Christina M. Robinson

Telephone Care Management To Improve Cancer Screening among Low-Income Women: A Randomized, Controlled Trial

Context Minority and low-income women have low screening rates for cancer. Contribution In this trial from 11 community and migrant health centers in New York City, 1413 women overdue for cancer screening were randomly assigned to receive a telephone-based intervention (delivered by 8 prevention care managers) or usual care. The intervention included information about breast, cervical, and colorectal cancer and motivational and logistical support for obtaining screening. Within 18 months, the screening rates for all 3 forms of cancer increased more with telephone support than through usual care. Implications Telephone support delivered by trained personnel can improve cancer screening rates among some minority, low-income women. The Editors Higher screening rates for breast, cervical, and colorectal cancer could reduce cancer mortality rates substantially (1-4). Current cancer screening rates are particularly disappointing among ethnic minorities and individuals with low socioeconomic status (5, 6) who often present with late-stage diagnoses (7) and have high mortality rates (8, 9). Interventions to increase cancer screening have shown limited sustainability and effect on health care disparities. A previous study showed that an office systems approach, which used a medical record flowsheet and practice teamwork, increased screening rates by 20% to 33% in small rural community practices (10); however, a similar intervention was less effective in larger urban practices (11). An office intervention in low-income settings in Florida increased mammography use and home fecal occult blood testing at 12 months (12), but rates decreased substantially after research support ended (13). Use of the telephone to support cancer screening is well documented (14-18), but interventions have typically addressed a single form of cancer screening. In some settings, telephone infrastructures to support childhood immunization (19) and patients with chronic illnesses (20-23) already exist. These infrastructures could add screening support for patients who are already enrolled, or they could expand services to others while making minimal additional demands on primary care practices (24). This paper reports the results of a randomized, controlled trial that tested the effect of centralized telephone care management on cancer screening rates among women 50 to 69 years of age who obtained care at community and migrant health centers in New York City. Methods Settings Federally qualified community and migrant health centers provide comprehensive community-oriented primary care to over 12 million patients nationally (25) and are uniquely positioned to deliver cancer screenings to underserved and minority populations. We sought participation from 15 of the 21 community and migrant health centers in New York City because of their anticipated ability to provide sufficient patients for the study and their affiliations with tertiary care facilities that conduct mammography and colorectal screening and provide follow-up services for abnormal test results. Of these 15 sites, 2 were involved in competing research projects, 2 had few patients who were likely to be eligible and therefore served as pilot sites, and the remaining 11 participated. Clinical Directors Network, a practice-based research network in New York City, was responsible for recruiting clinicians, practices, and women and for implementing the intervention and evaluation. The project was approved by the Committee for the Protection of Human Subjects at Dartmouth College, by the institutional review board at Clinical Directors Network, and by all relevant bodies responsible for reviewing research at participating community and migrant health centers. Patients Recruitment Women were approached by research assistants during routine visits to the centers or were referred by a clinician. Research assistants explained the study and obtained written informed consent from women who agreed to participate. Women were compensated

Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.

