates. No statistically significant difference was found in the overall CHC screening rates (P=.052), which were 47.69% and 40.84% in 2013 and 2014, respectively. During the study period, 99 eligible patients were seen. An incidental finding revealed a substantial EMR flaw in uniform data system reporting measures: self-reported colorectal cancer screenings by patients, without official documentation provided, were documented in an EMR section that is not retrieved during uniform data system reporting. CONCLUSION No associated change in colorectal cancer screening rates was found at the CHC after increasing participants' awareness of patients' screening eligibility using electronic flagging. However, colorectal cancer screening results cannot be reported with certainty given that incidental documentation and data collection discrepancies were found.
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Hills RL, Kulbok PA, Clark M. Evaluating a Quality Improvement Program for Cervical Cancer Screening at an Urban Safety Net Clinic. Health Promot Pract 2015; 16:631-41. [DOI: 10.1177/1524839915587269] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article evaluates a quality improvement program for improving guideline-consistent cervical cancer screening practices in an urban safety net clinic. Quality improvement initiatives that combine policy with practice are particularly timely in light of the alignment of cervical cancer screening guidelines released in 2012 by the most influential national organizations. A descriptive comparison design was employed using the Healthy People 2020 target of 93% screened according to guidelines. Provider-, patient-, and workflow-based strategies included (1) addition of a clinical decision support system, (2) provider educational outreach, (3) patient reminder letters, and (4) development of a clinic procedure manual. Through the application of an established quality measurement tool, three quality indicators were measured: screened according to evidence-based guidelines, not screened, and screened more frequently than recommended. Data from the sample (N = 1,032) were collected at baseline and 12 months postimplementation. Each quality indicator category was significant at follow-up. Patients screened according to guidelines nearly doubled while the number of underscreened patients was reduced by nearly half. Similarly, there was a threefold decrease in patients screened more frequently than recommended. Clinical administrators, quality improvement specialists, and health care providers in primary care settings can use the strategies implemented in this study as a starting point for continuous quality improvement initiatives for cervical cancer screening.
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Affiliation(s)
- Robin L. Hills
- University of Virginia School of Nursing, Charlottesville, VA, USA
| | - Pamela A. Kulbok
- University of Virginia School of Nursing, Charlottesville, VA, USA
| | - Myra Clark
- University of Virginia School of Nursing, Charlottesville, VA, USA
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Beaber EF, Kim JJ, Schapira MM, Tosteson ANA, Zauber AG, Geiger AM, Kamineni A, Weaver DL, Tiro JA. Unifying screening processes within the PROSPR consortium: a conceptual model for breast, cervical, and colorectal cancer screening. J Natl Cancer Inst 2015; 107:djv120. [PMID: 25957378 PMCID: PMC4838064 DOI: 10.1093/jnci/djv120] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 02/18/2015] [Accepted: 04/03/2015] [Indexed: 12/13/2022] Open
Abstract
General frameworks of the cancer screening process are available, but none directly compare the process in detail across different organ sites. This limits the ability of medical and public health professionals to develop and evaluate coordinated screening programs that apply resources and population management strategies available for one cancer site to other sites. We present a trans-organ conceptual model that incorporates a single screening episode for breast, cervical, and colorectal cancers into a unified framework based on clinical guidelines and protocols; the model concepts could be expanded to other organ sites. The model covers four types of care in the screening process: risk assessment, detection, diagnosis, and treatment. Interfaces between different provider teams (eg, primary care and specialty care), including communication and transfer of responsibility, may occur when transitioning between types of care. Our model highlights across each organ site similarities and differences in steps, interfaces, and transitions in the screening process and documents the conclusion of a screening episode. This model was developed within the National Cancer Institute-funded consortium Population-based Research Optimizing Screening through Personalized Regimens (PROSPR). PROSPR aims to optimize the screening process for breast, cervical, and colorectal cancer and includes seven research centers and a statistical coordinating center. Given current health care reform initiatives in the United States, this conceptual model can facilitate the development of comprehensive quality metrics for cancer screening and promote trans-organ comparative cancer screening research. PROSPR findings will support the design of interventions that improve screening outcomes across multiple cancer sites.
