Physician payment models and preventive cancer screening: a population-based retrospective cohort analysis from Ontario, Canada

EPH43 Impact of COVID-19 Pandemic on Cancer Preventive Screening

e22519 Background: Colorectal cancer screening has been associated with a marked reduction in cancer- related mortality, and the achievement of screening targets has been identified as a national objective by the Healthy People 2030 initiative. Although various social determinants of health (SDoH) have been demonstrated to impact healthcare access, the association between food insecurity (FI) and colorectal screening rates (CSR) remains unexplored. As such, we sought to assess the impact of FI on county-level colorectal screening rates (CSR). Methods: Data on county-level colorectal cancer screening and food insecurity rates in 2018 were extracted from the Centers for Disease Control (CDC) PLACES and County Health Rankings & Roadmaps databases, respectively. Notably, FI and CSR were categorized as low (lowest quartile), intermediate (middle two quartiles) and high (highest quartile). Multivariable logistic regression analyses were used to evaluate the association between FI and CSR. Results: Among 3,106 counties, the median CSR was 62.1% (IQR 58.9%–65.2%) and ranged from 39.8% (Kusilvak, Alaska) to 74.4% (Newport, Rhode Island). A majority of counties were urban (Metropolitan: n = 790, 25.4% vs. Urban: n = 1,671, 53.8% vs. Rural: n = 645, 20.8%). Overall, a fourth of counties had high screening rates (Low CSR : n = 788, 25.4% vs. Intermediate CSR : n = 1,545, 49.7% vs. High CSR : n = 773, 24.9%). Similarly, 25.0% of counties demonstrated high FI (Low FI : n = 777, 25.0% vs. Intermediate FI : n = 1,552, 50.0% vs. High FI: n = 777, 25.0%). Notably, counties with increasing FI were markedly less likely to have High CSR (Low FI : n = 353, 45.4% vs. Intermediate FI: n = 370, 23.8% vs. High FI: n = 50, 6.4%)(p<0.001). After adjusting for county-level rurality, population-to-primary care physician ratio, household income, unemployment, race/ethnicity, education and uninsurance, intermediate and high FI was associated with an incrementally lower likelihood of having High CSR compared with low FI counties (ref: Low FI ; Intermediate FI : OR 0.61, 95%CI 0.47–0.80; High FI : OR 0.31, 95%CI 0.20–0.50). Conclusions: Increasing county-level FI was independently associated with markedly lower colorectal cancer screening rates, indicating that FI may play a key role in driving disparities in access to cancer care. As such, policies targeted at vulnerable communities characterized by high food insecurity and social deprivation are critically needed to ensure equitable access to preventive cancer care measures such as colorectal cancer screening.

Screening and follow-up rates for breast and cervical cancer vary across socioeconomic and demographic groups. While patient navigation services can help patients overcome barriers to health care, they are not commonly used in cancer screening. To determine the effectiveness and harms of patient navigation services to increase screening and follow-up rates for breast and cervical cancer. A search of the MEDLINE, Scopus, CENTRAL, and Cochrane Database of Systematic Reviews was conducted for English-language articles published between January 1, 2000, and September 19, 2024. A manual review of article references supplemented the search. Eligible articles were randomized clinical trials comparing the effectiveness of patient navigation services in participants eligible for breast or cervical cancer screening with usual care or control groups, as well as observational studies for harm. Investigators independently dual-reviewed abstracts and full-text articles to identify studies meeting prespecified eligibility criteria. Disagreements were resolved by consensus with a third reviewer. Of all abstracts and full-text articles reviewed, 2.9% were selected for analysis. This report followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. A single investigator extracted data from each study. A second investigator reviewed the data for accuracy. Investigators independently dual-rated individual study quality as good, fair, or poor. Discordant quality ratings were resolved with a third reviewer. Data were combined using a profile likelihood random-effects model. The main outcomes were breast and cervical cancer screening rates within 1 year of the intervention, follow-up rates within 2 years, and any harm. A total of 42 randomized clinical trials with 39 111 participants assessing the effectiveness of patient navigation services to increase screening and follow-up rates for breast and cervical cancer were included in the meta-analysis; no studies described harms. For breast cancer, patient navigation resulted in higher rates of screening (risk ratio [RR], 1.50; 95% CI, 1.30-1.75; I2 = 88.0%; 30 trials; n = 34 744 participants) and follow-up (RR, 1.23; 95% CI, 1.15-1.41; I2 = 12.6%; 3 trials; n = 1008 participants) compared with comparison groups. For cervical cancer, patient navigation also resulted in higher rates of screening (RR, 1.62; 95% CI, 1.28-2.09; I2 = 89.6%; 20 trials; n = 11 820 participants) and follow-up (RR, 1.63; 95% CI, 0.86-2.65; I2 = 69.0%; 2 trials; n = 401 participants). Sensitivity analyses demonstrated higher screening rates with patient navigation vs comparison groups for general populations and populations based on race, ethnicity, low-income status, and other characteristics. Predicted 1-year absolute rates following patient navigation were 13.8% higher for breast cancer screening and 15.6% higher for cervical cancer screening than for comparison groups. The results of this systematic review and meta-analysis suggest that patient navigation services can increase breast and cervical cancer screening and follow-up. Reducing barriers with patient navigation services could improve access and engage patients in more effective and equitable cancer preventive care.