15 for participating in an interview whether or not they met eligibility criteria. Eligibility Eligible women were 50 to 69 years of age, were overdue for at least 1 cancer screening according to their medical records, were patients of the center for at least 6 months, and had no plans to move or change health centers within 15 months. We excluded women whose primary language was not English, Spanish, or Haitian Creole and those who were acutely ill or currently receiving cancer treatment. After we obtained consent, a research assistant reviewed patient medical records to confirm eligibility. Mammography and Papanicolaou tests that were performed within the past year were seen as evidence of breast and cervical cancer screening, respectively, whereas reports of home fecal occult blood testing within the past year, sigmoidoscopy within the past 5 years, or colonoscopy within the past 10 years were seen as evidence of colorectal cancer screening. Women whose charts indicated that they were up to date on all 3 cancer screenings were excluded. We also excluded women with unresolved abnormal screening results (for example, positive results on home fecal occult blood testing; mammography results that were categorized as American College of Radiology level 0, 4, or 5; and certain Papanicolaou test results) and notified their physicians of these findings. Design Eligible, consenting women were grouped by center, duration of enrollment at their center (12 months or >12 months), and the number of cancer screenings that they had received at recommended intervals (0 or 1 screening or 2 screenings). The New Yorkbased research assistant assigned women in each group to receive the intervention or usual care by using sealed randomization forms that were produced by Dartmouth College staff with a computer-based random-number generator. Patients were informed of their group assignment individually by telephone. At time of consent, all women received the publication titled Put Prevention into Practice Personal Health Guide (26), which contained information regarding recommended preventive services. Women who were assigned to the usual care group received a single telephone call during which trial staff answered questions about preventive care, informed women of their usual care status, advised them to obtain needed preventive care from their primary care clinician, and thanked them for their participation. Women who were assigned to the intervention group received a series of telephone support calls from a trained prevention care manager who was monitored to ensure quality and consistency. In much the same way that patient navigators guide women through the health care system during cancer treatment (27), prevention care managers facilitated the screening process for each woman by addressing barriers that prevent or delay receipt of cancer screenings. Prevention care managers received 7 hours of training, including an overview of the U.S. Preventive Services Task Force guidelines (28-30); a review of barriers to breast, cervical, and colorectal cancer screenings; and detailed explanations of the targeted screenings. Additional training included role-playing telephone calls during which the managers used the intervention scripts. Thereafter, logs were reviewed in monthly meetings to ensure fidelity to the intervention. The 8 prevention care managers were women, and most were college graduates. Their assignments were determined by patient language needs. Each care manager focused most of her work on patients from 1 or 2 sites while supporting smaller numbers of patients from other sites; contact with clinicians was limited. During the first call with a patient in the intervention group, the prevention care manager answered questions about the health guide and confirmed or updated screening dates found in the womans medical record. She next determined how ready the woman was to act on each screening (31) and worked with the woman to prioritize overdue screenings. The prevention care manager then provided motivational support, responding to each participants specific barriers to screening by using a structured script that was developed through an earlier series of interviews with women (32). Some participants had been advised during office visits with their clinicians to undergo screening; those who had not received such recommendations were sent a written recommendation from their clinician. Women who reported that they had difficulty communicating with their physician were sent brightly colored patient activation cards that listed overdue screenings, which they could share with their clinician at their next appointment. Care managers also scheduled appointments, provided accurate information about screenings over the telephone and by mail, prompted women with appointment reminder calls and letters, provided directions to screening facilities, and helped women to find a means of transportation to appointments. During subsequent calls, which continued for 18 months or until the patient was up to date for all screenings, the prevention care manager asked about future appointments and screenings the patient had received since the last call. The manager then responded to new and ongoing barriers for remaining overdue screenings. Only clinicians, not care managers, were responsible for ordering screenings at all but 2 centers, which permitted care managers to mail home fecal occult blood test kits directly to women who were willing to perform this test. Evaluation Descriptive data on the centers were gathered from surveys that were completed by clinicians and clinical directors. Outcome data were based on reviews of patient medical records, which were conducted at least 3 months after the intervention period to allow for the time lag between receipt of a service and the availability of documentation. Data included patient demographic characteristics, screening dates and results, chronic il

Translation of an Efficacious Cancer-Screening Intervention to Women Enrolled in a Medicaid Managed Care Organization

OBJECTIVES:Detection and removal of adenomas and clinically significant serrated polyps (CSSPs) is critical to the effectiveness of colonoscopy in preventing colorectal cancer. Although longer withdrawal time has been found to increase polyp detection, this association and the use of withdrawal time as a quality indicator remains controversial. Few studies have reported on withdrawal time and serrated polyp detection. Using data from the New Hampshire Colonoscopy Registry, we examined how an endoscopists withdrawal time in normal colonoscopies affects adenoma and serrated polyp detection.METHODS:We analyzed 7,996 colonoscopies performed in 7,972 patients between 2009 and 2011 by 42 endoscopists at 14 hospitals, ambulatory surgery centers, and community practices. CSSPs were defined as sessile serrated polyps and hyperplastic polyps proximal to the sigmoid. Adenoma and CSSP detection rates were calculated based on median endoscopist withdrawal time in normal exams. Regression models were used to estimate the association of increased normal withdrawal time and polyp, adenoma, and CSSP detection.RESULTS:Polyp and adenoma detection rates were highest among endoscopists with 9 min median normal withdrawal time, and detection of CSSPs reached its highest levels at 8–9 min. Incident rate ratios for adenoma and CSSP detection increased with each minute of normal withdrawal time above 6 min, with maximum benefit at 9 min for adenomas (1.50, 95% confidence interval (CI) (1.21, 1.85)) and CSSPs (1.77, 95% CI (1.15, 2.72)). When modeling was used to set the minimum withdrawal time at 9 min, we predicted that adenomas and CSSPs would be detected in 302 (3.8%) and 191 (2.4%) more patients. The increase in detection was most striking for the CSSPs, with nearly a 30% relative increase.CONCLUSIONS:A withdrawal time of 9 min resulted in a statistically significant increase in adenoma and serrated polyp detection. Colonoscopy quality may improve with a median normal withdrawal time benchmark of 9 min.

Can Language-Concordant Prevention Care Managers Improve Cancer Screening Rates?

