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Arevalo M, Sutton SK, Abdulla R, Christy SM, Meade CD, Roetzheim RG, Gwede CK. Longitudinal adherence to annual colorectal cancer screening among Black persons living in the United States enrolled in a community-based randomized trial. Cancer 2024; 130:1684-1692. [PMID: 38150285 PMCID: PMC11009071 DOI: 10.1002/cncr.35169] [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: 04/04/2023] [Revised: 11/07/2023] [Accepted: 11/27/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND This study examined repeat colorectal cancer screening rates at 12 and 24 months as part of a randomized intervention trial among Black persons living in the United States and factors associated with screening adherence. METHODS Participants completed a survey assessing demographics and Preventive Health Model (PHM) factors (e.g., self efficacy, susceptibility) and received either a culturally targeted photonovella plus free fecal immunochemical test (FIT) kits (intervention group) or a standard educational brochure plus free FIT kits (comparison group). FIT return was assessed at 6, 12, and 24 months. Descriptive statistics summarized patterns of repeat screening. Logistic regression models assessed FIT uptake overtime, and demographic and PHM factors associated with screening adherence. RESULTS Participants (N = 330) were U.S.-born (93%), non-Hispanic (97%), and male (52%). Initial FIT uptake within 6 months of enrollment was 86.6%, and subsequently dropped to 54.5% at 12 months and 36.6% at 24 months. Higher FIT return rates were observed for the brochure group at 24 months (51.5% vs 33.3% photonovella, p = .023). Multiple patterns of FIT kit return were observed: 37% completed FIT at all three time points (full adherence), 22% completed two of three (partial adherence), 29% completed one of three (partial adherence), and 12% did not return any FIT kits (complete nonadherence). Predictors of full adherence were higher levels of education and self-efficacy. CONCLUSIONS Full adherence to repeat screening was suboptimal. Most participants had partial adherence (one or two of three) to annual FIT screening. Future studies should focus on strategies to support repeat FIT screening.
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Affiliation(s)
- Mariana Arevalo
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA
| | - Steven K. Sutton
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Oncological Sciences, University of South Florida, Tampa, Florida, USA
| | - Rania Abdulla
- NTRO Non-Therapeutic Research Office, Moffitt Cancer Center, Tampa, FL, USA
| | - Shannon M. Christy
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Oncological Sciences, University of South Florida, Tampa, Florida, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Cathy D. Meade
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Oncological Sciences, University of South Florida, Tampa, Florida, USA
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
| | - Richard G. Roetzheim
- Department of Family Medicine, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Clement K. Gwede
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Oncological Sciences, University of South Florida, Tampa, Florida, USA
- Department of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, Florida, USA
- Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida, USA
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Coronado GD, Nyongesa DB, Petrik AF, Thompson JH, Escaron AL, Pham T, Leo MC. The Reach of Calls and Text Messages for Mailed FIT Outreach in the PROMPT Stepped-Wedge Colorectal Cancer Screening Trial. Cancer Epidemiol Biomarkers Prev 2024; 33:525-533. [PMID: 38319289 DOI: 10.1158/1055-9965.epi-23-0940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/27/2023] [Accepted: 02/02/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening participation. We assessed the reach and effectiveness of adding notifications to mailed FIT programs. METHODS We conducted secondary analyses of a stepped-wedge evaluation of an enhanced mailed FIT program (n = 15 clinics). Patients were stratified by prior FIT completion. Those with prior FIT were sent a text message (Group 1); those without were randomized 1:1 to receive a text message (Group 2) or live phone call (Group 3). All groups were sent automated phone call reminders. In stratified analysis, we measured reach and effectiveness (FIT completion within 6 months) and assessed patient-level associations using generalized estimating equations. RESULTS Patients (n = 16,934; 83% Latino; 72% completed prior FIT) were reached most often by text messages (78%), followed by live phone calls (71%), then automated phone calls (56%). FIT completion was higher in patients with prior FIT completion versus without [44% (Group 1) vs. 19% (Group 2 + Group 3); P < 0.01]. For patients without prior FIT, effectiveness was higher in those allocated to a live phone call [20% (Group 3) vs. 18% (Group 2) for text message; P = 0.04] and in those who personally answered the live call (28% vs. 9% no call completed; P < 0.01). CONCLUSIONS Text messages reached the most patients, yet effectiveness was highest in those who personally answered the live phone call. IMPACT Despite the broad reach and low cost of text messages, personalized approaches may more successfully boost FIT completion.
