Colorectal Cancer Screening Delivery Research Articles

Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

Advancing Health Equity for Medicaid Beneficiaries by Adding Colorectal Cancer Screening to the Centers for Medicare and Medicaid Services Adult Core Set

Associations of multimorbidity with breast, cervical, and colorectal cancer screening delivery: a cross-sectional study of a nationally representative Japanese sample

BackgroundMultimorbidity is associated with a high mortality rate and low health-related quality of life. Previous studies have indicated that multimorbidity tends to be associated with not receiving cancer screening, although this association remains unclear. This study aimed to investigate the associations between multimorbidity and the delivery of breast, cervical, and colorectal cancer screening in Japan, and to identify subgroups that did not receive cancer screening. MethodsThis study used cross-sectional data from the 2016 Comprehensive Survey of Living Conditions, which used a stratified random sample of the general Japanese population. Multivariable logistic regression models were used to evaluate the associations between the number of chronic conditions and each cancer’s screening proportion. The relevant covariates included age, marital status, education level, occupation, and household income. ResultsRelative to subjects with no chronic conditions, subjects with two chronic conditions received more screening for breast, cervical, and colorectal cancers (breast cancer, adjusted odds ratio [aOR]: 5.42, 95% confidence interval [CI]: 2.80–10.5; cervical cancer, aOR: 4.59, 95% CI: 2.03–10.4; male colorectal cancer, aOR: 3.26, 95% CI: 1.29–8.24; female colorectal cancer, aOR: 1.05, 95% CI: 0.39–2.81). Low socioeconomic status was associated with not receiving any type of cancer screening consistently. ConclusionMultimorbidity and high socioeconomic status were associated with higher proportions of screening for breast, cervical, and colorectal cancers in the Japanese population. More aggressive strategies may be needed to promote screening among Japanese individuals with no chronic conditions and individuals with low socioeconomic status.

Abstract C120: Evidence-based strategies to enhance colorectal cancer screening in American Indian communities

Abstract Despite the proven effectiveness of colorectal cancer (CRC) screening, American Indians (AIs) have some of the lowest CRC screening rates. Nearly two-thirds of US adults are current with US Preventive Services Task Force guidelines for CRC screening. In contrast, based on Indian Health Service (IHS) Government Performance and Results Act (GPRA) data, AI screening rates range from a low of 28% in the Phoenix Area, to 30% in the Albuquerque Area and a high of only 51% in the Oklahoma Area. The AI CRC Screening Consortium was formed by the National Cancer Institute-Designated Cancer Centers at the Universities of Arizona, New Mexico, and Oklahoma to address the major regional CRC screening disparities. The Consortium’s overall objective is to increase CRC screening delivery and uptake in AIs aged 50 to 75 years at average risk for CRC through the implementation of cost-effective multilevel, multicomponent evidence-based interventions (EBIs) across AI populations (on and off tribal lands) in the tri-state region. As part of the planning phase of the project (Year 1), we completed mixed-methods environmental scans (focus group and interviews, and readiness to change surveys) among tribal members and multisector healthcare providers practicing at Indian Health Service (IHS, I), Tribal (T), and Urban Indian (U) (I/T/U) healthcare facilities across the three states. In all, we conducted seven focus groups, 71 interviews, and three surveys at nine I/T/U healthcare facilities. We organized the focus group and interview data according to The Guide to Community Preventive Services (The Community Guide) recommendations for strategies to increase: community demand, community access, and provider delivery of CRC screening. We will provide quotes and summaries underscoring the EBIs and strategies recommended by the multisector healthcare action teams for implementation at their healthcare facilities. We will also describe the establishment of the Consortium and challenges experienced in conducting research with multiple tribal and federal entities and regulatory authorities. The use of community-academic participatory approaches has facilitated bidirectional and mutually beneficial knowledge integration, collaborative inter-dependent partnerships, equity in data ownership, and capacity enhancement. The scope of this project presents an opportunity to reduce CRC incidence and mortality affecting thousands of AIs. Our collaborative work will create opportunities for future research addressing the spectrum of CRC prevention, detection, and treatment in AI populations across the US. Citation Format: Shiraz I Mishra, Mark P Doescher, Jennifer Hatcher, Kevin English, Dorothy Rhoades, Peter Lance, Shane Pankratz, Jessica Blanchard, Nicholas Edwardson, Michelle Hopkins, Andrew Sussman, Zsolt Nagykaldi, Cheyenne Jim. Evidence-based strategies to enhance colorectal cancer screening in American Indian communities [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C120.