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Affiliation(s)
- Elisabeth F Beaber
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT).
| | - Jane J Kim
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Marilyn M Schapira
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Anna N A Tosteson
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Ann G Zauber
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Ann M Geiger
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Aruna Kamineni
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Donald L Weaver
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
| | - Jasmin A Tiro
- : Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA (EFB); Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (JJK); Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA (MMS); Department of Veterans Affairs Medical Center, Philadelphia, PA (MMS); Department of Medicine and The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH (ANAT); Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY (AGZ); Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD (AMG); Group Health Research Institute, Seattle, WA (AK); Department of Pathology and University of Vermont Cancer Center, University of Vermont, Burlington, VT (DLW); Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX (JAT)
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Daly JM, Levy BT, Moss CA, Bay CP. System Strategies for Colorectal Cancer Screening at Federally Qualified Health Centers. Am J Public Health 2015; 105:212-219. [PMID: 24832146 DOI: 10.2105/ajph.2013.301790] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. We assessed the protocols and system processes for colorectal cancer (CRC) screening at federally qualified health centers (FQHCs) in 4 midwestern states. Methods. We identified 49 FQHCs in 4 states. In January 2013, we mailed their medical directors a 49-item questionnaire about policies on CRC screening, use of electronic medical records, types of CRC screening recommended, clinic tracking systems, referrals for colonoscopy, and barriers to providing CRC. Results. Forty-four questionnaires (90%) were returned. Thirty-three of the respondents (75%) estimated the proportion of their patients up-to-date with CRC screening, with a mean of 35%. One major barrier to screening was inability to provide colonoscopy for patients with a positive fecal occult blood test (59%). The correlation of system strategies and estimated percentage of patients up-to-date with CRC screening was 0.43 (P = .01). Conclusions. CRC system strategies were associated with higher CRC screening rates. Implementing system strategies for CRC screening takes time and effort and is important to maintain, to help prevent, or to cure many cases of CRC, the second leading cause of cancer in the United States.
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Affiliation(s)
- Jeanette M Daly
- The authors are with the Department of Medicine, and Jeanette M. Daly, Barcey T. Levy, and Camden P. Bay are also with the Department of Epidemiology, College of Public Health, University of Iowa, Iowa City
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Robinson RF, Dillard DA, Hiratsuka VY, Smith JJ, Tierney S, Avey JP, Buchwald DS. Formative Evaluation to Assess Communication Technology Access and Health Communication Preferences of Alaska Native People. INTERNATIONAL JOURNAL OF INDIGENOUS HEALTH 2015; 10:88-101. [PMID: 27169131 DOI: 10.18357/ijih.102201515042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Information technology can improve the quality, safety, and efficiency of healthcare delivery by improving provider and patient access to health information. We conducted a nonrandomized, cross-sectional, self-report survey to determine whether Alaska Native and American Indian (AN/AI) people have access to the health communication technologies available through a patient-centered medical home. METHODS In 2011, we administered a self-report survey in an urban, tribally owned and operated primary care center serving AN/AI adults. Patients in the center's waiting rooms completed the survey on paper; center staff completed it electronically. RESULTS Approximately 98% (n = 654) of respondents reported computer access, 97% (n = 650) email access, and 94% (n = 631) mobile phone use. Among mobile phone users, 60% had Internet access through their phones. Rates of computer access (p = .011) and email use (p = .005) were higher among women than men, but we found no significant gender difference in mobile phone access to the Internet or text messaging. Respondents in the oldest age category (65-80 years of age) were significantly less likely to anticipate using the Internet to schedule appointments, refill medications, or communicate with their health care providers (all p < .001). CONCLUSION Information on use of health communication technologies enables administrators to deploy these technologies more efficiently to address health concerns in AN/AI communities. Our results will drive future research on health communication for chronic disease screening and health management.
