Melissa DiCarlo

Tailored navigation in colorectal cancer screening.

Background:Colorectal cancer (CRC) screening is underutilized. Effective methods to increase screening use are needed. This study sought to determine the impact of tailored navigation on CRC screening in primary care. Methods:The study included 154 primary care practice patients who were 50 or more years of age, were eligible for CRC screening, and had an office visit within 2 years before study initiation. Baseline telephone survey data were collected on participant sociodemographic characteristics, psychosocial factors, and screening test [fecal occult blood test (FOBT) or colonoscopy] decision stage. By comparing decision stage data, we identified that test with the highest decision stage (ie, preferred screening test). Participants who preferred FOBT were sent an FOBT kit and a reminder. Those preferring colonoscopy were sent colonoscopy instructions. After this mailing, a study patient navigator made a telephone call to guide participants towards screening. Six-month end point survey and medical records data were obtained. Univariable and multivariable analyses were performed to identify predictors of screening and of change in preferred screening test decision stage. Results:At end point, 63 (41%) study participants had screened. From baseline to end point, overall screening preference increased for 75 (63%) participants. Age and perceived salience and coherence (ie, screening is important and sensible) were positive, significant predictors of screening use (P = 0.02 and P = 0.05, respectively); while only age predicted change in overall screening preference (P = 0.03). Conclusions:Study participant screening use and preference increased. Age and attitudes predicted outcomes. Randomized trials are needed to determine intervention impact at the population level.

A Randomized Controlled Trial of a Tailored Navigation and a Standard Intervention in Colorectal Cancer Screening

Background: This randomized, controlled trial assessed the impact of a tailored navigation intervention versus a standard mailed intervention on colorectal cancer screening adherence and screening decision stage (SDS). Methods: Primary care patients (n = 945) were surveyed and randomized to a Tailored Navigation Intervention (TNI) Group (n = 312), Standard Intervention (SI) Group (n = 316), or usual care Control Group (n = 317). TNI Group participants were sent colonoscopy instructions and/or stool blood tests according to reported test preference, and received a navigation call. The SI Group was sent both colonoscopy instructions and stool blood tests. Multivariable analyses assessed intervention impact on adherence and change in SDS at 6 months. Results: The primary outcome, screening adherence (TNI Group: 38%, SI Group: 33%, Control Group: 12%), was higher for intervention recipients than controls (P = 0.001 and P = 0.001, respectively), but the two intervention groups did not differ significantly (P = 0.201). Positive SDS change (TNI Group: +45%, SI Group: +37%, and Control Group: +23%) was significantly greater among intervention recipients than controls (P = 0.001 and P = 0.001, respectively), and the intervention group difference approached significance (P = 0.053). Secondary analyses indicate that tailored navigation boosted preferred test use, and suggest that intervention impact on adherence and SDS was attenuated by limited access to screening options. Conclusions: Both interventions had significant, positive effects on outcomes compared with usual care. TNI versus SI impact had a modest positive impact on adherence and a pronounced effect on SDS. Impact: Mailed screening tests can boost adherence. Research is needed to determine how preference, access, and navigation affect screening outcomes. Cancer Epidemiol Biomarkers Prev; 22(1); 109–17. ©2012 AACR.

Cost-effectiveness of targeted and tailored interventions on colorectal cancer screening use.

Colorectal cancer (CRC) screening is cost‐effective but underused. The objective of this study was to determine the cost‐effectiveness of targeted and tailored behavioral interventions to increase CRC screening use by conducting an economic analysis associated with a randomized trial among patients in a large, racially and ethnically diverse, urban family practice in Philadelphia.