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Affiliation(s)
- Gloria D Coronado
- Kaiser Permanente Center for Health Research, Portland, Oregon
- University of Arizona Cancer Center, Tucson, Arizona
| | | | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Anne L Escaron
- AltaMed Health Services Corporation, Los Angeles, California
| | - Tuan Pham
- AltaMed Health Services Corporation, Los Angeles, California
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon
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Badicke B, Coury J, Myers E, Petrik AF, Hiebert Larson J, Bhadra S, Coronado GD, Davis MM. Effort Required and Lessons Learned From Recruiting Health Plans and Rural Primary Care Practices for a Cancer Screening Outreach Study. J Prim Care Community Health 2024; 15:21501319241259915. [PMID: 38864248 PMCID: PMC11177742 DOI: 10.1177/21501319241259915] [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: 03/28/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Recruiting organizations (i.e., health plans, health systems, or clinical practices) is important for implementation science, yet limited research explores effective strategies for engaging organizations in pragmatic studies. We explore the effort required to meet recruitment targets for a pragmatic implementation trial, characteristics of engaged and non-engaged clinical practices, and reasons health plans and rural clinical practices chose to participate. METHODS We explored recruitment activities and factors associated with organizational enrollment in SMARTER CRC, a randomized pragmatic trial to increase rates of CRC screening in rural populations. We sought to recruit 30 rural primary care practices within participating Medicaid health plans. We tracked recruitment outreach contacts, meeting content, and outcomes using tracking logs. Informed by the Consolidated Framework for Implementation Research, we analyzed interviews, surveys, and publicly available clinical practice data to identify facilitators of participation. RESULTS Overall recruitment activities spanned January 2020 to April 2021. Five of the 9 health plans approached agreed to participate (55%). Three of the health plans chose to operate centrally as 1 site based on network structure, resulting in 3 recruited health plan sites. Of the 101 identified practices, 76 met study eligibility criteria; 51% (n = 39) enrolled. Between recruitment and randomization, 1 practice was excluded, 5 withdrew, and 7 practices were collapsed into 3 sites for randomization purposes based on clinical practice structure, leaving 29 randomized sites. Successful recruitment required iterative outreach across time, with a range of 2 to 17 encounters per clinical practice. Facilitators to recruitment included multi-modal outreach, prior relationships, effective messaging, flexibility, and good timing. CONCLUSION Recruiting health plans and rural clinical practices was complex and iterative. Leveraging existing relationships and allocating time and resources to engage clinical practices in pragmatic implementation research may facilitate more diverse representation in future trials and generalizability of research findings.
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Affiliation(s)
| | | | - Emily Myers
- Oregon Health & Science University, Portland, OR, USA
| | | | | | | | - Gloria D. Coronado
- University of Arizona Cancer Center and College of Public Health, Tucson, AZ, USA
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Peng X, Tang G, Wang Y, Zeng F, Chen Y, Zhang W, Mo C, Yang Y, Li S, Bai L, Xiao D, Zheng G, Ran W, Chen C, Yang Y, Gao Y, Zhu S, Huang Z, Zhao D, Wu C, Xu L, Wei Z. Application of the 'online assessment + FOBT at home' to improve participation and the efficacy of opportunistic screening for colorectal cancer: a retrospective cohort study. BMC Public Health 2023; 23:2534. [PMID: 38110887 PMCID: PMC10729553 DOI: 10.1186/s12889-023-17426-5] [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: 05/14/2023] [Accepted: 12/06/2023] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND Colorectal cancer (CRC) screening faces two major challenges: insufficient screening coverage and poor adherence. A smartphone applet named "Early Screening Assistant (ESA)" was developed to create an online risk-assessment and fecal occult blood test (FOBT) at home. This retrospective study was designed to evaluate whether the new CRC screening strategy can improve the colonoscopy participation rate (PR) and lesion detection rate (DR). METHODS In total, 6194 individuals who accepted normal health examinations and CRC screening based on the ESA from June 2020 to May 2022 were assigned to the ESA group. Accordingly, 7923 inhabitants who only accepted normal health examinations were assigned to the control group. The colonoscopy PR and neoplastic lesion DR were then compared between the two groups. RESULTS Overall, a higher proportion of subjects in the ESA group (285 of 6194 [4.6%]) completed colonoscopy than in the control group (126 of 7923, [1.6%]), p < 0.01). The neoplastic lesion DR also significantly increased in the ESA group (76 of 6194 [1.22%]) compared with the control group (15 of 7923 [0.19%]) (p < 0.01). The adjusted diagnostic sensitivity and specificity of the "Online assessment + FOBT at home" were 41.5% and 62.6% for neoplastic lesions, respectively. CONCLUSIONS This retrospective cohort study confirmed that the new CRC screening strategy based on the "Online assessment + FOBT at home" can improve colonoscopy participation and the neoplastic lesion detection rate and may represent a promising screening strategy for CRC. TRIAL REGISTRATION This study was registered in China Clinical Trial Registry ( https://www.chictr.org.cn ) on 29/09/2022. REGISTRATION NUMBER ChiCTR2200064186.