Our Family Health Team is located in Toronto, Canada and provides care to over 35 000 patients. Like many practices in Canada, we took an opportunistic approach to cervical, breast,...

The COVID-19 pandemic disrupted cancer screenings in the United States, with disproportionate impact on health disparity populations. The objective of this study was to examine the impact of the pandemic on routine screening for breast, cervical, and colorectal cancer among Medicaid enrollees. This study is a retrospective, descriptive analysis to estimate the rate of breast, colorectal, and cervical cancer screenings among Medicaid enrollees age 50-75 years in New Jersey. Secondary enrollment and claims from the 2017-2022 Medicaid Management Information System were used. The results were stratified by screening type and socioeconomic factors. Bivariate analysis assessed between-group differences. Although April 2020 had the lowest screening rates in the 6-year period, rates for all three cancer types rebounded to prepandemic levels by late summer 2020. In 2022, breast cancer screening rates exceeded previous peaks. However, cervical and colorectal screening rates did not resume their prepandemic trajectories. Key findings comparing 2022 with 2019 were (1) across all three cancer screening groups, the younger group (50-64 years) had a higher screening rate than the older group (65-75 years); (2) Hispanic enrollees consistently had the highest screening rates; (3) the screening rate among dually eligible enrollees increased throughout the pandemic; and (4) there was wide screening variation by geographic region. Multilevel, multisectoral approaches, including policy and health system strategies, are critical to addressing gaps in care for Medicaid enrollees. Future efforts should focus on bolstering cervical and colorectal cancer screening rates and ensuring equitable access to cancer screening and treatment.

The Healthy People 2030 initiative has set national cancer screening targets for breast, colon, and cervical cancers, as well as aims for reducing cancer mortality. State-level tax policy is an underappreciated social determinant of health that may improve cancer screening and mortality rates. To define the association of tax revenue and tax progressivity with state-level cancer screening and mortality. This ecologic, population-based, cross-sectional study assessed cancer screening (2020 and 2022) and mortality rates (1999-2021) in the US relative to state-level tax revenue (1997-2019) and tax progressivity (2002, 2009, 2012, 2014, and 2018) with a 2-year lag. The study included 50 states through 23 years with state-years used as the unit of analysis. Cancer screening rates were derived from the Centers for Disease Control and Prevention (CDC) Population Level Analysis and Community Estimates database. State-level cancer-related death and population counts were derived from the CDC Wide-Ranging Online Data for Epidemiologic Research database. Data analysis occurred from September to January 2024. State-level tax policy was proxied by tax revenue per capita and the Suits index of tax progressivity, with progressive taxation equaling lower tax burden for more disadvantaged populations. Outcomes included screening rates for colon, breast, and cervical cancer, as well as mortality rates for all malignant neoplasms and malignant neoplasms with guideline-recommended screening. Multivariable models were adjusted for tax-related, socioeconomic, and demographic variables. In total, 1150 state-years were included in the analysis. Median (IQR) tax revenue per capita was $4432 ($3862-$5210), and the median (IQR) number of cancer-related deaths was 8341 (3150-13 585) across all state-years. Of note, each $1000 increase in tax revenue per capita was associated with a 1.61% (95% CI, 0.50%-2.73%) increase in colorectal cancer screening, 2.17% (95% CI, 1.39%-2.96%) increase in breast cancer screening, and 0.72% (95% CI, 0.34%-1.10%) increase in cervical cancer screening rate. For malignant neoplasms with guideline-recommended screening, each $1000 increase in tax revenue per capita was associated with a decreased cancer mortality rate among White (adjusted incidence rate ratio, 0.95, 95% CI, 0.93-0.98), but not racial and ethnic minority (adjusted incidence rate ratio, 0.99, 95% CI, 0.97-1.02) populations. In this cross-sectional study, tax policy was associated with increased state-level cancer screening rates, as well as decreased cancer mortality rates, which mostly benefited White populations, suggesting that state-level policies may contribute to bridging ongoing cancer care gaps.