Simulation modeling validity and utility in colorectal cancer screening delivery: A systematic review.

ObjectiveThis study sought to assess the impact and validity of simulation modeling in informing decision making in a complex area of healthcare delivery: colorectal cancer (CRC) screening.Materials and MethodsWe searched 10 electronic databases for English-language articles published between January 1, 2008, and March 1, 2019, that described the development of a simulation model with a focus on average-risk CRC screening delivery. Included articles were reviewed for evidence that the model was validated, and provided real or potential contribution to informed decision making using the GRADE EtD (Grading of Recommendations Assessment, Development, and Evaluation Evidence to Decision) framework.ResultsA total of 43 studies met criteria. The majority used Markov modeling (n = 31 [72%]) and sought to determine cost-effectiveness, compare screening modalities, or assess effectiveness of screening. No study reported full model validation and only (58%) reported conducting any validation. Majority of models were developed to address a specific health systems or policy question; few articles report the model’s impact on this decision (n = 39 [91%] vs. n = 5 [12%]). Overall, models provided evidence relevant to every element important to decision makers as outlined in the GRADE EtD framework.Discussion and ConclusionSimulation modeling contributes evidence that is considered valuable to decision making in CRC screening delivery, particularly in assessing cost-effectiveness and comparing screening modalities. However, the actual impact on decisions and validity of models is lacking in the literature. Greater validity testing, impact assessment, and standardized reporting of both is needed to understand and demonstrate the reliability and utility of simulation modeling.

Use of Simulation Modeling to Inform Decision Making for Health Care Systems and Policy in Colorectal Cancer Screening: Protocol for a Systematic Review.

BackgroundSimulation modeling has frequently been used to assess interventions in complex aspects of health care, such as colorectal cancer (CRC) screening, where clinical trials are not feasible. Simulation models provide estimates of outcomes, unintended consequences, and costs of an intervention; thus offering an invaluable decision aid for policy makers and health care leaders. However, the contribution that simulation models have made to policy and health system decisions is unknown.ObjectiveThis study aims to assess if simulation modeling has supported evidence-informed decision making in CRC screening.MethodsA preliminary literature search and pilot screening of 100 references were conducted by three independent reviewers to define and refine the inclusion criteria of this systematic review. Using the developed inclusion criteria, a search of the academic and gray literature published between January 1, 2008, and March 1, 2019, will be conducted to identify studies that developed a simulation model focusing on the delivery of CRC screening of average-risk individuals. The three independent reviewers will assess the validation process and the extent to which the study contributed evidence toward informed decision making (both reported and potential). Validation will be assessed based on adherence to the best practice recommendations described by the International Society for Pharmacoeconomics and Outcomes Research-Society for Medical Decision Making (ISPOR-SMDM). Criteria for potential contribution to decision making will be defined as outlined in the internationally recognized Grading of Recommendations Assessment, Development and Evaluation Evidence to Decision (GRADE EtD) framework. These criteria outline information that the health system and policy decision makers should consider when making an evidence-informed decision including an intervention’s resource utilization, cost-effectiveness, impact on health equity, and feasibility. Subgroup analysis of articles based on their GRADE EtD criteria will be conducted to identify methods associated with decision support capacity (ie, participatory, quantitative, or mixed methods).ResultsA database search of the literature yielded 484 references to screen for inclusion in the systematic review. We anticipate that this systematic review will provide an insight into the contribution of simulation modeling methods to informed decision making in CRC screening delivery and discuss methods that may be associated with a stronger impact on decision making. The project was funded in May 2019. Data collection took place from January 2008 to March 2019. Data analysis was completed in November 2019, and are expected to be published in spring 2020.ConclusionsOur findings will help guide researchers and health care leaders to mobilize the potential for simulation modeling to inform evidence-informed decisions in CRC screening delivery. The methods of this study may also be replicated to assess the utility of simulation modeling in other areas of complex health care decision making.International Registered Report Identifier (IRRID) DERR1-10.2196/16103Trial RegistrationPROSPERO no. 130823; https://www.crd.york.ac.uk/PROSPERO