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Affiliation(s)
- Xudong Peng
- Gastrointestinal Surgical Unit, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Gang Tang
- Gastrointestinal Surgical Unit, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Yonghong Wang
- Health Management Center, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Fanling Zeng
- Health Management Center, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Yuedong Chen
- Department of Gastrointestinal Surgery, People's Hospital of Tongliang District, Chongqing, China
| | - Weidan Zhang
- Department of Gastrointestinal Surgery, People's Hospital of Tongliang District, Chongqing, China
| | - Chunmei Mo
- Health Management Center, People's Hospital of Tongliang District, Chongqing, China
| | - Yana Yang
- Health Management Center, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Shuang Li
- Gastrointestinal Surgical Unit, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Lian Bai
- Gastrointestinal surgery Unit, Yongchuan hospital of Chongqing Medical university, Chongqing, China
| | - Dachun Xiao
- Gastrointestinal surgery Unit, Yongchuan hospital of Chongqing Medical university, Chongqing, China
| | - Guolian Zheng
- Health Management Department, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Wenhua Ran
- Department of General Surgery, Qianjiang Central Hospital, Chongqing, Chongqing, China
| | - Cheng Chen
- Department of General Surgery, Qianjiang Central Hospital, Chongqing, Chongqing, China
| | - Yonghong Yang
- Department of Health Management, Qianjiang Central Hospital, Chongqing, Chongqing, China
| | - Yuanze Gao
- Anorectal Department, The Ninth People's Hospital of Chongqing, Chongqing, China
| | - Shuangwei Zhu
- Gastroenteroanal Surgery, Fuling People's Hospital Of Chongqing, Chongqing, China
| | - Zheng Huang
- Gastrointestinal Surgical Unit, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Dongqing Zhao
- Gastrointestinal Surgical Unit, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Chaofeng Wu
- Gastrointestinal Surgical Unit, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China
| | - Li Xu
- Health Management Center, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China.
| | - Zhengqiang Wei
- Gastrointestinal Surgical Unit, The First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuzhong District, 400000, Chongqing, China.
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Coronado GD, Nyongesa DB, Escaron AL, Petrik AF, Thompson JH, Smith D, Davis MM, Schneider JL, Rivelli JS, Laguna T, Leo MC. Effectiveness and Cost of an Enhanced Mailed Fecal Test Outreach Colorectal Cancer Screening Program: Findings from the PROMPT Stepped-Wedge Trial. Cancer Epidemiol Biomarkers Prev 2023; 32:1608-1616. [PMID: 37566431 DOI: 10.1158/1055-9965.epi-23-0597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/18/2023] [Accepted: 08/09/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening rates, yet little is known about how to optimize these programs for effectiveness and cost. METHODS PROMPT was a pragmatic, stepped-wedge, cluster-randomized effectiveness trial of mailed FIT outreach. Participants in the standard condition were mailed a FIT and received live telephone reminders to return it. Participants in the enhanced condition also received a tailored advance notification (text message or live phone call) and two automated phone call reminders. The primary outcome was 6-month FIT completion; secondary outcomes were any colorectal cancer screening completion at 6 months, implementation, and program costs. RESULTS The study included 27,585 participants (80% ages 50-64, 82% Hispanic/Latino; 68% preferred Spanish). A higher proportion of enhanced participants completed FIT at 6 months than standard participants, both in intention-to-treat [+2.8%, 95% confidence interval (CI; 0.4-5.2)] and per-protocol [limited to individuals who were reached; +16.9%, 95% CI (12.3-20.3)] analyses. Text messages and automated calls were successfully delivered to 91% to 100% of participants. The per-patient cost for standard mailed FIT was $10.84. The enhanced program's text message plus automated call reminder cost an additional $0.66; live phone calls plus an automated call reminder cost an additional $10.82 per patient. CONCLUSIONS Adding advance notifications and automated calls to a standard mailed FIT program boosted 6-month FIT completion rates at a small additional per-patient cost. IMPACT Enhancements to mailed FIT outreach can improve colorectal cancer screening participation. Future research might test the addition of educational video messaging for screening-naïve adults.