e19197 Background: Despite the low five-year expected survival of patients with advanced cancer, it has been suggested that up to 1.7% of patients aged 65 and older with advanced cancer may continue to undergo screening for colorectal cancer and up to 8.9% of female patients 65 and older with an advanced cancer may receive a screening mammography.1 The intent of our study was to determine the rate of colorectal and breast cancer screening in men ages 50-75 and women ages 40-75 after these patients were diagnosed with an advanced cancer. Methods: The medical records of 208 patients (median age 63.5, range 42-75) with a diagnosis of stage IV colorectal, prostate, breast, liver, gastroesophageal, skin, uterine, bladder, kidney and stage III-IV pancreatic and lung cancer were reviewed for documentation of a screening mammography, colonoscopy or FIT-DNA testing after the patient was diagnosed with an advanced cancer. Results: Overall, 4.8% of patients were screened for colorectal cancer and 10% of the females received at least one mammogram. The screening mammography rate in patients less than 64 years of age was 13.3% and the colorectal screening rate in this age group was 4.4%. In patients 65 and older, the screening mammography rate was 7% and the colorectal screening rate was 5.2%. Conclusions: Colorectal and breast cancer screening rates in patients with advanced cancer were higher within our fully integrated healthcare system in comparison to previously reported findings in patients 65 and older. In addition, the rate of screening with mammography may be more prevalent amongst patients 64 or younger with advanced cancer in comparison to patients 65 and older with a similar diagnosis. The next phase of this quality improvement project involves disabling health maintenance prompts within the electronic medical record of patients with advanced cancer.

To investigate the relative importance of patient and general practice characteristics in explaining variations between practices in the uptake of breast cancer screening. Ecological study examining variations in breast cancer screening rates among 131 general practices using routine data. Merton, Sutton, and Wandsworth Family Health Services Authority, which covers parts of inner and outer London. Percentage of eligible women aged 50-64 who attended for mammography during the first round of screening for breast cancer (1991-1994). Of the 43,063 women eligible for breast cancer screening, 25,826 (60%) attended for a mammogram. Breast cancer screening rates in individual practices varied from 12.5% to 84.5%. The estimated percentage list inflation for the practices was the variable most highly correlated with screening rates (r = -0.69). There were also strong negative correlations between screening rates and variables associated with social deprivation, such as the estimated percentage of the practice population living in households without a car (r = -0.61), and with variables that measured the ethnic make-up of practice populations, such as the estimated percentage of people in non-white ethnic groups (r = -0.60). Screening rates were significantly higher in practices with a computer than in those without (59.5% v 53.9%, difference 5.6%, 95% confidence interval 1.1 to 10.2%). There was no significant difference in screening rates between practices with and without a female partner; with and without a practice nurse; and with and without a practice manager. In a forward stepwise multiple regression model that explained 58% of the variation in breast cancer screening rates, four factors were significant independent predictors (at P = 0.05) of screening rates: list inflation and people living in households without a car were both negative predictors of screening rates, and chronic illness and the number of partners in a practice were both positive predictors of screening rates. The practice with the highest screening rate (84.5%) contacted all women invited for screening to encourage them to attend for their mammogram and achieved a rate 38% higher than predicted from the regression model. Breast cancer screening rates were on average lower than cervical cancer screening rates (mean difference 14.5%, standard deviation 12.0%) and were less strongly associated with practice characteristics. The strong negative correlation between breast cancer screening rates and list inflation shows the importance of accurate age-sex registers in achieving high breast cancer screening rates. Breast cancer screening units, family health services authorities, and general practitioners need to collaborate to improve the accuracy of the age-sex registers used to generate invitations for breast cancer screening. The success of the practice with the highest screening rate suggests that practices can influence the uptake of breast cancer screening among their patients. Giving general practitioners a greater role in breast cancer screening, either by offering them financial incentives or by giving them clerical support to check prior notification lists and contact nonattenders, may also help to increase breast cancer screening rates.