Increasing Colon Cancer Screening in Primary Care Among African Americans

BACKGROUND The study aimed to determine the effect of preference-based tailored navigation on colorectal cancer (CRC) screening adherence and related outcomes among African Americans (AAs). METHODS We conducted a randomized controlled trial that included 764 AA patients who were age 50 to 75 years, were eligible for CRC screening, and had received care through primary care practices in Philadelphia. Consented patients completed a baseline telephone survey and were randomized to either a Standard Intervention (SI) group (n = 380) or a Tailored Navigation Intervention (TNI) group (n = 384). The SI group received a mailed stool blood test kit plus colonoscopy instructions, and a reminder. The TNI group received tailored navigation (a mailed stool blood test kit or colonoscopy instructions based on preference, plus telephone navigation) and a reminder. A six-month survey and a 12-month medical records review were completed to assess screening adherence, change in overall screening preference, and perceptions about screening. Multivariable analyses were performed to assess intervention impact on outcomes. RESULTS At six months, adherence in the TNI group was statistically significantly higher than in the SI group (OR = 2.1, 95% CI = 1.5 to 2.9). Positive change in overall screening preference was also statistically significantly greater in the TNI group compared with the SI group (OR = 1.5, 95% CI = 1.0 to 2.3). There were no statistically significant differences in perceptions about screening between the study groups. CONCLUSIONS Tailored navigation in primary care is a promising approach for increasing CRC screening among AAs. Research is needed to determine how to maximize intervention effects and to test intervention impact on race-related disparities in mortality and survival.

Cost‐effectiveness of a standard intervention versus a navigated intervention on colorectal cancer screening use in primary care

Colorectal cancer (CRC) screening is cost‐effective but underused. The objective of this study was to determine the cost‐effectiveness of a mailed standard intervention (SI) and tailored navigation interventions (TNIs) to increase CRC screening use in the context of a randomized trial among primary care patients.

The Effects of Test Preference, Test Access, and Navigation on Colorectal Cancer Screening

Background: Little is known about how colorectal cancer screening test preferences operate together with test access and navigation to influence screening adherence in primary care. Methods: We analyzed data from a randomized trial of 945 primary care patients to assess the independent effects of screening test preference for fecal immunochemical test (FIT) or colonoscopy, mailed access to FIT and colonoscopy, and telephone navigation for FIT and colonoscopy, on screening. Results: Preference was not associated with overall screening, but individuals who preferred FIT were more likely to complete FIT screening (P = 0.005), whereas those who preferred colonoscopy were more likely to perform colonoscopy screening (P = 0.032). Mailed access to FIT and colonoscopy was associated with increased overall screening (OR = 2.6, P = 0.001), due to a 29-fold increase in FIT use. Telephone navigation was also associated with increased overall screening (OR = 2.1, P = 0.005), mainly due to a 3-fold increase in colonoscopy performance. We estimated that providing access and navigation for both screening tests may substantially increase screening compared with a preference-tailored approach, mainly due to increased performance of nonpreferred tests. Conclusions: Preference influences the type of screening tests completed. Test access increases FIT and navigation mainly increases colonoscopy. Screening strategies providing access and navigation to both tests may be more effective than preference-tailored approaches. Impact: Preference tailoring in colorectal cancer screening strategies should be avoided if the objective is to maximize screening rates, although other factors (e.g., costs, necessary follow-up) should also be considered. Cancer Epidemiol Biomarkers Prev; 23(8); 1521–8. ©2014 AACR.

A randomized trial of genetic and environmental risk assessment (GERA) for colorectal cancer risk in primary care: Trial design and baseline findings

PURPOSE This paper describes an ongoing randomized controlled trial designed to assess the impact of genetic and environmental risk assessment (GERA) on colorectal cancer (CRC) screening. METHODS The trial includes asymptomatic patients who are 50-79years and are not up-to-date with CRC screening guidelines. Patients who responded to a baseline telephone survey are randomized to a GERA or Control group. GERA group participants meet with a nurse, decide whether to have a GERA blood test (a combination of genetic polymorphism and folate), and, if tested, receive GERA feedback. Follow-up telephone surveys are conducted at 1 and 6months. A chart audit is performed at 6months. RESULTS Of 2,223 eligible patients, 562 (25%) have enrolled. Patients who enrolled in the study were significantly younger than those who did not (p<0.001). Participants tended to be 50-59years (64%), female (58%), white (52%), married (51%), and have more than a high school education (67%). At baseline, most participants had some knowledge of CRC screening and GERA, viewed CRC screening favorably, and reported that they had decided to do screening. Almost half had worries and concerns about CRC. CONCLUSIONS One in four eligible primary care patients enrolled in the study. Age was negatively associated with enrollment. Prospective analyses using data for all participants will provide more definitive information on GERA uptake and the impact of GERA feedback.