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Affiliation(s)
| | | | - Anne L Escaron
- AltaMed Health Services, Corporation, Los Angeles, California
| | - Amanda F Petrik
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | - Dave Smith
- Kaiser Permanente Center for Health Research, Portland, Oregon
| | | | | | | | - Tanya Laguna
- AltaMed Health Services, Corporation, Los Angeles, California
| | - Michael C Leo
- Kaiser Permanente Center for Health Research, Portland, Oregon
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Davis MM, Coury J, Larson JH, Gunn R, Towey EG, Ketelhut A, Patzel M, Ramsey K, Coronado GD. Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot. J Rural Health 2023; 39:279-290. [PMID: 35703582 PMCID: PMC9969840 DOI: 10.1111/jrh.12685] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer (CRC) screening rates. We piloted a collaborative mailed FIT program with health plans and rural clinics to evaluate preliminary effectiveness and refine implementation strategies. METHODS We conducted a single-arm study using a convergent, parallel mixed-methods design to evaluate the implementation of a collaborative mailed FIT program. Enrollees were identified using health plan claims and confirmed via clinic scrub. The intervention included a vendor-delivered automated phone call (auto-call) prompt, FIT mailing, and reminder auto-call; clinics were encouraged to make live reminder calls. Practice facilitation was the primary implementation strategy. At 12 months post mailing, we assessed the rates of: (1) mailed FIT return and (2) completion of any CRC screening. We took fieldnotes and conducted postintervention key informant interviews to assess implementation outcomes (eg, feasibility, acceptability, and adaptations). RESULTS One hundred and sixty-nine Medicaid or Medicare enrollees were mailed a FIT. Over the 12-month intervention, 62 participants (37%) completed screening of which 21% completed the mailed FIT (most were returned within 3 months), and 15% screened by other methods (FITs distributed in-clinic, colonoscopy). Enrollee demographics and the reminder call may encourage mailed FIT completion. Program feasibility and acceptability was high and supported by perceived positive benefit, alignment with existing workflows, adequate staffing, and practice facilitation. CONCLUSION Collaborative health plan-clinic mailed FIT programs are feasible and acceptable for implementation in rural clinics and support CRC screening completion. Studies that pragmatically test collaborative approaches to mailed FIT and patient navigation follow-up after abnormal FIT and support broad scale-up in rural settings are needed.
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Affiliation(s)
- Melinda M. Davis
- Oregon Rural Practice-based Research Network, Portland, Oregon, USA,Department of Family Medicine and School of Public Health, Oregon Health & Science University, Portland, Oregon, USA
| | - Jen Coury
- Oregon Rural Practice-based Research Network, Portland, Oregon, USA
| | | | | | | | | | - Mary Patzel
- Oregon Rural Practice-based Research Network, Portland, Oregon, USA
| | - Katrina Ramsey
- Biostatistics, Epidemiology, and Research Design (BERD) Program, Oregon Health & Science University, Portland, Oregon, USA
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Escaron AL, Garcia J, Petrik AF, Ruiz E, Nyongesa DB, Thompson JH, Coronado GD. Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center. J Prim Care Community Health 2022; 13:21501319221138423. [PMID: 36448466 PMCID: PMC9716593 DOI: 10.1177/21501319221138423] [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: 12/02/2022] Open
Abstract
OBJECTIVE Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC. METHODS As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients' preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient's electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes. RESULTS We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%). CONCLUSIONS Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.