Preventative cancer screening among African and Afro-Caribbean immigrants.

10540 Background: The sexual and gender minority (SGM) populations experience a greater cancer burden than their heterosexual or cisgender counterparts. Screening rates for cancer within this cohort are frequently suboptimal, highlighting notable deficiencies in screening recommendations. Inadequate culturally competent care and screening guidelines may contribute to delays in cancer diagnosis and treatment, ultimately impacting survival and quality of life. We sought to investigate the existing disparities in cancer screening among SGM populations. Methods: We conducted a systematic review and meta-analysis to assess the cancer screening rates in SGM. The SGM population included in this study were gays, lesbians, bisexuals, transgender men, and transgender women. Two reviewers conducted a systematic search of numerous databases, including PubMed, PsycINFO, and CINAHL, and then extracted relevant information from eligible studies. For this study, we conducted a meta-analysis using a random-effects model. Pooled estimates of the odds ratio were calculated for any combination of outcomes and population when at least two studies had relevant data. Study heterogeneity was assessed using I² statistics. Meta-regression, accounting for the study weight, year, and latitude, was performed on variables potentially associated with heterogeneity. Newcastle-Ottawa Scale was used to assess the quality of selected studies. Results: We analyzed data from a total of 60 eligible studies with 65,315 patients. Pooled analysis showed that sexual minority groups were at lower risk for cancer screening such as breast cancer screening (OR: 0.79, 95% CI, 0.75-0.82; Chi2=835.23; p<0.001; I2=97%), cervical cancer screening (OR: 0.62, 95% CI, 0.56-0.72; Chi2=926.23; p<0.001; I2=96%), colorectal cancer screening (OR: 0.51, 95% CI, 0.45-0.61; Chi2=3272.21; p<0.001; I2=98%), and prostate cancer screening (OR: 0.71, 95% CI, 0.63-0.82; Chi2=1282.92; p<0.001; I2=99%). The prevalence of lung cancer (p<0.001) and anal cancer screening (p<0.001) were also lower in sexual minority groups. The analysis also showed no small study effects (Egger test: 1.33; 95% CI: −5.42, −0.63; p=0.182). All the subgroups (geographical location, screening procedure, screening period) had high between-study heterogeneity. Conclusions: Our findings indicate that cancer screening rates for breast, cervical, colorectal, prostate, lung, and anal cell cancer are significantly lower in SGM populations and emphasize the urgent need for targeted interventions, culturally competent care, and inclusive screening guidelines to address these disparities. Understanding and addressing these issues are crucial for reducing delays in cancer diagnosis and improving survival and quality of life for SGM population. Further research and comprehensive strategies are warranted to bridge these gaps in cancer screening accessibility and uptake.

The Taiwanese national cancer screening program was established in 1985 by providing Pap smear tests for women. At the same time, trial-based screening for colorectal, oral, and breast cancer screening was initiated. In 1999, outreach services for cancer screening were started and gradually scaled up to the national level. Our hospital is located in Hsinchu, Taiwan. Like many hospitals in Taiwan, we provide cancer screening services to the community. Our baseline screening rate was 96.6% in 2016. Aiming to increase the overall cancer (including colorectal, oral, breast, and cervical cancer) screening rates, we implemented two strategies. First, we modified the cancer screening workflow so that patients could receive screening counseling before the scheduled appointment. Second, we redesigned the clinic waiting room layout by moving check-in and cancer screening counters next to each other. By the end of 2017, the overall cancer screening rate increased from 96.6% to 105.4%. Our future efforts will be focused on collecting patient feedback, increasing coverage of hard-to-reach populations, and understanding barriers to cancer screening for specific groups of patients.

