Provider-directed Interventions Research Articles

Assessment of barriers to cancer screening and interventions implemented to overcome these barriers in 27 Latin American and Caribbean countries.

There is a gap in the understanding of the barriers to cancer screening participation and complying with downstream management in the Community of Latin American and Caribbean states (CELAC). Our study aimed to assess barriers across the cancer screening pathway from the health system perspective, and interventions in place to improve screening in CELAC. A standardized tool was used to collect information on the barriers across the screening pathway through engagement with the health authorities of 27 member states of CELAC. Barriers were organized in a framework adapted from the Tanahashi conceptual model and consisted of the following dimensions: availability of services, access (covering accessibility and affordability), acceptability, user-provider interaction, and effectiveness of services (which includes governance, protocols and guidelines, information system, and quality assurance). The tool also collected information of interventions in place, categorized in user-directed interventions to increase demand, user-directed interventions to increase access, provider-directed interventions, and policy and system-level interventions. All countries prioritized barriers related to the information systems, such as the population register not being accurate or complete (N = 19; 70.4%). All countries implemented some kind of intervention to improve cancer screening, group education being the most reported (N = 23; 85.2%). Training on screening delivery was the most referred provider-directed intervention (N = 19; 70.4%). The study has identified several barriers to the implementation of cancer screening in the region and interventions in place to overcome some of the barriers. Further analysis is required to evaluate the effectiveness of these interventions in achieving their objectives.

A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: Results of the TESTsmART Trial in western Kenya.

ACTs are responsible for a substantial proportion of the global reduction in malaria mortality over the last ten years, made possible by publicly-funded subsidies making these drugs accessible and affordable in the private sector. However, inexpensive ACTs available in retail outlets have contributed substantially to overconsumption. We test an innovative, scalable strategy to target ACT-subsidies to clients with a confirmatory diagnosis. We supported malaria testing(mRDTs) in 39 medicine outlets in western Kenya, randomized to three study arms; control arm offering subsidized mRDT testing (0.4USD), client-directed intervention where all clients who received a positive RDT at the outlet were eligible for a free (fully-subsidized) ACT, and a combined client and provider directed intervention where clients with a positive RDT were eligible for free ACT and outlets received 0.1USD for every RDT performed. Our primary outcome was the proportion of ACT dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients tested at the outlet and adherence to diagnostic test results. 43% of clients chose to test at the outlet. Test results informed treatment decisions, resulting in targeting of ACTs to confirmed malaria cases- 25.3% of test-negative clients purchased an ACT compared to 75% of untested clients. Client-directed and client+provider-directed interventions did not offer further improvements, compared to the control arm, in testing rates(RD = 0.09, 95%CI:-0.08,0.26) or dispensing of ACTs to test-positive clients(RD = 0.01,95% CI:-0.14, 0.16). Clients were often unaware of the price they paid for the ACT leading to uncertainty in whether the ACT subsidy was passed on to the client. This uncertainty undermines our ability to definitively conclude that client-directed subsidies are not effective for improving testing and appropriate treatment. We conclude that mRDTs could reduce ACT overconsumption in the private retail sector, but incentive structures are difficult to scale and their value to private providers is uncertain. Trial registration: ClinicalTrials.gov NCT04428307.

Provider discussion of genetic counseling among high-risk Spanish-preferring Latina breast cancer survivors.