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Affiliation(s)
- Anne L. Escaron
- AltaMed Health Services Corporation, Los Angeles, CA, USA,Anne L. Escaron, AltaMed Health Services Corporation, 2040 Camfield Ave, Los Angeles, CA 90040-1589, USA.
| | - Joanna Garcia
- AltaMed Health Services Corporation, Los Angeles, CA, USA
| | | | - Esmeralda Ruiz
- AltaMed Health Services Corporation, Los Angeles, CA, USA
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Levitz CE, Kuo ES, Guo M, Ruiz E, Torres-Ozadali E, Brar Prayaga R, Escaron A. Using Text Messages and Fotonovelas to Increase Return of Home-Mailed Colorectal Cancer Screening Tests: Evaluation of a Quality Improvement Project (Preprint). JMIR Cancer 2022. [DOI: 10.2196/39645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Zoellner JM, Porter KJ, Thatcher E, Allanson D, Brauns M. Improving Fecal Immunochemical Test Return Rates: A Colorectal Cancer Screening Quality Improvement Project in a Multisite Federally Qualified Health Center. Health Promot Pract 2022:15248399221083294. [PMID: 35382617 DOI: 10.1177/15248399221083294] [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: 11/16/2022]
Abstract
The goal of this quality improvement project was to improve colorectal cancer (CRC) screening rates in a multicenter federally qualified health center (FQHC) within the Central Appalachian region of rural, southwestern Virginia. Guided by the Plan-Do-Study-Act (PDSA) cycle, the objectives were to (1) evaluate implementation processes and effectiveness of an automated electronic medical record patient reminder system to promote fecal immunochemical test (FIT) completion, compared with live telephone reminders delivered by a care coordinator (i.e., usual care), and (2) explore staff perceptions related to improving CRC screening rates. In total, 119 FITs were distributed with 59 assigned to usual care and 60 to the automated groups. In the usual care group, 79% patients with completed protocol returned their FIT; 9% were positive. In the automated reminder group, 76% patients with completed protocol returned their FIT; 10% were positive. There was no significant difference in the number of contacts per patients between the usual care (2.0, SD = 0.82 contacts/patient) and automated (1.8, SD = 0.98 contacts/patient) groups (p = .248). In total, the usual care and automated groups required 56 and 17 live calls, respectively. Overall, FQHC system-wide CRC screening rates increase from 30.5% to 47.3%. Ten staff interviews revealed perceptions of CRC screening, the QI project, and organizational change processes that may inform future cancer control projects. Researcher and practitioners should consider PDSA quality improvement projects as an initial step to build capacity and improve CRC screening rates, especially when working in FQHC with limited resources to engage in large complex research projects.
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Affiliation(s)
- Jamie M Zoellner
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | | | - Dylan Allanson
- University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Michelle Brauns
- Community Health Center of the New River Valley, Christiansburg, VA, USA
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Mittendorf KF, Knerr S, Kauffman TL, Lindberg NM, Anderson KP, Feigelson HS, Gilmore MJ, Hunter JE, Joseph G, Kraft SA, Zepp JM, Syngal S, Wilfond BS, Goddard KAB. Systemic Barriers to Risk-Reducing Interventions for Hereditary Cancer Syndromes: Implications for Health Care Inequities. JCO Precis Oncol 2021; 5:PO.21.00233. [PMID: 34778694 PMCID: PMC8585306 DOI: 10.1200/po.21.00233] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/21/2021] [Accepted: 09/28/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kathleen F. Mittendorf
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Sarah Knerr
- School of Public Health, University of Washington, Seattle, WA
| | - Tia L. Kauffman
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Nangel M. Lindberg
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | | | | | - Marian J. Gilmore
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Jessica Ezzell Hunter
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Galen Joseph
- Department of Humanities and Social Sciences, University of California, San Francisco, School of Medicine, San Francisco, CA
| | - Stephanie A. Kraft
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Jamilyn M. Zepp
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