We examined the relationship between cancer screening and life expectancy predictors, focusing on the influence of age versus health and function, in older adults with limited life expectancy. Longitudinal cohort study SETTING: National Health and Aging Trends Study (NHATS) with linked Medicare claims. Three cohorts of adults 65+ enrolled in fee-for-service Medicare were constructed: women eligible for breast cancer screening (n = 2043); men eligible for prostate cancer screening (n = 1287); men and women eligible for colorectal cancer screening (n = 3759). We assessed 10-year mortality risk using 2011 NHATS data, then used claims data to assess 2-year prostate and breast cancer screening rates and 3-year colorectal cancer screening rates. Among those with limited life expectancy (10-year mortality risk > 50%), we stratified participants at each level of predicted mortality risk and split participants in each risk stratum by the median age. We assembled two sub-groups from these strata that were matched on predicted life expectancy: a "younger sub-group" with relatively poorer health/functional status and an "older sub-group" with relatively better health/functional status. We compared screening rates between sub-groups. For all three cancer screenings, the younger sub-groups (average ages 73.4-76.1) had higher screening rates than the older sub-groups (average ages 83.6-86.9); screening rates were 42.9% versus 34.2% for prostate cancer screening (p = 0.02), 33.6% versus 20.6% for breast cancer screening (p < 0.001), 13.1% versus 6.7% for colorectal cancer screening in women (p =0.006), and 20.5% versus 12.1% for colorectal cancer screening in men (p = 0.002). Among older adults with limited life expectancy, those who are relatively younger with poorer health and functional status are over-screened for cancer at higher rates than those who are older with the same predicted life expectancy.

1565 Background: Understanding the prevalence of cancer screening in the US and the factors associated with its accessibility is important for public health promotion. Methods: The 2004 and 2010 Behavioral Risk Factor Surveillance Systems were used to ascertain cancer screening rates among populations indicated for each test by age, gender, and the American Cancer Society recommendation for cancer screenings [fecal occult blood test (FOBT) or endoscopy for colorectal cancer (CRC) screening, digital rectal examination (DRE) or prostate specific antigen (PSA) for prostate cancer screening, clinical breast examination (CBE) or mammogram for breast cancer screening, and Papanicolaou (Pap) test for cervical cancer screening]. Results: Over this period, CRC and breast cancer screening rates significantly increased (15.9%, 13.9%) while prostate and cervical cancer screening rates significantly decreased (1.2%, 5.2%). Race/ethnicity might be an influence in CRC and cervical cancer screening accessibility. Prostate cancer screening accessibility might be influenced by education and income. The older-aged populations (70-79, &gt;79) had high prevalence of CRC, prostate and breast cancer screenings even though there is insufficient evidence for the benefits and harms of screenings in the older-aged group. Conclusions: The disparities in age, race/ethnicity, health insurance, education, employment, and income for the accession to cancer screening of the US population have decreased since 2004. The trajectory of increasing rates of CRC and breast cancer screenings should be maintained. To reverse the trend, the causes of the decreased rate of cervical cancer screening and the high rates of screenings in older-aged populations should, however, be further explored. [Table: see text]

Cancer Prevention in a Postpandemic World: A One-Stop-Shop Approach

Cancer screening is often fully covered under high-deductible health plans (HDHP), but low socioeconomic status (SES) women still might forego testing. To determine the impact of switching to a HDHP on breast and cervical cancer screening among women of low SES. Pre-post with comparison group. Four thousand one hundred and eighty-eight health plan members enrolled for one year before and up to two years after an employer-mandated switch from a traditional HMO to an HMO-based HDHP, compared with 9418 propensity score matched controls who remained in HMOs by employer choice. Both groups had low outpatient copayments. High-deductible members had full coverage of mammography and Pap smears, but $500 to $2000 individual deductibles for most other services. HMO members had full coverage of cancer screening and low copayments for other services without any deductible. We stratified analyses by SES. Transition to a HDHP. Annual breast and cervical cancer screening rates; rates of annual preventive outpatient visits. In follow-up years 1 and 2, low SES HDHP members experienced no statistically detectable changes in rates of breast cancer screening (ratio of change, 1.14, 95 % CI, [0.93,1.40] and 1.05, [0.80,1.37], respectively) or preventive visits (difference-in-differences, +1.9 %, [-11.9 %,+17.7 %] and +10.1 %, [-9.4 %,+33.7 %], respectively) relative to HMO counterparts. Similarly, among low SES HDHP members eligible for cervical cancer screening, no significant changes occurred in either screening rates (1.01, [0.86,1.20] and 1.08, [0.86,1.35]) or preventive visits (+0.2 %, [-11.4 %,+13.3 %] and -1.4 %, [-18.1,+18.6]). Patterns were statistically similar for high SES members. During two follow-up years, transition to an HMO-based HDHP with coverage of primary care visits and cancer screening did not lead to differentially lower rates of breast and cervical cancer screening or preventive visits for low SES women. Generalizability is limited to commercially insured women transitioning to HDHPs with low cost-sharing for cancer screening and primary care visits, a common design.