Among high-risk breast cancer (BC) survivors, genetic counseling (GC) and genetic testing (GT) may inform cascade testing and risk management. Compared to non-Hispanic White BC survivors, Spanish-preferring Latina BC survivors are less likely to report discussing GC with a healthcare provider. However, few studies have examined Latinas' experiences with GC/GT, particularly outside of the mainland USA. This study aimed to compare frequency of provider discussion of GC between Spanish-preferring Latina BC survivors living in Florida (FL) and Puerto Rico (PR). We conducted secondary data analysis of baseline assessments from a randomized pilot of an educational intervention for Spanish-preferring Latina BC survivors. Participants (N = 52) were GC/GT-naive, but met clinical criteria for GC/GT referral. Participants self-reported sociodemographic, clinical, and cultural variables, including previous provider discussion of GC. Descriptive statistics characterized frequency of GC discussion. Logistic regression examined the relationships between sociodemographic, clinical, and cultural characteristics and GC discussion. Only 31% of participants reported previous GC discussion. More participants from PR reported having GC discussions (43% vs. 21% in the mainland USA). In multivariable analyses, greater likelihood of GC discussion was associated with PR (vs. mainland USA) residence (odds ratio [OR] = 6.00, p = .03), older age at baseline (OR = 1.19, p = .04), and younger age at BC diagnosis (OR = 0.80, p = .03). Few high-risk Spanish-preferring Latina BC survivors in the mainland USA and PR had discussed GC with their providers. These results highlight a gap in the implementation of evidence-based genetics guidelines. Provider-directed interventions may be needed to increase uptake of GC/GT among Latina BC survivors.

Implementation of a provider-focused intervention for maximizing human papillomavirus (HPV) vaccine uptake in young cancer survivors receiving follow-up care in pediatric oncology practices: protocol for a cluster-randomized trial of the HPV PROTECT intervention

BackgroundChildhood cancer survivors are at high risk for developing new cancers (such as cervical and anal cancer) caused by persistent infection with the human papillomavirus (HPV). HPV vaccination is effective in preventing the infections that lead to these cancers, but HPV vaccine uptake is low among young cancer survivors. Lack of a healthcare provider recommendation is the most common reason that cancer survivors fail to initiate the HPV vaccine. Strategies that are most successful in increasing HPV vaccine uptake in the general population focus on enhancing healthcare provider skills to effectively recommend the vaccine, and reducing barriers faced by the young people and their parents in receiving the vaccine. This study will evaluate the effectiveness and implementation of an evidence-based healthcare provider-focused intervention (HPV PROTECT) adapted for use in pediatric oncology clinics, to increase HPV vaccine uptake among cancer survivors 9 to 17 years of age.MethodsThis study uses a hybrid type 1 effectiveness-implementation approach. We will test the effectiveness of the HPV PROTECT intervention using a stepped-wedge cluster-randomized trial across a multi-state sample of pediatric oncology clinics. We will evaluate implementation (provider perspectives regarding intervention feasibility, acceptability and appropriateness in the pediatric oncology setting, provider fidelity to intervention components and change in provider HPV vaccine-related knowledge and practices [e.g., providing vaccine recommendations, identifying and reducing barriers to vaccination]) using a mixed methods approach.DiscussionThis multisite trial will address important gaps in knowledge relevant to the prevention of HPV-related malignancies in young cancer survivors by testing the effectiveness of an evidence-based provider-directed intervention, adapted for the pediatric oncology setting, to increase HPV vaccine initiation in young cancer survivors receiving care in pediatric oncology clinics, and by procuring information regarding intervention delivery to inform future implementation efforts. If proven effective, HPV PROTECT will be readily disseminable for testing in the larger pediatric oncology community to increase HPV vaccine uptake in cancer survivors, facilitating protection against HPV-related morbidities for this vulnerable population.Trial registrationClinicalTrials.gov Identifier: NCT04469569, prospectively registered on July 14, 2020.

Interventions to Improve Immunization Coverage Among Children and Adolescents: A Meta-analysis.

