Deborah S Porterfield

Systematic Review: Enhancing the Use and Quality of Colorectal Cancer Screening

BACKGROUND National guideline groups recommend screening and discussion of screening options for persons at average risk for colorectal cancer (CRC). However, emerging evidence suggests that CRC screening is simultaneously underused, overused, and misused and that adequate patient-provider discussions about screening are infrequent. PURPOSE To summarize evidence on factors that influence CRC screening and strategies that increase the appropriate use and quality of CRC screening and CRC screening discussions. DATA SOURCES MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were searched for English-language publications describing studies conducted in the United States from January 1998 through September 2009. STUDY SELECTION Two reviewers independently selected studies that addressed the study questions and met eligibility criteria. DATA EXTRACTION Information on study design, setting, intervention, outcomes, and quality were extracted by one reviewer and double-checked by another. Reviewers assigned a strength-of-evidence grade for intervention categories by using criteria plus a consensus process. DATA SYNTHESIS Reviewers found evidence of simultaneous underuse, overuse, and misuse of CRC screening as well as inadequate clinical discussions about CRC screening. Several patient-level factors were independently associated with lower screening rates, including having low income or less education, being uninsured, being Hispanic or Asian, being less acculturated into the United States, or having limited access to care. Evidence that interventions that included patient reminders or one-on-one interactions (that is, between patients and nonphysician clinic staff), eliminated structural barriers (for example, simplifying access to fecal occult blood test cards), or made system-level changes (for example, using systematic screening as opposed to opportunistic screening) were effective in enhancing use of CRC screening was strong. Evidence on how best to enhance discussions about CRC screening options is limited. No studies focused on reducing overuse, and very few focused on misuse. LIMITATIONS Reporting and publication bias may have affected our findings. The independent effect of individual elements of multicomponent interventions was often uncertain. CONCLUSION Although CRC screening is underused overall, important problems of overuse and misuse also exist. System- and policy-level interventions that target vulnerable populations are needed to reduce underuse. Interventions aimed at reducing barriers by making the screening process easier are likely to be effective. Studies aimed at reducing overuse and misuse and at enhancing the quality and frequency of discussions about CRC screening options are needed. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

The Prevalence of Overweight and Obesity among U.S. Military Veterans

Overweight and obesity are increasingly contributing to disease burden among military populations. The purpose of this study was to calculate and examine the prevalence of overweight and obesity among the veteran population. Data were obtained from the 2004 Behavioral Risk Factor Surveillance System. Overweight (body mass index > or = 25 kg/m2) prevalence in veterans was 73.3% (SE, 0.4%) for males and 53.6% (SE 1.7%) for females. Obesity (body mass index > or = 30 kg/m2) prevalence in veterans was 25.3% (SE, 0.4%) for males and 21.2% (SE, 1.4%) for females. After adjusting for sociodemographics and health status, veterans were no more likely to be overweight (odds ratio, 1.05; 95% confidence interval, 0.99-1.11) or obese (odds ratio 0.99; confidence interval, 0.93-1.05) than nonveterans. Despite previous participation in a culture and environment that selects for and enforces body weight standards, veterans have a high prevalence of overweight and obesity that is similar to general population estimates.

Barriers to cancer pain management: home-health and hospice nurses and patients

GoalsUndertreatment of cancer pain remains a major health-care problem. We utilized focus groups of hospice and home-health nurses and patients to elucidate factors contributing to inadequate pain management and to generate solutions for closing the gap between the current reality and optimal pain management.Patients and methodsFocus groups were conducted among hospice and home-health-care nurses (two groups; n=22) and patients (six groups; n=54) using a standardized question guide. Audiotapes were transcribed and analyzed using NUD*IST software. Themes discovered among patients and nurses were analyzed for similarities and differences.Main resultsOf 22 participants in the two home-health and hospice nurses focus groups, all were white women, the average age was 43 (range 29–64) years, and the average number of years in nursing was 21 (range 8–47) years. Of 54 participants in the six cancer patient focus groups, 80% were women, the average age was 54 (range 25–76) years, and 76% were white. Fifty-four percent of patients reported a history of pain associated with their cancer, and almost 30% had pain that they rated as 8 or higher on the pain scale. Barriers to adequate pain management fell into four categories: fears; attitudes, beliefs, and values; patient and provider behaviors; and structural barriers. Patients and nurses reported similar barriers to pain management; however, patients identified more barriers related to provider behavior and structure of the health care system.ConclusionsThis study identified several barriers to cancer pain control not previously identified in the literature. Strategies to improve cancer pain control are suggested.