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Plescia M, Wong F, Pieters J, Joseph D. The National Breast and Cervical Cancer Early Detection Program in the era of health reform: a vision forward. Cancer 2014; 120 Suppl 16:2620-4. [PMID: 25099907 DOI: 10.1002/cncr.28826] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 03/10/2014] [Indexed: 11/12/2022]
Abstract
For the last 22 years, the Centers for Disease Control and Prevention (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has provided high quality breast and cervical cancer screening to women who do not have health insurance or who have inadequate insurance. As the health care landscape changes, it is time for CDC to address new identified needs and opportunities to increase cancer screening and to further explore new or expanded roles for the program looking to the future. The NBCCEDP is well positioned to build upon its experience, established clinical and community partnerships, and success in serving disadvantaged and diverse populations to address important barriers to cancer screening that will persist as health reform is implemented. Additionally, the program can adapt its extensive experience with establishing and managing an organized system of delivering cancer screening and apply it to promote a more organized approach to screening through health care systems on a population level. Emphasis is placed on the implementation of evidenced-based interventions proven effective in increasing cancer screening rates, promising practices and other organizational policy and health systems interventions.
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Affiliation(s)
- Marcus Plescia
- Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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Miller JW, Baldwin LM, Matthews B, Trivers KF, Andrilla CH, Lishner D, Goff BA. Physicians' beliefs about effectiveness of cancer screening tests: a national survey of family physicians, general internists, and obstetrician-gynecologists. Prev Med 2014; 69:37-42. [PMID: 25038531 PMCID: PMC4539137 DOI: 10.1016/j.ypmed.2014.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 06/04/2014] [Accepted: 07/09/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To study physicians' beliefs about the effectiveness of different tests for cancer screening. METHODS Data were examined from the Women's Health Survey of 1574 Family Medicine, Internal Medicine, and Obstetrics-Gynecology physicians to questions about their level of agreement about the clinical effectiveness of different tests for breast, cervical, ovarian, and colorectal cancer screening among average risk women. Data were weighted to the U.S. physician population based on the American Medical Association Masterfile. Multivariable logistic regression identified physician and practice characteristics significantly associated with physicians' beliefs. RESULTS There were 1574 respondents, representing a 62% response rate. The majority of physicians agreed with the effectiveness of mammography for women aged 50-69years, Pap tests for women aged 21-65years, and colonoscopy for individuals aged ≥50years. A substantial proportion of physicians believed that non-recommended tests were effective for screening (e.g., 34.4% for breast MRI and 69.1% for annual pelvic exam). Physicians typically listed their respective specialty organizations as a top influential organization for screening recommendations. CONCLUSIONS There were several substantial inconsistencies between physician beliefs in the effectiveness of cancer screening tests and the actual evidence of these tests' effectiveness which can lead both to underuse and overuse of cancer screening tests.