Vaccinations are recognized as a feasible, cost-effective public health intervention for reducing the burden and associated mortality of many infectious diseases. The purpose of this study was to evaluate the effectiveness of potential interventions to improve the uptake of vaccines among children and adolescents. We performed a literature search until December 2020. Eligible studies were identified using Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and other sources. We included studies conducted on children and adolescents aged 5 to 19 years. Studies comprised of hospitalized children and those with comorbid conditions were excluded. Two authors independently performed the meta-analysis. Findings from 120 studies (123 articles), of which 95 were meta-analyzed, reveal that vaccination education may increase overall vaccination coverage by 19% (risk ratio [RR], 1.19; 95% confidence interval [CI], 1.12-1.26), reminders by 15% (RR, 1.15; 95% CI, 1.11-1.18), interventions for providers by 13% (RR, 1.13; 95% CI, 1.07-1.19), financial incentives by 67% (RR, 1.67; 95% CI, 1.40-1.99), and multilevel interventions by 25% (RR, 1.25; 95% CI, 1.10-1.41). The impact of school-based clinics and policy and legislation on overall vaccination coverage is still uncertain, and no impact of a multicomponent intervention on overall vaccination coverage was found. Educational interventions, reminders, provider-directed interventions, financial incentives, and multilevel interventions may improve vaccination coverage among school-aged children and adolescents.

Characteristics and Network Influence of Providers Involved in the Treatment of Patients With Chronic Back, Neck or Joint Pain in Arkansas

Increasing emphasis on guidelines and prescription drug monitoring programs highlight the role of healthcare providers in pain treatment. Objectives of this study were to identify characteristics of key players and influence of opioid prescribers through construction of a referral network of patients with chronic pain. A retrospective cohort study was performed and patients with commercial or Medicaid coverage with chronic back, neck, or joint pain were identified using the Arkansas All-Payer Claims-Database. A social network comprised of providers connected by patient referrals based on 12-months of healthcare utilization following chronic pain was constructed. Network measures evaluated were indegree and eigen (referrals obtained), betweenness (involvement), and closeness centrality (reach). Outcomes included influence of providers, opioid prescribers, and brokerage status. Exposures included provider demographics, specialties and network characteristics. There were 51,941 chronic pain patients who visited 8,110 healthcare providers. Primary care providers showed higher betweenness and closeness whereas specialists had higher indegree. Opioid providers showed higher centrality compared to non-opioid providers, which decreased with increasing volume of opioid prescribing. Non-pharmacologic providers showed significant brokerage scores. Findings from this study such as primary care providers having better reach, non-central positions of high-volume prescribers and non-pharmacologic providers having higher brokerage can aid interventional physician detailing. PerspectiveOpioid providers held central positions in the network aiding provider-directed interventions. However, high-volume opioid providers were at the borders making them difficult targets for interventions. Primary care providers had the highest reach, specialists received the most referrals and non-pharmacological providers and specialists acted as brokers between non-opioid and opioid prescribers.

Interventions to Influence the Use of Antibiotics for Acute Upper Respiratory Tract Infections


 Thirteen systematic reviews (SRs) were identified. Two of these SRs addressed delayed antibiotic prescribing and 12 of these SRs investigated family medicine interventions. Delayed antibiotic prescribing reduced antibiotic use for upper respiratory tract infections (URTIs) compared to immediate prescribing and did not appear to impact patient satisfaction or re-consultation rates; however, there was less evidence on clinical outcomes, health care utilization, or antibiotic resistance. One systematic review concluded that there was no difference between delayed and immediate antibiotics for many clinical outcomes, but that immediate antibiotics may modestly improve symptoms for acute otitis media (AOM) and sore throat compared with delayed antibiotics.
 Various family medicine interventions were evaluated; however, there were generally few relevant primary studies in each of these reviews for most of the interventions. Rapid or point-of-care tests to guide the treatment of URTIs appeared to reduce antibiotic prescribing compared to control or usual care; however, there was relatively little evidence on clinical outcomes for these tests. One systematic review on procalcitonin-guided treatment suggested that this intervention led to no difference in the number of days with restricted activities or rates of treatment failure compared to control, while another systematic review found that C-reactive protein (CRP) point-of-care tests to guide antibiotic prescribing resulted in no difference in recovery or time to resolution of the symptoms; however, this was based on only 2 randomized controlled trials (RCTs). Evidence was mixed on different patient- or provider-directed interventions, such as education, training, and tools. In some of the primary studies from the eligible SRs, these interventions reduced antibiotic prescribing; while in others, they had no effect on antibiotic prescribing.