Linkages between clinical practices and community organizations for prevention: A literature review and environmental scan

CONTEXT A literature review and environmental scan were conducted to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts. EVIDENCE ACQUISITION A search was made of four major health services and social science electronic databases and an Internet search was conducted to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity. EVIDENCE SYNTHESIS In all, 49 interventions were identified, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics. CONCLUSIONS An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Advancing Cervical Cancer Prevention in India: Implementation Science Priorities

Cervical cancer is the leading cause of cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025, but there are few large-scale, organized cervical cancer prevention programs in the country. We conducted a review of the cervical cancer prevention research literature and programmatic experiences in India to summarize the current state of knowledge and practices and recommend research priorities to address the gap in services. We found that research and programs in India have demonstrated the feasibility and acceptability of cervical cancer prevention efforts and that screening strategies requiring minimal additional human resources and laboratory infrastructure can reduce morbidity and mortality. However, additional evidence generated through implementation science research is needed to ensure that cervical cancer prevention efforts have the desired impact and are cost-effective. Specifically, implementation science research is needed to understand individual- and community-level barriers to screening and diagnostic and treatment services; to improve health care worker performance; to strengthen links among screening, diagnosis, and treatment; and to determine optimal program design, outcomes, and costs. With a quarter of the global burden of cervical cancer in India, there is no better time than now to translate research findings to practice. Implementation science can help ensure that investments in cervical cancer prevention and control result in the greatest impact.

Cancer Plan Index: a measure for assessing the quality of cancer plans.

OBJECTIVE To (1) conduct an in-depth assessment of the content of comprehensive cancer control plans and (2) obtain data that can be used to provide guidance to grantees supported by the Centers for Disease Control and Preventions National Comprehensive Cancer Control Program (NCCCP) as they refine their plans, and to other health professionals as similar planning is done. DESIGN Through an iterative development process, a workgroup of subject matter experts from NCCCP and Research Triangle Institute International (RTI International) identified 11 core or essential components that should be considered in cancer plans on the basis of their professional experience and expertise. They also developed a tool, the Cancer Plan Index (CPI), to assess the extent to which cancer plans addressed the 11 core components. SETTING Sixty-five comprehensive cancer control programs in states, tribes, territories, and jurisdictions funded by the NCCCP. DATA SOURCE Raters reviewed and abstracted all available cancer plans (n = 66), which included plans from 62 funded programs and 4 states of the Federated States of Micronesia funded by Centers for Disease Control and Prevention as a subcontractor of one funded program. Of the 66 plans, 3 plans were used to pilot test the CPI and the remaining 63 plans were subsequently reviewed and abstracted. MAIN OUTCOME MEASURE(S) The primary outcome measures are national-level component scores for 11 defined domains (global involvement of stakeholders, developing the plan, presentation of data on disease burden, goals, objectives, strategies, reduction of cancer disparities, implementation, funds for implementation of plan, evaluation, usability of plan), which represent an average of the component scores across all available cancer plans. RESULTS To aid in the interpretation and usability of findings, the components were segmented into 3 tiers, representing a range high (average score = 2.01-4.00), moderate (average score = 1.01-2.00), and low (average score = 0-1.00) levels of description of the component. Programs overall provided relatively comprehensive descriptions of goals, objectives, and strategies; moderate description of the plan development process, presentation of data on disease burden, and plans on the reduction of cancer disparities; and little to no description of stakeholder involvement plans for implementation, funds for implementation, and evaluation of the plan. CONCLUSIONS Areas of the CPI with low average component scores should stimulate technical assistance to the funded programs, either to increase program activities or to increase discussion of key activities in the plan.

Piloting performance measurement for Comprehensive Cancer Control programs.

OBJECTIVE To implement a pilot test of performance measures for National Comprehensive Cancer Control (CCC) programs funded by the Centers for Disease Control and Prevention (CDC). DESIGN A cross-sectional assessment conducted in 2008. SETTING A total of 65 CCC-funded entities (51 states, 7 tribes, and 7 territories or jurisdictions) representing 69 CCC programs. PARTICIPANTS Comprehensive Cancer Control program staff. MAIN OUTCOME MEASURES In a process that involved stakeholders from funded programs, academia, and nonprofit organizations, the CDC developed a framework for evaluation and a performance measures worksheet containing 11 performance measures for CCC programs that assessed grantee attainment of key components of CCC as required in the funding announcement. The framework was based on a CCC logic model. The performance measures worksheet contained detailed description of the measures, definitions, and suggested data sources for the 11 measures. RESULTS Of the 69 programs, 61 completed the worksheets. The median time reported to complete the worksheet was 10 hours (interquartile range = 6-20). Almost all programs reported having representation of relevant populations in their coalition and having conducted a recent assessment of the burden of cancer. Less frequently, programs reported having a written evaluation plan or having enacted policy changes. Additional performance measures described non-CDC funding, the percentage of partners implementing CCC activities, and the percentage of implemented interventions that were evidence-based. CONCLUSIONS This pilot test of the performance measures worksheet established the feasibility of conducting a standardized survey of CCC programs to identify issues of importance to developing and implementing the CCC program at national and program levels. The performance measures provided unique data on CCC grantees to the CDC funders and feedback on performance measures for improving questions on future surveys. Refinement of the performance measures will provide a tool for monitoring processes of action and accountability of grantees and will encourage a culture of quality improvement through systematic evaluation.