The Best Test Is the One That Gets Done: Interventions to Increase Colorectal Cancer Screening

Differences in Barriers to Cancer Screening and Navigator Activities in Two Federally Qualified Health Centers Implementing Patient Navigation

Authors:

Antoinette Romanzo-Smith (Presenter)
New York State Department of Health

Margaret Gates, New York State Department of Health
Sharon Bisner, New York State Department of Health
Elise Collins, New York State Department of Health
Heather LeBlanc, New York State Department of Health

Public Health Statement: Patient navigation has been shown to be effective in increasing cancer screening rates. This study looks to further define the role of patient navigators in order to inform facilities that are implementing navigation programs.

Purpose: Patient navigation (PN) is an effective strategy to overcome patient barriers and to get patients screened for cancer. This study aims to examine PN activities performed to address patient-reported barriers to cancer screening at two federally qualified health centers (FQHC) in New York State.

Methods/Approach: PN programs were implemented at Hudson Headwaters Health Network (HHHN), an FQHC serving the rural upstate community, and Charles B. Wang (CBW) Health Center, an FQHC serving the Asian American community in Queens. HHHN employed 2 full-time PNs during the study period (2011-2012) and focused primarily on breast and cervical cancer screening. Patients were primarily White (97.8%), spoke English as their primary language (100%) and 12.1% reported having no health insurance. CBW employed 1 full-time and 1 part-time PN for the study period (2012-2015) and focused on PN for colorectal cancer screening. Patients were primarily Asian (98.4%), spoke either Cantonese or Mandarin as their primary language (94%) and 55.0% reported having no health insurance.

Results: At HHHN, 1,375 (61.9%) out of 2,219 patients contacted for cancer screening completed a barrier assessment. Of these patients, the most common barriers were scheduling appointments (25.2%), transportation issues (18.1%) and financial barriers (11.4%). The most common PN activities were obtaining reports from outside providers (45.5%), education on importance of cancer screening (45.1%), and following up with patients after their appointment (43.6%). At CBW, 2,834 (76.5%) out of 3,703 patients contacted for cancer screening completed a barrier assessment. Of these patients, the most common barriers were language (95.4%), insurance coverage (53.9%), and scheduling appointments (9.4%). The most common PN activities were education on importance of cancer screening (77.6%), help with paperwork (29.7%) and referral to the Cancer Services Program (23.6%).

Conclusions/Implications: Differences in patient populations and region likely contributed to the differences seen in patient reported barriers and PN activities across the two sites. Considering patient demographics as well as geographic location of the health center when implementing a PN program can be useful to further refine the PN role in increasing cancer screening.

A Centralized Mailed Program with Stepped Increases of Support Increases Time in Compliance with Colorectal Cancer Screening Guidelines over Five Years: A Randomized Trial

Authors:

Beverly Green (Presenter)
Kaiser Permanente Washington

Melissa Anderson, Kaiser Permanente Washington
Andrea Cook, Kaiser Permanente Washington
Jessica Chubak, Kaiser Permanente Washington
Sharon Fuller, Kaiser Permanente Washington
Richard Meenan, Kasier Permanente Northwest
Sally Vernon, University of Texas Houston

Public Health Statement: Colorectal cancer (CRC) is the second-leading cause of cancer deaths in the United States. Morbidity and mortality could be reduced through higher uptake and adherence to CRC screening. Information on longer-term screening adherence comes from organized programs that lack a comparison group.

Purpose: Systems of Support to Increase Colorectal Cancer Screening and Follow-Up (SOS) is an ongoing trial testing a centralized mailed and phone-based program to increase long-term CRC screening adherence. We hypothesized that compared to usual care (UC), patients receiving a centralized mailed and phone intervention would have more time in compliance with CRC screening guidelines over 5 years.