Incentivizing appropriate malaria case management in the private sector: a study protocol for two linked cluster randomized controlled trials to evaluate provider- and client-focused interventions in western Kenya and Lagos, Nigeria

BackgroundA large proportion of artemisinin-combination therapy (ACT) anti-malarial medicines is consumed by individuals that do not have malaria. The over-consumption of ACTs is largely driven by retail sales in high malaria-endemic countries to clients who have not received a confirmatory diagnosis. This study aims to target ACT sales to clients receiving a confirmatory diagnosis using malaria rapid diagnostic tests (mRDTs) at retail outlets in Kenya and Nigeria.MethodsThis study comprises two linked four-arm 2 × 2 factorial cluster randomized controlled trials focused on malaria diagnostic testing and conditional ACT subsidies with the goal to evaluate provider-directed and client-directed interventions. The linked trials will be conducted at two contrasting study sites: a rural region around Webuye in western Kenya and the urban center of Lagos, Nigeria. Clusters are 41 and 48 participating retail outlets in Kenya and Nigeria, respectively. Clients seeking care at participating outlets across all arms will be given the option of paying for a mRDT—at a study-recommended price—to be conducted at the outlet. In the provider-directed intervention arm, the outlet owner receives a small monetary incentive to perform the mRDT. In the client-directed intervention arm, the client receives a free ACT if they purchase an mRDT and receive a positive test result. Finally, the fourth study arm combines both the provider- and client-directed interventions. The diagnosis and treatment choices made during each transaction will be captured using a mobile phone app. Study outcomes will be collected through exit interviews with clients, who sought care for febrile illness, at each of the enrolled retail outlets.ResultsThe primary outcome measure is the proportion of all ACTs that are sold to malaria test-positive clients in each study arm. For all secondary outcomes, we will evaluate the degree to which the interventions affect purchasing behavior among people seeking care for a febrile illness at the retail outlet.ConclusionsIf our study demonstrates that malaria case management can be improved in the retail sector, it could reduce overconsumption of ACTs and enhance targeting of publicly funded treatment reimbursements, lowering the economic barrier to appropriate diagnosis and treatment for patients with malaria.Trial registrationClinicalTrials.govNCT04428307, registered June 9, 2020, and NCT04428385, registered June 9, 2020.

208. Trends in Antibiotic Prescribing for Acute Respiratory Tract Infections and Implementation of a Provider-Directed Intervention Within the Veterans Affairs Healthcare System (VA)

BackgroundWe report VA-wide trends over time in acute respiratory infection (ARI) antibiotic prescribing, and early assessment of an intervention to improve ARI management.MethodsWe created a retrospective cohort of ARI (sinusitis, pharyngitis, bronchitis, and URI-NOS) visits between 2009 and April 2018. Patients with complicating conditions were excluded. Antibiotic prescribing rates were calculated. A provider-directed VA-wide ARI campaign was initiated in October 2017. The Campaign was implemented locally by antibiotic stewards or regional personnel trained in academic detailing (AD). Campaign components: dashboards for tracking provider and facility prescribing metrics, printable feedback reports, and AD educational materials. Metrics include: ARI antibiotic prescribing rates, bronchitis/URI-NOS antibiotic prescribing rates, guideline-concordant antibiotic selection for sinusitis or pharyngitis, and proportion of ARI visits with a sinusitis diagnosis. A Logistic generalized estimating equation model assessed metrics over time pre-/postintervention and χ2 tests compared guideline concordant antibiotic proportions pre-/postintervention.ResultsThere were 1,580,612 and 137,421 ARI visits pre-/postintervention, respectively. Antibiotic prescribing decreased from 2009, annual odds ratio (OR) 0.94 [95% CI 0.93, 0.96; P < 0.001]. An additional effect was observed postintervention [OR 0.88, (0.84, 0.88), P < 0.001]. Bronchitis/URI-NOS prescribing rates decreased from 2009 [annual OR 0.94 (CI 0.93, 0.95), P < 0.001]. Additional effect was observed postintervention [OR 0.86, (0.81, 0.91), P < 0.001]. Overall, the proportion of ARI visits diagnosed with sinusitis increased [annual OR 1.09 (1.08, 1.10), P < 0.01], but the proportion of sinusitis diagnoses decreased [OR 0.72 (0.69, 0.75), P < 0.001] postintervention. Guideline-concordant antibiotic selection was 61.5% vs. 71.2% for sinusitis and 63.3% vs. 67.8% for pharyngitis pre-/postintervention, respectively (both P < 0.001).ConclusionAntibiotic prescribing rates for ARIs within the VA have steadily declined since 2010. Additional decline in antibiotic prescribing was associated with the launch of a national campaign to improve ARI management. Disclosures All authors: No reported disclosures.