PURPOSE An earlier randomized controlled trial of prevention care management (PCM) found significant improvement in breast, cervical, and colorectal cancer-screening rates among women attending Community Health Centers but required substantial research support. This study evaluated the impact of a streamlined PCM delivered through a Medicaid managed care organization (MMCO), an infrastructure with the potential to sustain this program for the long term. METHODS This randomized trial was conducted within an MMCO serving New York City between May 2005 and December 2005. A total of 1,316 women aged 40 to 69 years and not up to date for at least 1 targeted cancer-screening test were randomized to either PCM or a comparison group. Women in the PCM group received up to 3 scripted telephone calls to identify barriers and provide support to obtain any needed breast, cervical, and colorectal cancer-screening tests. Women in the comparison group received a modified version of the MMCO’s established mammography telephone outreach program, also in up to 3 calls. Women in both groups received a financial incentive on confirmation that they had received a mammogram. Screening status was assessed through MMCO administrative data. Groups were compared using odds ratios. RESULTS In an intent-to-treat comparison adjusted for baseline screening status, PCM women were 1.69 times more likely to be up-to-date for colorectal cancer-screening tests at follow-up than women in the comparison group (95% confidence interval, 1.03–2.77). Follow-up screening rates for cervical and breast cancer did not differ significantly between study groups on an intent-to-treat basis. CONCLUSIONS The abbreviated PCM telephone intervention was feasible to deliver through an MMCO and improved screening for 1 cancer. This approach has the potential to improve cancer-screening rates significantly in settings that can provide telephone support to women known to be overdue.

Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

Objective: There is evidence that non-English speakers in the United States receive lower quality health care and preventive services than English speakers. We tested the hypothesis that Spanish-speaking women would respond differently to an intervention to increase up-to-date status for cancer screening. Study Design and Setting: A multisite randomized controlled trial showed that scripted telephone support, provided by a Prevention Care Manager (PCM), increased up-to-date rates for breast, cervical, and colorectal cancer screening. This subgroup analysis investigated the relative efficacy of the PCM among women who chose to communicate with the PCM in Spanish versus English. Results: Of 1,346 women in this analysis, 63% were Spanish speakers. Whereas the PCM intervention increased cancer screening rates generally, Spanish-speaking women seemed to benefit disproportionately more than English-speaking women for cervical cancer screening (unadjusted odds ratio, 1.77; 95% confidence interval, 1.03-3.05). In addition, in this exploratory analysis, there was a trend toward Spanish-speaking women receiving more benefit than English-speaking women from the intervention in increased breast and colorectal cancer screening rates. Conclusion: Spanish-speaking women seemed to benefit more than did English-speaking women from a bilingual telephone support intervention aimed at increasing cancer screening rates. (Cancer Epidemiol Biomarkers Prev 2007;16(10):2058–64)

Barriers to Colorectal Cancer Screening Among Publicly Insured Urban Women: No Knowledge of Tests and No Clinician Recommendation

PURPOSE Health Plans are uniquely positioned to deliver outreach to members. We explored whether telephone outreach, delivered by Medicaid managed care organization (MMCO) staff, could increase colorectal cancer (CRC) screening among publicly insured urban women, potentially reducing disparities. METHODS We conducted an 18-month randomized clinical trial in 3 MMCOs in New York City in 2008–2010, randomizing 2,240 MMCO-insured women, aged 50 to 63 years, who received care at a participating practice and were overdue for CRC screening. MMCO outreach staff provided cancer screening telephone support, educating patients and helping overcome barriers. The primary outcome was the number of women screened for CRC during the 18-month intervention, assessed using claims. RESULTS MMCO staff reached 60% of women in the intervention arm by telephone. Although significantly more women in the intervention (36.7%) than in the usual care (30.6%) arm received CRC screening (odds ratio [OR] = 1.32; 95% CI, 1.08–1.62), increases varied from 1.1% to 13.7% across the participating MMCOs, and the overall increase was driven by increases at 1 MMCO. In an as-treated comparison, 41.8% of women in the intervention arm who were reached by telephone received CRC screening compared with 26.8% of women in the usual care arm who were not contacted during the study (OR = 1.84; 95% CI, 1.38, 2.44); 7 women needed to be reached by telephone for 1 to become screened. CONCLUSIONS The telephone outreach intervention delivered by MMCO staff increased CRC screening by 6% more than usual care among randomized women, and by 15.1% more than usual care among previously overdue women reached by the intervention. Our research-based intervention was successfully translated to the health plan arena, with variable effects in the participating MMCOs.

Staffing time required to increase cancer-screening rates through telephone support.