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Affiliation(s)
- Jacqueline W Miller
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Laura-Mae Baldwin
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Barbara Matthews
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Katrina F Trivers
- Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - C Holly Andrilla
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Denise Lishner
- Department of Family Medicine, University of Washington, Seattle, WA, USA
| | - Barbara A Goff
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
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Tsui J, Hofstetter AM, Soren K. Cervical cytology screening among low-income, minority adolescents in New York City following the 2009 ACOG guidelines. Prev Med 2014; 63:81-6. [PMID: 24650625 PMCID: PMC4075324 DOI: 10.1016/j.ypmed.2014.03.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/04/2014] [Accepted: 03/10/2014] [Indexed: 11/18/2022]
Abstract
OBJECTIVES In December 2009, the American College of Obstetricians and Gynecologists recommended that cervical cancer screening begin at age 21 for young women. In this study, we examine receipt of first lifetime Papanicolaou (Pap) test and predictors of over-screening among adolescents within a large urban ambulatory care network. METHODS We compared the proportion of first lifetime Pap test of adolescents aged 13-20years between June 2007 - November 2009 (n=7700) and December 2009-June 2012 (n=9637) using electronic health records. We employed multivariable regression models to identify demographic and health care factors associated with receiving a first lifetime Pap test at age <21years in the post-guideline period (over-screening). RESULTS The proportion of Pap tests declined from 19.3% to 4.2% (p<0.001) between the two periods. Multivariable logistic regression results showed receiving care from gynecologic/obstetric/family planning clinics compared to pediatric clinics, having more clinic encounters, and older age were associated with over-screening in the post-guideline period. CONCLUSIONS We found that guideline adherence differed by clinic type, insurance status, and health care encounters. In the quickly evolving field of cervical cancer control, it is important to monitor practice trends as they relate to shifts in population-based guidelines, especially in high-risk populations.
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Affiliation(s)
- Jennifer Tsui
- Columbia University, Mailman School of Public Health, Department of Epidemiology, 722 West 168th St., New York, NY 10032, USA.
| | - Annika M Hofstetter
- Columbia University Medical Center, Division of Child and Adolescent Health, 622 West 168th St., New York, NY 10032, USA
| | - Karen Soren
- Columbia University Medical Center, Division of Child and Adolescent Health, 622 West 168th St., New York, NY 10032, USA; Columbia University, Mailman School of Public Health, Department of Population and Family Health, 722 West 168th St., New York, NY 10032, USA
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Abstract
Skin cancer screening (SCS) promotes early detection and improves treatment. Primary care providers are strategically positioned to provide screenings, yet the frequency is low. Strategies to improve SCS include increasing skin cancer awareness, targeting high-risk patient populations, and advocating for primary care providers to conduct screenings.
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Affiliation(s)
- Randy Gordon
- Randy Gordon is a doctor of nursing practice, Graduate Faculty, Department of Community/Mental Health at the University of South Alabama, College of Nursing, Mobile, Ala
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Pruitt SL, Leonard T, Zhang S, Schootman M, Halm EA, Gupta S. Physicians, clinics, and neighborhoods: multiple levels of influence on colorectal cancer screening. Cancer Epidemiol Biomarkers Prev 2014; 23:1346-55. [PMID: 24732630 DOI: 10.1158/1055-9965.epi-13-1130] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We (i) described variability in colorectal cancer (CRC) test use across multiple levels, including physician, clinic, and neighborhood; and (ii) compared the performance of novel cross-classified models versus traditional hierarchical models. METHODS We examined multilevel variation in CRC test use among patients not up-to-date with screening in a large, urban safety net health system (2011-2012). Outcomes included: (i) fecal occult blood test (FOBT) or (ii) colonoscopy and were ascertained using claims data during a 1-year follow-up. We compared Bayesian (i) cross-classified four-level logistic models nesting patients within separate, nonoverlapping "levels" (physicians, clinics, and census tracts) versus (ii) three hierarchical two-level models using deviance information criterion. Models were adjusted for covariates (patient sociodemographic factors, driving time to clinic, and census tract poverty rate). RESULTS Of 3,195 patients, 157 (4.9%) completed FOBT and 292 (9.1%) completed colonoscopy during the study year. Patients attended 19 clinics, saw 177 physicians, and resided in 332 census tracts. Significant variability was observed across all levels in both hierarchical and cross-classified models that was unexplained by measured covariates. For colonoscopy, variance was similar across all levels. For FOBT, physicians, followed by clinics, demonstrated the largest variability. Model fit using cross-classified models was superior or similar to 2-level hierarchical models. CONCLUSIONS Significant and substantial variability was observed across neighborhood, physician, and clinic levels in CRC test use, suggesting the importance of factors at each of these levels on CRC testing. IMPACT Future multilevel research and intervention should consider the simultaneous influences of multiple levels, including clinic, physician, and neighborhood.