Interventions to improve the management of asthma in primary care settings

The Global Initiative for Asthma (GINA 2002), in its Practical Guide to Asthma Management provides an evidence-based management strategy that addresses severity assessment, pharmacotherapy, monitoring, environmental control and the patient-provider partnership (GINA 2002). Despite the existence of effective therapies, including inhaled anti-inflammatory and long-acting bronchodilators, current practice falls short of guidelines and consequently, inadequate asthma control continues to be the norm. Although evidence based guidelines have been established, there is significant variation among practitioners in treating this condition, indicating a significant gap between what we know is optimal care and current practice (Finkelstein 2000, Finkelstein 2002, Lozano 2003). We propose to undertake a review of interventions to improve the management of asthma in primary care. A variety of approaches have been taken to improve asthma care including; patient self-management support, provider directed education and behavior change, and organizational approaches. Considerable work has been done in reviewing patient self-management support interventions. For example, Gibson found that information only patient education programs did not appear to improve outcomes (Gibson 2001). Toelle found insufficient evidence about the effectiveness of written management plans for adults and children (Toelle 2001). Reviews of more complex self-management interventions have shown positive results: self-management support education for children directed at prevention and attack management showed demonstrably improved outcomes (Wolf 2002). Positive outcomes were found in studies of asthma education for adults that included self-monitoring of either peak flow or symptoms, when combined with regular medical review and a written action plan (Gibson 2002). Another review of multifaceted adult interventions showed equivalent effects for control of asthma management by regular medical review of inhaled corticosteroid use vs. control by self-adjustment using written self management plan (Powell 2002). To complement these reviews, we will focus our review on provider-directed interventions and organizational approaches, only including patient-oriented interventions when they are part of a multi-focus study. The objectives of this review are to determine the effectiveness of various interventions to improve the management of asthma in primary care settings.

Abstract B79: Addressing patient barriers to cancer screening in safety net clinics