| | - Sapna Syngal
- Dana Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Brigham and Women's Hospital, Boston, MA
| | - Benjamin S. Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital and Research Institute, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Katrina A. B. Goddard
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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Coronado GD, Nyongesa DB, Petrik AF, Thompson JH, Escaron AL, Younger B, Harbison S, Leo MC. Randomized Controlled Trial of Advance Notification Phone Calls vs Text Messages Prior to Mailed Fecal Test Outreach. Clin Gastroenterol Hepatol 2021; 19:2353-2360.e2. [PMID: 32739569 PMCID: PMC9285860 DOI: 10.1016/j.cgh.2020.07.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 07/21/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Mailing fecal immunochemical test (FITs) to individuals who are due for screening (mailed FIT outreach) increases colorectal cancer (CRC) screening. Little is known about how phone-based advance notifications (primers) affect the effectiveness of mailed FIT outreach programs. METHODS We performed a prospective study of patients at a large urban health center, 50-75 years old and due for screening, with no record of a prior FIT. Participants were randomly assigned to groups that received a live phone call primer (n = 1203) or a text message primer (n = 1622), from June through December 2018. The participants were then mailed a FIT kit, followed by 2 automated calls, and live reminder calls delivered by the care team. The main outcome was completion of FIT within 3 months of assignment to the live phone call or text message group. RESULTS Participants had a FIT completion rate of 16.8%, a mean age of 58 years, and 80% were Latino. In adjusted intention to treat analyses (n = 2825), FIT completion rates were higher in the patients assigned to receive a live phone call vs text message primer (percentage point difference, 3.3%; 95% CI, 0.4%-6.2%). Between-group differences increased to 7.3% points (95% CI, 3.6%-11.0%) in the per-protocol analysis of 2144 participants reached by the text message (1320/1622, 81%), live call (438/1203, 36%), or voice message (386/1203, 32%). This rate increased to 14.9% points (95% CI; 9.6%-20.1%) in the per-protocol analysis of 1758 participants reached by the text message or reached by the live call. CONCLUSIONS In a randomized trial, advance notification live phone calls outperformed text messages in prompting health center patients who had not previously completed a FIT to complete a mailed FIT. Clinicaltrials.gov no: NCT03167125.
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Affiliation(s)
- Gloria D. Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Denis B. Nyongesa
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Amanda F. Petrik
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | - Jamie H. Thompson
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
| | | | | | | | - Michael C. Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon
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12
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Rozario MA, Walton A, Kang M, Padilla BI. Colorectal Cancer Screening: A Quality Improvement Initiative Using a Bilingual Patient Navigator, Mobile Technology, and Fecal Immunochemical Testing to Engage Hispanic Adults. Clin J Oncol Nurs 2021; 25:423-429. [PMID: 34269353 DOI: 10.1188/21.cjon.423-429] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fecal immunochemical tests (FITs) are an effective screening method to detect and prevent colorectal cancer (CRC) when done in appropriate intervals. The use of bilingual patient navigators (PNs) and secure short message service (SMS) has been demonstrated to increase CRC screening rates among Hispanic adults. OBJECTIVES The purpose of this quality improvement project is to increase CRC screening rates among Hispanic adults in a family clinic by 25% in the post-project implementation period using an unlicensed bilingual PN, secure SMS, and at-home FITs. METHODS A retrospective chart review was used. Spanish-translated educational videos were delivered using SMS, and instructional screening guidance was provided via telephone in Spanish by the PN. Participants were surveyed to determine satisfaction with the support received from the PN. FINDINGS Findings showed a 35% increase in the clinic's FIT rates. Findings also showed that having a PN's support influenced the decision to complete FIT as compared to the use of secure SMS.