Screening colonoscopy in the US: attitudes and practices of primary care physicians.

Rising colorectal cancer (CRC) screening rates in the last decade are attributable almost entirely to increased colonoscopy use. Little is known about factors driving the increase, but primary care physicians (PCPs) play a central role in CRC screening delivery. Explore PCP attitudes toward screening colonoscopy and their associations with CRC screening practice patterns. Cross-sectional analysis of data from a nationally representative survey conducted in 2006-2007. 1,266 family physicians, general practitioners, general internists, and obstetrician-gynecologists. Physician-reported changes in the volume of screening tests ordered, performed or supervised in the past 3 years, attitudes toward colonoscopy, the influence of evidence and perceived norms on their recommendations, challenges to screening, and practice characteristics. The cooperation rate (excludes physicians without valid contact information) was 75%; 28% reported their volume of FOBT ordering had increased substantially or somewhat, and the majority (53%) reported their sigmoidoscopy volume decreased either substantially or somewhat. A majority (73%) reported that colonoscopy volume increased somewhat or substantially. The majority (86%) strongly agreed that colonoscopy was the best of the available CRC screening tests; 69% thought it was readily available for their patients; 59% strongly or somewhat agreed that they might be sued if they did not offer colonoscopy to their patients. All three attitudes were significantly related to substantial increases in colonoscopy ordering. PCPs report greatly increased colonoscopy recommendation relative to other screening tests, and highly favorable attitudes about colonoscopy. Greater emphasis is needed on informed decision-making with patients about preferences for test options.

Influence of Primary Care Use on Population Delivery of Colorectal Cancer Screening

Colorectal cancer (CRC) screening is commonly initiated during primary care visits. Thus, at the population level, limited primary care attendance may constitute a substantial barrier to CRC screening uptake. Within a defined population, we quantified the percent of CRC screening underuse that is potentially explained by low use of primary care visits. Among 48,712 adults ages 50 to 78 years eligible for CRC screening within a Washington state health plan, we estimated the degree to which a lack of CRC screening in 2002 to 2003 (fecal occult blood testing, sigmoidoscopy, or colonoscopy) was attributable to low primary care use, expressed as the population attributable risk percent (PAR%) associated with 0 to 3 primary care visits during the 2-year period. In analyses adjusted for age, comorbidity, nonprimary care visit use, and prior preventive service use, low primary care use in 2002 to 2003 was strongly associated with a lack of CRC screening among both women and men. However, a majority of unscreened women and men had > or =4 primary care visits. Thus, whether low primary care use was defined as 0, 0 to 1, 0 to 2, or 0 to 3 primary care visits, the PAR% associated with low primary care use was large in neither women (range, 3.0-6.8%) nor men (range: 5.6-11.5%). Health plan outreach efforts to encourage primary care attendance would be unlikely to substantially increase population uptake of CRC screening. In similar settings, resources might be more fruitfully devoted to the optimization of screening delivery during primary care visits that patients already attend.