Abstract Background: Medically underserved, uninsured patients experience individual and structural barriers to screening for breast and colon cancer, contributing to ongoing cancer health disparities. Community-based safety net clinics serving this patient population use a variety of policy and system-level strategies that can reduce patient barriers. A qualitative study conducted by The American Cancer Society (Society) and the Emory Prevention Research Center (EPRC) on safety net clinics highlights key patient barriers and strategies employed to overcome these barriers to increase cancer screening in this population. Methods: Society evaluators conducted site visits to nine safety net clinics receiving grant funds from the Society to increase breast and colon cancer screening among underserved populations in 2013. The evaluation assessed the implementation process of client and provider-directed intervention strategies. Evaluation staff conducted 52 in-depth interviews with 3-10 staff at each clinic. Interviews were digitally recorded and transcribed verbatim. Transcriptions were coded and analyzed by a team of researchers from both organizations using the Consolidated Framework for Implementation Research (CFIR) constructs to assess factors associated with effective implementation. Results: A majority of interviewees (67%-100%, mean 87%) in all 9 sites talked about patient needs and barriers and ways to address them. Patient barriers identified included low English proficiency, presenting challenges in communicating with providers; low health literacy; additional challenges to preparing for colonoscopies; limited transportation to services; lack of insurance/underinsurance; fear of cancer and co-morbidities that add to the complexity of the screening process. At the system level, structural barriers included perceived complexity of the healthcare system; requirement of multiple clinic visits to different locations to receive education and screening; and inconsistent messages received from providers at different facilities. While sites employed a variety of strategies to address patient barriers, almost all sites stressed that they are patient-centered and that the clinic staff prioritized improving patients' experience and meeting their needs. Some mentioned the importance of patient activation, ensuring the patients had all necessary information and were fully engaged in decisions about the screening process. One such respondent commented, “If we empower the patients with knowledge and give them the information up front and establish that accountability, then we'll see a reduction in lost patients.” Besides providing interpretation, transportation assistance, and assistance in getting insurance or other access to screening services, many sites utilized patient navigators to conduct education and patient reminders to promote cancer screening. Some sites implemented system-level changes to streamline the workflow of clinical processes to reduce the steps required of patients when accessing screening services. Respondents felt that system-level changes increased the likelihood of sustainable improvement in patient experiences, completion of screening, and the quality of preparation for screening. Conclusion: This presentation will describe in detail the strategies employed by safety net clinics and discuss potential approaches to strengthen safety nets' capacity in addressing patient barriers, which has great potential to further reduce cancer health disparities experienced by underserved and uninsured populations. Citation Format: Rentonia Morton, Megan Cotter, Kara Riehman, Lily Shuting Liang, Michelle Kegler, Emily Phillips, Derrick Beasley, April Hermstad, Jeremy Martinez. Addressing patient barriers to cancer screening in safety net clinics. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr B79.

Randomized Clinical Trial of HIV Treatment Adherence Counseling Interventions for People Living With HIV and Limited Health Literacy

Limited health literacy is a known barrier to medication adherence among people living with HIV. Adherence improvement interventions are urgently needed for this vulnerable population. This study tested the efficacy of a pictograph-guided adherence skills-building counseling intervention for limited literacy adults living with HIV. Men and women living with HIV and receiving antiretroviral therapy (N = 446) who scored <90% correct on a test of functional health literacy were partitioned into marginal and lower literacy groups and randomly allocated to 1 of 3 adherence-counseling conditions: (1) pictograph-guided adherence counseling, (2) standard adherence counseling, or (3) general health improvement counseling. Participants were followed for 9 months postintervention with unannounced pill count adherence and blood plasma viral load as primary end points. Preliminary analyses demonstrated the integrity of the trial and >90% of participants were retained. Generalized estimating equations showed significant interactions between counseling conditions and levels of participant health literacy across outcomes. Participants with marginal health literacy in the pictograph-guided and standard-counseling conditions demonstrated greater adherence and undetectable HIV viral loads compared with general health counseling. In contrast and contrary to hypotheses, participants with lower health literacy skills in the general health improvement counseling demonstrated greater adherence compared with the 2 adherence counseling conditions. Patients with marginal literacy skills benefit from adherence counseling regardless of pictographic tailoring, and patients with lower literacy skills may require more intensive or provider-directed interventions.

Interventions to reduce racial and ethnic disparities in colorectal cancer care: A systematic review.

e16509 Background: Disparities in colorectal cancer (CRC) outcomes among underrepresented racial and ethnic minority patients continue to widen. We performed, and present here, the results of a systematic review of the literature evaluating interventions to reduce racial and ethnic disparities in CRC care. Methods: The MEDLINE, PsycINFO, CINAHL, and Cochrane databases were searched for articles that focused on interventions to reduce disparities in CRC screening, treatment, survivorship and end-of-life care from 1950 to 2010. Studies included were those that evaluated interventions in US populations that were composed of ≥50% racial/ethnic minorities (or that included a specific sub-analysis by race/ethnicity). Results: Following the electronic search, abstract and full text review, and reference reviews; a total of thirty-three studies were included in our final analysis. All of these were related to CRC screening; no studies evaluating the rest of the cancer care continuum were found. Nineteen studies (58%) were randomized controlled trials, nine (27%) were pre-test/post-test analyses, and five (15%) were cohort studies. Thirteen studies (39%) targeted African-American populations, eight (24%) targeted Hispanics, two (6%) targeted Asian populations, seven (21%) included a mixed population of ethnic minorities, and three (9%) were listed as “non-white” or included a subgroup analysis. The main results related to the magnitude of the effect of these patient-directed, patient navigator, and provider-directed interventions on CRC screening is outlined in the table below. Conclusions: Patient education involving personal contact, patient navigation services, and provider-directed education and reminder systems can modestly improve adherence to CRC screening among minority patients. Further studies targeting the rest of the colon cancer care continuum are needed. [Table: see text]