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Affiliation(s)
- Sandi L Pruitt
- Authors' Affiliations: Department of Clinical Sciences; Harold C. Simmons Comprehensive Cancer Center;
| | - Tammy Leonard
- School of Economic, Political, and Policy Sciences, University of Texas-Dallas, Dallas, Texas
| | - Song Zhang
- Authors' Affiliations: Department of Clinical Sciences
| | - Mario Schootman
- Department of Epidemiology, College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri
| | - Ethan A Halm
- Authors' Affiliations: Department of Clinical Sciences; Department of General Internal Medicine, University of Texas Southwestern Medical Center
| | - Samir Gupta
- Division of Gastroenterology, Department of Internal Medicine, Moores Cancer Center, University of California San Diego; and Department of Veterans Affairs, San Diego Healthcare System, San Diego, California
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Brown ML, Klabunde CN, Cronin KA, White MC, Richardson LC, McNeel TS. Challenges in meeting Healthy People 2020 objectives for cancer-related preventive services, National Health Interview Survey, 2008 and 2010. Prev Chronic Dis 2014; 11:E29. [PMID: 24576396 PMCID: PMC3938963 DOI: 10.5888/pcd11.130174] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction Healthy People (HP) is the US program that formulates and tracks national health objectives for the nation. The National Health Interview Survey (NHIS) is a designated data source for setting and evaluating several HP targets in cancer. We used data from the 2008 and 2010 NHIS to provide a benchmark for national performance toward meeting HP 2020 cancer-related objectives. Methods HP 2020 cancer screening, provider counseling, and health care access objectives were selected. For each objective, NHIS measures for the overall population and several sociodemographic subgroups were calculated; the findings were compared with established HP 2020 targets. Results From 2008 to 2010, rates of breast and cervical cancer screening declined slightly while colorectal cancer screening rates increased by 7 percentage points. Rates of cancer screening and provider counseling were below HP targets. Meeting HP targets seems less likely for subgroups characterized by low income, no health insurance, or no usual source of care. Meeting HP targets for access to health services will require an increase of 18 percentage points in the proportion of persons under age 65 with health insurance coverage and an increase of 10 percentage points in the proportion aged 18 to 64 with a usual source of care. Conclusion Whether HP objectives for cancer screening and health care access are met may depend on implementation of health care reform measures that improve access to and coordination of care. Better integration of clinical health care and community-based efforts for delivering high-quality screening and treatment services and elimination of health disparities are also needed.
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Affiliation(s)
| | | | | | - Mary C White
- Centers for Disease Control and Prevention, Atlanta, Georgia
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Breast and Cervical Cancer Screening Disparities Associated with Disability Severity. Womens Health Issues 2014; 24:e147-53. [DOI: 10.1016/j.whi.2013.10.009] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 10/25/2013] [Accepted: 10/28/2013] [Indexed: 11/13/2022]
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Rustagi AS, Kamineni A, Weiss NS. Counterpoint: cervical cancer screening guidelines--approaching the golden age. Am J Epidemiol 2013; 178:1023-6; discussion 1027. [PMID: 23966564 PMCID: PMC3783099 DOI: 10.1093/aje/kwt171] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Changes in screening guidelines that imply suppression of procedures once recommended are always controversial because of the perception that benefits are being curtailed. Prior to 2012, cervical cancer screening guidelines issued by US-based expert bodies differed in several decision areas, making clinicians essentially cherry-pick among recommendations. To some extent, this approach to screening practices also served to shield clinicians from litigation. It implied starting screening earlier, doing it more frequently, and stopping later in life than necessary. This state of affairs changed in 2012, when the most influential professional groups updated their cervical screening guidelines, and recommendations became essentially unified. All groups recommended that women older than 65 years of age discontinue cervical cancer screening on the basis of evidence that screening benefits in this age group were minor and far outweighed by harms. The guidelines are very specific about the exceptions, which ensure acceptable safety. It is expected that the new guidelines will permit less wasteful cervical screening, while fostering the opportunity to direct resources towards ensuring adequate coverage of high-risk women.