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13
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Ruco A, Dossa F, Tinmouth J, Llovet D, Jacobson J, Kishibe T, Baxter N. Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis. J Med Internet Res 2021; 23:e26759. [PMID: 34328423 PMCID: PMC8367160 DOI: 10.2196/26759] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/15/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023] Open
Abstract
Background Cancer is a leading cause of death, and although screening can reduce cancer morbidity and mortality, participation in screening remains suboptimal. Objective This systematic review and meta-analysis aims to evaluate the effectiveness of social media and mobile health (mHealth) interventions for cancer screening. Methods We searched for randomized controlled trials and quasi-experimental studies of social media and mHealth interventions promoting cancer screening (breast, cervical, colorectal, lung, and prostate cancers) in adults in MEDLINE, Embase, PsycINFO, Scopus, CINAHL, Cochrane Central Register of Controlled Trials, and Communication & Mass Media Complete from January 1, 2000, to July 17, 2020. Two independent reviewers screened the titles, abstracts, and full-text articles and completed the risk of bias assessments. We pooled odds ratios for screening participation using the Mantel-Haenszel method in a random-effects model. Results We screened 18,008 records identifying 39 studies (35 mHealth and 4 social media). The types of interventions included peer support (n=1), education or awareness (n=6), reminders (n=13), or mixed (n=19). The overall pooled odds ratio was 1.49 (95% CI 1.31-1.70), with similar effect sizes across cancer types. Conclusions Screening programs should consider mHealth interventions because of their promising role in promoting cancer screening participation. Given the limited number of studies identified, further research is needed for social media interventions. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42019139615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=139615 International Registered Report Identifier (IRRID) RR2-10.1136/bmjopen-2019-035411
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Affiliation(s)
- Arlinda Ruco
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Fahima Dossa
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jill Tinmouth
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Prevention & Cancer Control, Ontario Health (Cancer Care Ontario), Toronto, ON, Canada.,Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Diego Llovet
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Prevention & Cancer Control, Ontario Health (Cancer Care Ontario), Toronto, ON, Canada
| | - Jenna Jacobson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Ted Rogers School of Management, Ryerson University, Toronto, ON, Canada
| | - Teruko Kishibe
- Library Services, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Nancy Baxter
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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14
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Gruner LF, Amitay EL, Heisser T, Guo F, Niedermaier T, Gies A, Hoffmeister M, Brenner H. The Effects of Different Invitation Schemes on the Use of Fecal Occult Blood Tests for Colorectal Cancer Screening: Systematic Review of Randomized Controlled Trials. Cancers (Basel) 2021; 13:cancers13071520. [PMID: 33806234 PMCID: PMC8037417 DOI: 10.3390/cancers13071520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary There is large heterogeneity in invitation schemes and participation rates in colorectal cancer screening programs offering fecal occult blood tests (nowadays mostly fecal immunochemical tests). It is unclear what the most effective invitation strategies are for fecal occult blood tests. In this systematic review, advance notification, mailed fecal occult blood test, and reminders had major, consistent, and complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening. Our findings show that the effectiveness of invitations for fecal occult blood test-based colorectal cancer screening can be substantially increased across several settings by the implementation of comprehensive invitation strategies. Abstract Personal invitations for fecal occult blood tests (nowadays mostly fecal immunochemical tests) are increasingly used to raise their usage for colorectal cancer screening. However, there is a large heterogeneity in applied invitation schemes. We aimed to review evidence for the effectiveness of various invitation schemes. The main outcome was the fecal occult blood test usage rate. A systematic search was performed in Medline and Web of Science (up to 9 July 2020). Randomized controlled trials or cluster-randomized controlled trials were eligible, which reported on general invitations for fecal occult blood test-based colorectal cancer screening sent to the general population at average colorectal cancer risk. (PROSPERO 2020 CRD42020169409). Overall, 34 studies were included. Invitations with an attached, i.e., mailed fecal occult blood test consistently increased test usage by 4–19.7% points, compared to other methods of test provision. Likewise, the introduction of advance notification consistently led to a higher usage rate, with an increase of 3.3–10.8% points. Reminders showed positive but varying effects by method. With an increase of 8.5–15.8% points, letter or email reminders were more effective than reminders by phone call or text message (0.6–6.5% points). Inconsistent results were found for financial incentives ((−8.4)–20% points) and for added or changed invitation material ((−3.5)–11.8% points). With 3.5–24.7% points, the strongest increases in use were achieved by multifaceted invitation, implementing multiple components. Any invitation scheme was superior over no invitation. Advance notification, mailing of fecal occult blood test, and reminders were consistently shown to have major, complementary potential to increase participation in fecal occult blood test-based colorectal cancer screening settings.
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Affiliation(s)
- Laura F. Gruner
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Medical Faculty Heidelberg, Heidelberg University, 69120 Heidelberg, Germany
| | - Efrat L. Amitay
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Thomas Heisser
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Medical Faculty Heidelberg, Heidelberg University, 69120 Heidelberg, Germany
| | - Feng Guo
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Tobias Niedermaier
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Anton Gies
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
| | - Michael Hoffmeister
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
| | - Hermann Brenner
- German Cancer Research Center (DKFZ), Division of Clinical Epidemiology and Aging Research, 69120 Heidelberg, Germany; (L.F.G.); (E.L.A.); (T.H.); (F.G.); (T.N.); (M.H.)
- Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), 69120 Heidelberg, Germany;
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-6221-421300; Fax: +49-6221-4213002
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15
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Davis MM, Schneider JL, Gunn R, Rivelli JS, Vaughn KA, Coronado GD. A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program. Transl Behav Med 2021; 11:540-548. [PMID: 32083287 PMCID: PMC7963281 DOI: 10.1093/tbm/ibaa010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English- and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2-3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.
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Affiliation(s)
- Melinda M Davis
- Oregon Rural Practice-Based Research Network, Department of Family Medicine, and School of Public Health, Oregon Health and Science University, Mail Code, Portland, OR, USA
| | | | - Rose Gunn
- Oregon Rural Practice-based Research Network, Oregon Health and Science University, Portland, OR, USA
| | - Jennifer S Rivelli
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Katherine A Vaughn
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
| | - Gloria D Coronado
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR, USA
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16
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Myers L, Goodwin B, Ralph N, Castro O, March S. Implementation Strategies for Interventions Aiming to Increase Participation in Mail-Out Bowel Cancer Screening Programs: A Realist Review. Front Oncol 2020; 10:543732. [PMID: 33117681 PMCID: PMC7550731 DOI: 10.3389/fonc.2020.543732] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/13/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Bowel cancer is the third most commonly diagnosed cancer and the third most common cause of cancer-related death, with 1,849,518 new cases of bowel diagnosed and 880,792 deaths reported globally in 2018 alone. Survival can be improved through early detection via national mail-out bowel cancer screening programs; however, participation remains low in many countries. Behavior change is therefore required to increase participation. This realist review aims to (a) identify the behavior change techniques (BCTs) used in each intervention, (b) understand the mechanisms of action (MoAs) responsible for the BCT effectiveness, and (c) apply a behavior change model to inform how MoAs can be combined to increase screening participation. Methods: We systematically reviewed the literature for interventions aiming to increase participation in mail-out bowel cancer screening. We used a four-stage realist synthesis approach whereby (1) interventions were extracted from each study; (2) BCTs applied in each intervention were identified and coded using the BCT Taxonomy-v1; (3) the Theory and Techniques Tool was used to link BCTs to their MoA; and (4) BCTs and MoAs were categorized according to their effectiveness and what Health Action Process Approach (HAPA) stage of change they would affect. Results: We identified 68 intervention trials using 26 unique BCTs and 13 MoAs to increase participation. Sixteen BCTs and 10 MoAs were identified within the interventions that successfully increased participation rates. Interventions targeting both stages of the HAPA model had a higher success rate (80%) than those targeting one stage of change (51%). When targeting only one stage, interventions targeting the volitional stage had a higher success rate (71%) than interventions targeting only the motivational stage of change (26%). Conclusion: Importantly, this review identified a suite of BCTs and MoAs effective for increasing participation in mail-out bowel cancer screening programs. With increased participation in bowel cancer screening leading to improved survival, our findings are key to informing the improvement of policy and interventions that aim to increase screening using specific strategies at key stages of health decision-making.
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Affiliation(s)
- Larry Myers
- Centre for Health, Informatics, and Economic Research, University of Southern Queensland, Springfield Central, QLD, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Belinda Goodwin
- School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia.,Cancer Research Centre, Cancer Council Queensland, Brisbane, QLD, Australia
| | - Nicholas Ralph
- Cancer Research Centre, Cancer Council Queensland, Brisbane, QLD, Australia.,School of Nursing & Midwifery, University of Southern Queensland, Toowoomba, QLD, Australia.,Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Oscar Castro
- Physically Active Lifestyles Research Group, Institute for Resilient Regions, University of Southern Queensland, Springfield Central, QLD, Australia
| | - Sonja March
- Centre for Health, Informatics, and Economic Research, University of Southern Queensland, Springfield Central, QLD, Australia.,School of Psychology and Counselling, University of Southern Queensland, Springfield Central, QLD, Australia
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17
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Moses KA. Moving from theory to practice: A call to action on cancer disparities. Cancer 2019; 125:3504-3505. [PMID: 31355914 DOI: 10.1002/cncr.32419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/26/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Kelvin A. Moses
- Department of Urology Vanderbilt University Medical Center Nashville Tennessee
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