Methods/Approach: 4675 individuals initially aged 50–74 years, and not current for CRC screening. Patients were randomly assigned to receive UC or one of three stepped care interventions:

1. Mailings including information on screening choices, a call-in number if colonoscopy or sigmoidoscopy was preferred, and mailed fecal tests;
2. Mailings plus brief telephone assistance; or
3. Mailings and telephone assistance plus nurse navigation.

In year 3, intervention group participants still CRC screening-eligible were randomized to stopped or continued mailed interventions in years 3 and 5 (no interventions were conducted in year 4).

The primary outcomes was time in compliance with CRC screening over 5 years of follow-up (covered-time). Screening tests contributed time based on national guidelines for screening intervals (fecal tests annually, sigmoidoscopy 5 years, colonoscopy 10 years). All participants contributed data, but were censored at disenrollment, death, age 76, or diagnosis of CRC.

Results: On average, the percent of covered time was greater among intervention group participants (62.1% [95%CI 61.0–63.2]) compared to UC participants (47.5% [45.5–49.5]; adjusted rate ratio, 1.31 [1.25–1.37, P])

Conclusions/Implications: In conclusion, our study is the first randomized controlled trial to demonstrate that a centralized mailed screening program increases adherence to guideline recommended CRC screening rover 5 years. Longer-term data on CRC screening adherence and its impact on CRC outcomes are needed.

Combining a Colorectal Cancer Screening Decision Aid and Patient Navigation Improves Decision-Making Processes and Screening Completion in Linguistically Diverse Primary Care Patients

Authors:

Daniel Reuland (Presenter)
University of North Carolina School of Medicine

Alison Brenner, University of North Carolina at Chapel Hill
Richard Hoffman, University of Iowa
Andrew McWilliams, Carolinas HealthCare System
Robert Rhyne, University of New Mexico School of Medicine
Christina Getrich, University of Maryland
Hazel Tapp, Carolinas HealthCare System
Mark Weaver, University of North Carolina School of Medicine
Danelle Callan, University of New Mexico School of Medicine
Laura Cubillos, University of North Carolina at Chapel Hill
Brisa Urquieta de Hernandez, Carolinas HealthCare System
Michael Pignone, University of Texas Dell Medical School

Public Health Statement: Colorectal cancer (CRC) is the third leading cause of cancer death in the United States. Screening is effective but under-utilized, particularly in low-income, racial/ethnic minorities, which can lead to disparities in CRC mortality. Interventions designed to improve screening rates in these populations are needed to help reduce cancer disparities.

Purpose: Colorectal cancer (CRC) screening decision aids and patient navigation address multiple different screening barriers and are potentially complementary interventions. We conducted a randomized controlled trial to determine the effect of a CRC screening decision aid plus patient navigation on and screening completion in a diverse patient population.

Methods/Approach: We enrolled patients aged 50-75 who were: not up-to-date with recommended CRC screening and attending primary care visits at safety-net clinics in Charlotte, NC and Albuquerque, NM. After a baseline survey, participants were randomized to view either a CRC screening decision aid (presenting colonoscopy and fecal occult blood testing) or a food safety video (both in English or Spanish). After the provider encounter, intervention patients received support for screening completion from a bilingual/bicultural patient navigator. Screening completion was assessed by blinded chart review at six months. We used Mantel-Haenszel weights to estimate differences across study arms, adjusted for site. We explored subgroup differences and tested for interactions using a generalized linear model with identity link and binomial variance function.

Results: Participant characteristics (n=265): mean age 58 years, 65% female, 62% Latino; 15% White non-Latino; 23% Black/mixed race; 77% household income under $20,000; 40% low literacy; 30% Medicaid; 33% uninsured. Intervention participants were more likely to complete CRC screening within 6 months: (68% vs. 27%); adjusted-difference 40 percentage points (95%CI, 29, 51). The intervention was broadly effective across all measured demographic subgroups; it was more effective in women than in men (50 vs 21 percentage point increase, interaction p=0.015).

Conclusions/Implications: A combined decision aid plus patient navigation intervention substantially increases CRC screening completion in linguistically diverse, vulnerable patients.