Colorectal cancer screening: A comparison of 35 initiatives in 17 countries

Although in its infancy, organized screening for colorectal cancer (CRC) in the general population is increasing at regional and national levels. Documenting and describing these initiatives is critical to identifying, sharing and promoting best practice in the delivery of CRC screening. Subsequently, the International Colorectal Cancer Screening Network (ICRCSN) was established in 2003 to promote best practice in the delivery of organized screening programs. The initial aim was to identify and document organized screening initiatives that commenced before May 2004. Each identified initiative was sent 1 questionnaire per screening modality: fecal occult blood test, flexible sigmoidoscopy or total colonoscopy. Information was collected on screening methodology, testing details and initiative status. In total, 35 organized initiatives were identified in 17 countries, including 10 routine population-based screening programs, 9 pilots and 16 research projects. Fecal occult blood tests were the most frequently used screening modality, and total colonoscopy was seldom used as a primary screening test. The eligible age for screening ranged from 40 years old to no upper limit; most initiatives included participants aged 50 to 64. Recruitment was usually done by a mailed invitation or during a visit to a family physician. In conclusion, this is the first investigation describing the delivery of CRC screening protocols to various populations. The work of the ICRCSN is enabling valuable information to be shared and a common nomenclature to be established.

Do Physician Recommendations for Colorectal Cancer Screening Differ by Patient Age?

Colorectal cancer screening is underutilized, resulting in preventable morbidity and mortality. In the present study, age-related and other disparities associated with physicians' delivery of colorectal cancer screening recommendations were examined. The present cross-sectional study included 43 physicians and 618 of their patients, aged 50 to 80 years, without past or present colorectal cancer. Of the 285 screen-eligible patients, 45% received a recommendation. Multivariate analyses revealed that, compared with younger nondepressed patients, older depressed patients were less likely to receive fecal occult blood test recommendations, compared with no recommendation (OR=0.31, 95% CI 0.09 to 1.02), as well as less likely to receive colonoscopy recommendations, compared with no recommendation (OR=0.14; 95% CI 0.03 to 0.66). Comorbidity and marital status were associated with delivery of fecal occult blood test and colonoscopy recommendations, respectively, compared with no recommendation. In summary, patient age and other characteristics appeared to influence physicians' delivery of colorectal cancer screening and choice of modality.

Physicians' use of nonphysician healthcare providers for colorectal cancer screening

Background Data on the involvement of nonphysician healthcare providers in colorectal cancer (CRC) screening delivery are sparse. This article describes physicians' use of nurse practitioners and physician assistants to provide CRC screening with the fecal occult blood test (FOBT), flexible sigmoidoscopy, and colonoscopy, as well as physicians' attitudes toward using these providers to perform flexible sigmoidoscopy. Methods Nationally representative samples of primary care physicians, gastroenterologists, and general surgeons were surveyed in 1999–2000. Descriptive statistics and logistic regression were used to estimate the prevalence and predictors of physicians' use of nurse practitioners and physician assistants for CRC screening and to assess physicians' attitudes toward their use in providing CRC screening with flexible sigmoidoscopy. Results Overall, 24% of primary care physicians reported using a nurse practitioner or physician assistant to provide CRC screening with FOBT. However, only 3% of all physicians surveyed used nurse practitioners and physician assistants for CRC screening with flexible sigmoidoscopy, and less than 1% of gastroenterologists and general surgeons reported using these providers to perform CRC screening with colonoscopy. Approximately 15% of general surgeons, 40% of primary care physicians, and 60% of gastroenterologists who do not currently use nurse practitioners or physician assistants to perform CRC screening with flexible sigmoidoscopy agreed that these providers could effectively perform the procedure. Conclusions These results show current involvement of nurse practitioners and physician assistants in the delivery of CRC screening to be limited. Use of nonphysician healthcare providers for CRC screening with FOBT and flexible sigmoidoscopy is one possible solution to the challenge of boosting low screening rates. However, physician beliefs about the ability of nurse practitioners and physician assistants to perform flexible sigmoidoscopy are a potential barrier to increasing the involvement of nonphysician providers in CRC screening delivery.