Abstract A106: Patient, provider, protocol, and health systems barriers to cancer clinical trial accrual at an academic medical center: Identifying interventions to increase representation of racial/ethnic minorities

Abstract Background: Cancer is currently the second leading cause of death in the USA, however many gains are being made in cancer therapeutics due in large part to patient participation in clinical trials. It is estimated that 20% of patients nationwide are eligible for a clinical trial, but only 3% are actually enrolled. At the University of Chicago, almost 50% of new patients are eligible for a cancer clinical trial, but only 15% are enrolled. Furthermore, only half of eligible patients are offered enrollment. African-Americans have worse outcomes across the cancer care continuum compared to Caucasians; however these outcomes can be ameliorated when patients receive standardized care according to a clinical trial. African-Americans are underrepresented amongst cancer clinical trial participants, despite evidence from our institution that African-Americans were more than twice as likely as Caucasians to enroll in a cancer clinical trial when offered. We hypothesize that a provider-directed intervention will increase rates of cancer clinical trial enrollment amongst African-Americans. In order to identify potential intervention strategies, we surveyed staff in the Section of Hematology/Oncology at the University of Chicago regarding clinical trial accrual. Methods: A short, seven question, survey was distributed to all employees in the Section of Hematology/Oncology who were directly involved in clinical care or research. The survey queried respondents about their opinions on the current impediments to and facilitators of cancer clinical trial accrual at the University of Chicago as well as asking for their opinions on ways to improve the process. Results: 52/128 (41%) of the surveys were completed and returned, including 37/62 (60%) of MD's surveyed. We divided the results into four categories, patient barriers, provider barriers, protocol barriers and health system barriers. The following numbers reflect the percentage of survey respondents that mentioned a specific barrier. Per this metric, the most common patient-related barriers to enrollment were: distance of travel (27%), lack of interest (19%), perceived bias against trials (11.5%). The most common protocol related barriers were: strict eligibility criteria (19%), prolonged screening time (17%), complexity of trials (13.5%), and lack of trials (11.5%). The most common provider-related barriers were: busy schedule (21%) and lack of knowledge about trials (13.5%). The most common health systems related barriers were: insufficient staff (23%), clinic inefficiency (19%) and lack of advertising/communication in the community (17%). Conclusions: This survey revealed many barriers to cancer clinical trial accrual at an academic medical center. This was a hypothesis generating study and interventions based on these barriers should be further studied. Based on this data further work is planned in order to test the hypothesis that a provider-directed, reminder-based intervention will increase the rate that a trial is offered and increase the rate of trial enrollment amongst African-Americans. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A106.

Cost-effectiveness of a health care provider-directed intervention to promote colorectal cancer screening