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Affiliation(s)
- Alison S. Rustagi
- Correspondence to Dr. Alison S. Rustagi, Department of Global Health, Schools of Medicine and Public Health, University of Washington, Harris Hydraulics Building, 1510 San Juan Road, Seattle, WA 98195-7765 (e-mail: )
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Wagholikar KB, MacLaughlin KL, Kastner TM, Casey PM, Henry M, Greenes RA, Liu H, Chaudhry R. Formative evaluation of the accuracy of a clinical decision support system for cervical cancer screening. J Am Med Inform Assoc 2013; 20:749-57. [PMID: 23564631 PMCID: PMC3721177 DOI: 10.1136/amiajnl-2013-001613] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objectives We previously developed and reported on a prototype clinical decision support system (CDSS) for cervical cancer screening. However, the system is complex as it is based on multiple guidelines and free-text processing. Therefore, the system is susceptible to failures. This report describes a formative evaluation of the system, which is a necessary step to ensure deployment readiness of the system. Materials and methods Care providers who are potential end-users of the CDSS were invited to provide their recommendations for a random set of patients that represented diverse decision scenarios. The recommendations of the care providers and those generated by the CDSS were compared. Mismatched recommendations were reviewed by two independent experts. Results A total of 25 users participated in this study and provided recommendations for 175 cases. The CDSS had an accuracy of 87% and 12 types of CDSS errors were identified, which were mainly due to deficiencies in the system's guideline rules. When the deficiencies were rectified, the CDSS generated optimal recommendations for all failure cases, except one with incomplete documentation. Discussion and conclusions The crowd-sourcing approach for construction of the reference set, coupled with the expert review of mismatched recommendations, facilitated an effective evaluation and enhancement of the system, by identifying decision scenarios that were missed by the system's developers. The described methodology will be useful for other researchers who seek rapidly to evaluate and enhance the deployment readiness of complex decision support systems.
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Eckstrom E, Feeny DH, Walter LC, Perdue LA, Whitlock EP. Individualizing cancer screening in older adults: a narrative review and framework for future research. J Gen Intern Med 2013; 28:292-8. [PMID: 23054920 PMCID: PMC3614148 DOI: 10.1007/s11606-012-2227-x] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/21/2012] [Accepted: 08/31/2012] [Indexed: 12/18/2022]
Abstract
Older adults often have multiple chronic conditions that may decrease additional life expectancy. Research evaluating the benefits and harms of screening must include consideration of competing morbidities and patient heterogeneity (beyond age), potentially increased harms of screening, and patient preferences. Other areas in need of additional research include the lack of evidence for older adults on the harms of screening tests; the overdiagnosis of disease; the burden of disease labeling; the effects of inaccurate test results; the harms of disease treatment; and harms related to prioritization of healthcare (e.g., for a particular patient, lifestyle counseling may be more important than screening). Nontraditional outcomes, such as the effects on family caregivers, are also relevant. Studies comparing trajectories of quality-adjusted survival with and without screening to assess net benefit are typically lacking. There is little evidence on the preferences of older adults for deciding whether to be screened, the process of being screened, and the health states associated with being or not being screened. To enhance the quality and quantity of evidence, older adults need to be enrolled in screening trials and clinical studies. Measures of functional status and health-related quality of life (HRQL) need to be included in trials, registries, and cohort studies. This article addresses these challenges, and presents a framework for what research is needed to better inform screening decisions in older adults.
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Affiliation(s)
- Elizabeth Eckstrom
- Department of Medicine, Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L475, Portland, OR 97239, USA.
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