OBJECTIVES To assess barriers to colorectal cancer screening among urban publicly insured women and to evaluate how barriers among underscreened urban women have changed between 2001 and 2007-2008. METHODS Eligible women were selected using Medicaid Managed Care Organization (MMCO) administrative data. MMCO outreach staff interviewed women by phone between October 2007 and February 2008, and assessed their barriers to colorectal cancer screening. We compared the results of these interviews with interviews conducted in 2001 with women in community health center waiting rooms. RESULTS Thirty percent of overdue women had never heard of either colonoscopy or sigmoidoscopy, and 55% had never heard of home fecal occult blood testing (FOBT). Among overdue women who had heard of colonoscopy or sigmoidoscopy, 33% reported misconceptions and 28% reported worry as a barrier. No clinician recommendation was the most commonly reported barrier to home FOBT (44%) and was also reported as a barrier to endoscopy by 22% of women. Between 2001 and 2007-2008, the proportion of women reporting that they had not received a clinicians recommendation for endoscopy or home FOBT increased significantly. CONCLUSIONS A lack of information, no clinician recommendation, misconceptions, and worry persist as barriers to colon cancer screening among this underscreened urban population. An increased focus on clinician recommendation and patient education about stool-based as well as endoscopic screening methods could lead to greater screening compliance.

Hyper-Methylated Loci Persisting from Sessile Serrated Polyps to Serrated Cancers

We describe the staff time required by the prevention care manager–tailored telephone support intervention, which significantly increased breast, cervical, and colorectal cancer–screening rates among female patients of Community Health Centers in New York City. For a sample of 38 women whose intervention was timed, prevention care managers spent an average of 99 minutes per woman on the phone and on related follow-up tasks over 18 months, or 248 minutes for each additional cancer-screening test obtained. Potential modifications to decrease the time required include automation of common tasks and the use of administrative data to further tailor outreach calls.

Adenoma Detection Rates for Screening Colonoscopies in Smokers and Obese Adults: Data From the New Hampshire Colonoscopy Registry

Although serrated polyps were historically considered to pose little risk, it is now understood that progression down the serrated pathway could account for as many as 15%–35% of colorectal cancers. The sessile serrated adenoma/polyp (SSA/P) is the most prevalent pre-invasive serrated lesion. Our objective was to identify the CpG loci that are persistently hyper-methylated during serrated carcinogenesis, from the early SSA/P lesion through the later cancer phases of neoplasia development. We queried the loci hyper-methylated in serrated cancers within our right-sided SSA/Ps from the New Hampshire Colonoscopy Registry, using the Illumina Infinium Human Methylation 450 k panel to comprehensively assess the DNA methylation status. We identified CpG loci and regions consistently hyper-methylated throughout the serrated carcinogenesis spectrum, in both our SSA/P specimens and in serrated cancers. Hyper-methylated CpG loci included the known the tumor suppressor gene RET (p = 5.72 × 10−10), as well as loci in differentially methylated regions for GSG1L, MIR4493, NTNG1, MCIDAS, ZNF568, and RERG. The hyper-methylated loci that we identified help characterize the biology of SSA/P development, and could be useful as therapeutic targets, or for future identification of patients who may benefit from shorter surveillance intervals.

Prevention care management increases cancer screening among women: from efficacy to effectiveness to dissemination, implementation & scale-up

Goal: To examine screening adenoma detection rates (ADR) and serrated detection rates (SDR) among smokers and obese adults in the New Hampshire Colonoscopy Registry. Background: ADR, a quality measure for screening colonoscopies, is associated with protection from interval colorectal cancer. Currently, only sex-specific ADR benchmarks are reported. However, obesity and smoking ≥20 pack-years are strong predictors for colorectal neoplasia, as highlighted by the 2009 American College of Gastroenterology CRC Screening Guidelines. Data comparing ADR in smokers and obese adults to those without these risks are limited. Study: We calculated ADR, SDR, and 95% confidence intervals for screening colonoscopies in participants ≥50 years. Sex-specific and sex–age-specific rates were compared by smoking exposure (never vs. <20 vs. ≥20 pack-years) and body mass index (<30 vs. ≥30). Results: A total of 21,539 screening colonoscopies were performed by 77 endoscopists at 20 facilities (April 2009 to September 2013). The difference in ADR between nonsmokers and smokers with ≥20 pack-years was 8.8% (P<0.0001) and between obesity groups 5.0% (P<0.0001). Significant sex-specific and sex–age-specific increases in ADR and SDR were found among smokers and obese participants. Conclusions: ADR and SDR for smokers and obese adults were significantly higher than their counterparts without those risks. Endoscopists should consider the prevalence of these risks within their screening population when comparing their rates to established benchmarks. Calculating sex-specific or sex–age-specific ADR and SDR based on smoking and obesity may provide optimal protection for populations with a particularly high prevalence of smokers and obese adults.