6583 Background: Colorectal cancer (CRC) screening remains underutilized. Prior studies reported the cost-effectiveness of interventions to improve CRC screening, but none have been replicated in the setting of small medical practices. We recently conducted a randomized trial of an academic detailing strategy within 264 small physician offices in New York City. The objective of this analysis is to assess the cost-effectiveness of this intervention. Methods: 264 physician offices were randomized to usual care or to a series of ‘academic detailing’ visits from health educators trained in evidence-based CRC screening guidelines. CRC screening rates were measured at baseline and 12 months. Intervention-related costs were categorized as fixed or intervention delivery costs. The incremental cost effectiveness ratio (ICER) was expressed as cost per percentage point increase in CRC screening. Each practice contained an average of 4 physicians. Sensitivity analyses were estimated by varying the number of physicians per practice and accordingly, intervention delivery costs. Results: Academic detailing resulted in a 7% increase in CRC screening with colonoscopy. The cost of the intervention was $147,865. The ICER was $21,124 per percentage point increase in CRC screening. Sensitivity analyses that varied the intervention delivery costs by the average medical practice size were associated with ICERs ranging from $13,361 (8 physicians/office) to $36,109 (2 physicians/office) per percentage point increase in CRC screening rates. Conclusions: A multi-component academic detailing intervention conducted in small urban practices was clinically effective, but was not cost-effective when compared to other reported low-intensity patient-directed and infrastructural interventions ($131-$1,161 per percentage increase in CRC screening). (Table) While academic detailing may be more cost-effective in physician practices of larger size, new cost-effective approaches in small community practices are needed. [Table: see text] No significant financial relationships to disclose.

Recommendations for Client- and Provider-Directed Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening

Recommendations for Client- and Provider-Directed Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening

Interventions to Improve Cancer Screening: Opportunities in the Workplace

The Guide to Community Preventive Services (the Community Guide) provides an arsenal of evidence-based intervention strategies to improve cancer screening. 1 Task Force on Community Preventive ServicesRecommendations for client- and provider-directed interventions to increase breast, cervical, and colorectal cancer screening. Am J Prev Med. 2008; 35: S21-S25 PubMed Scopus (68) Google Scholar The challenge for health promotion practitioners using the Community Guide is to (1) transform these intervention strategies into specific intervention programs and (2) implement these programs in settings that may or may not match the settings in which the interventions were originally tested. Several resources are available to help practitioners find and adapt specific intervention programs, such as the National Cancer Institute's Research Tested Intervention Programs (RTIPs) 2 National Cancer InstituteResearch Tested Intervention Programs. http://rtips.cancer.gov/rtips/index.do Google Scholar and Using What Works. 3 Boyle L. Homer M. Using what works: adapting evidence-based programs to fit your needs National Cancer Institute. http://cancercontrol.cancer.gov/use_what_works/start.htm Google Scholar However, fewer resources are available to help practitioners think broadly about the various settings in which these programs could be implemented. This commentary offers guidance on implementing the Community Guide's new cancer screening recommendations in the workplace. 1 Task Force on Community Preventive ServicesRecommendations for client- and provider-directed interventions to increase breast, cervical, and colorectal cancer screening. Am J Prev Med. 2008; 35: S21-S25 PubMed Scopus (68) Google Scholar

Health Care Provider-Directed Intervention to Increase Colorectal Cancer Screening Among Veterans: Results of a Randomized Controlled Trial

Colorectal cancer screening is the most underused cancer screening tool in the United States. The purpose of this study was to test whether a health care provider-directed intervention increased colorectal cancer screening rates. The study was a randomized controlled trial conducted at two clinic firms at a Veterans Affairs Medical Center. The records of 5,711 patients were reviewed; 1,978 patients were eligible. Eligible patients were men aged 50 years and older who had no personal or family history of colorectal cancer or polyps, had not received colorectal cancer screening, and had at least one visit to the clinic during the study period. Health care providers in the intervention firm attended a workshop on colorectal cancer screening. Every 4 to 6 months, they attended quality improvement workshops where they received group screening rates, individualized confidential feedback, and training on improving communication with patients with limited literacy skills. Medical records were reviewed for colorectal cancer screening recommendations and completion. Literacy level was assessed in a subset of patients. Colorectal cancer screening was recommended for 76.0% of patients in the intervention firm and for 69.4% of controls (P = .02). Screening tests were completed by 41.3% of patients in the intervention group versus 32.4% of controls (P = .003). Among patients with health literacy skills less than ninth grade, screening was completed by 55.7% of patients in the intervention group versus 30% of controls (P < .01). A provider-directed intervention with feedback on individual and firm-specific screening rates significantly increased both recommendations and colorectal cancer screening completion rates among veterans.