A learning community approach to identifying interventions in health systems to reduce colorectal cancer screening disparities

Although colorectal cancer (CRC) screening in the United States has been increasing, screening rates are not optimal, and there are persistent disparities in CRC screening and mortality, particularly among minority patients. As most CRC screening takes place in primary care, health systems are well-positioned to address this important population health problem. However, most health systems have not actively engaged in identifying and implementing effective evidence-based intervention strategies that can raise CRC screening rates and reduce disparities. Drawing on the Collective Impact Model and the Interactive Systems Framework for Dissemination and Implementation, our project team applied a learning community strategy to help two health systems in southeastern Pennsylvania identify evidence-based CRC screening interventions for primary care patients. Initially, this approach involved activating a coordinating team, steering committee (health system leadership and stakeholder organizations), and patient and stakeholder advisory committee to identify candidate CRC screening intervention strategies. The coordinating team guided the steering committee through a scoping review to identify seven randomized trials that identified interventions that addressed CRC screening disparities. Subsequently, the coordinating team and steering committee applied a screening intervention classification typology to select an intervention strategy that involved using an outreach strategy to provide minority patients with access to both stool blood test and colonoscopy screening. Finally, the coordinating team and steering committee engaged the health system patient and stakeholder advisory committee in planning for intervention implementation, thus taking up the challenge of reducing and important health disparity in patient populations served by the two health systems.

Using a health system learning community strategy to address cancer disparities

Accountable care organizations and health systems have the potential to increase patient engagement in medical care, improve population health outcomes, and reduce costs. Characteristics of highly integrated learning health care systems that seek to achieve these goals have been described in the literature. However, there have been few reports on how health systems, especially those that are loosely integrated, can develop the infrastructure needed to support achievement of these goals. In this report, we describe a learning community strategy that involved forming a coordinating team, a steering committee, and patient and stakeholder advisory committees to address cancer screening and disparities in 2 health systems in southeastern Pennsylvania—Jefferson Health and the Lehigh Valley Health Network. This project engaged diverse patients, health care providers, health system leaders, public and private payers, and other stakeholders in identifying and adapting evidence‐based methods to increase colorectal and lung cancer screening in primary care. Here, we describe components of a health system learning community. In addition, we describe activities in which different components of the learning community were engaged. Finally, we explore prospects for using this type of approach to catalyze the development of learning health care systems.

Characteristics Associated with Smoking Among Patrons of Three Philadelphia Parks

To create healthy public spaces, Philadelphia prohibits smoking in city-owned and operated parks. Identifying the prevalence and characteristics of smoking in Philadelphia Parks would be useful for monitoring purposes; yet no studies have collected this data. This study identified the prevalence and characteristics of smoking among adult patrons entering three Philadelphia Parks (Washington Square Park, Independence Square Park, and Louis Kahn Park). During May and June 2016, we observed patrons entering the parks on Thursday afternoons. We used handheld electronic devices to categorize patrons by smoking status, age, gender, and tobacco product. We used logistic regression to assess the association of these variables with smoking. We observed 4822 people, of which 10.6% were children. Smoking was noted among 2.6% of adults in Washington Square Park, 2.6% of adults in Independence Square Park, and 7.7% of adults in Louis Kahn Park. Patronizing Louis Kahn Park was associated with greater likelihood of smoking (OR 3.11, CI 1.77–5.46) compared to Washington Square. Males were more likely than females to smoke (OR 1.45, CI 1.01–2.09). Higher likelihood of smoking among males concurs with previous studies. Higher prevalence in Louis Kahn Park may be due to differences in park patron demographics compared to other parks. Results could be used as a baseline for periodic monitoring of smoking in parks in order to inform implementation of the smoke-free park policy in Philadelphia.