Impact of a Clinical Decision Support System on Guideline Adherence of Surveillance Recommendations for Colonoscopy After Polypectomy.

Background: Surveillance colonoscopy is required in patients with polyps due to an elevated colorectal cancer (CRC) risk; however, studies suggest substantial overuse and underuse of surveillance colonoscopy. The goal of this study was to characterize guideline adherence of surveillance recommendations after implementation of an electronic medical record (EMR)-based Colonoscopy Pathology Reporting and Clinical Decision Support System (CoRS). Methods: We performed a retrospective cohort study of patients who underwent colonoscopy with polypectomy at a safety-net healthcare system before (n=1,822) and after (n=1,320) implementation of CoRS in December 2013. Recommendations were classified as guideline-adherent or nonadherent according to the US Multi-Society Task Force on CRC. We defined surveillance recommendations shorter and longer than guideline recommendations as potential overuse and underuse, respectively. We used multivariable generalized linear mixed models to identify correlates of guideline-adherent recommendations. Results: The proportion of guideline-adherent surveillance recommendations was significantly higher post-CoRS than pre-CoRS (84.6% vs 77.4%; P<.001), with fewer recommendations for potential overuse and underuse. In the post-CoRS period, CoRS was used for 89.8% of cases and, compared with cases for which it was not used, was associated with a higher proportion of guideline-adherent recommendations (87.0% vs 63.4%; RR, 1.34; 95% CI, 1.23-1.42). In multivariable analysis, surveillance recommendations were also more likely to be guideline-adherent in patients with adenomas but less likely among those with fair bowel preparation and those with family history of CRC. Of 203 nonadherent recommendations, 70.4% were considered potential overuse, 20.2% potential underuse, and 9.4% were not provided surveillance recommendations. Conclusions: An EMR-based CoRS was widely used and significantly improved guideline adherence of surveillance recommendations.

Financial Incentives for Promoting Colorectal Cancer Screening: A Randomized, Comparative Effectiveness Trial.

OBJECTIVES: Offering financial incentives to promote or "nudge" participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population. METHODS: We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50-64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis. RESULTS: FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%, P=0.32 vs. no incentive) or $5 incentive (39.2%, P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups. CONCLUSIONS: Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.

A long term study of pulmonary function among US refractory ceramic fibre workers.

BACKGROUND: Cross-sectional studies have shown declines in lung function among refractory ceramic fibre (RCF) workers with increasing fibre exposure. This study followed current and former workers (n=1396) for up to 17 years and collected 5243 pulmonary function tests. METHODS: Cumulative fibre exposure and production years were categorised into exposure levels at five manufacturing locations. Conventional longitudinal models did not adequately partition age-related changes from other time-dependent variables. Therefore, a restricted cubic spline model was developed to account for the non-linear decline with age. RESULTS: Cumulative fibre >60 fibre-months/cc showed a significant loss in lung function at the first test. When results were examined longitudinally, cumulative exposure was confounded with age as workers with the highest cumulative exposure were generally older. A longitudinal model adjusted by age groups was implemented to control for this confounding. No consistent longitudinal loss in lung function was observed with RCF exposure. Smoking, initial weight and weight increase were significant factors. CONCLUSION: No consistent decline was observed longitudinally with exposure to RCF, although cross-sectional and longitudinal findings were discordant. Confounding and accelerated lung function declines with ageing and the correlation of multiple time-dependent variables should be considered in order to minimise error and maximise precision. An innovative statistical methodology for these types of data is described.

Low-level fiber-induced radiographic changes caused by Libby vermiculite: a 25-year follow-up study.

RATIONALE: From 1921 to 1990, vermiculite ore from Libby, Montana, was shipped worldwide for commercial and residential use. A 1980 study of a manufacturing facility using Libby vermiculite was the first to demonstrate a small but significant prevalence of pleural chest radiographic changes associated with amphibole fibers contained in the ore. OBJECTIVES: This follow-up study of the original cohort evaluated the extent of radiographic changes and cumulative fiber exposure (CFE) 25 years after cessation of exposure. METHODS: From the original cohort of 513 workers, 431 (84%) were living and available for participation and exposure reconstruction. Of these, 280 (65%) completed both chest radiographs and interviews. Primary outcomes were pleural and/or interstitial changes. MEASUREMENTS AND MAIN RESULTS: Pleural and interstitial changes were demonstrated in 80 (28.7%) and 8 (2.9%) participants, respectively. Of those participants with low lifetime CFE of less than 2.21 fiber/cc-years, 42 (20%) had pleural changes. A significant (P < 0.001) exposure-response relationship of pleural changes with CFE was demonstrated, ranging from 7.1 to 54.3% from the lowest to highest exposure quartile. Removal of individuals with commercial asbestos exposure did not alter this trend. CONCLUSIONS: This study indicates that exposure within an industrial process to Libby vermiculite ore is associated with pleural thickening at low lifetime CFE levels. The propensity of the Libby amphibole fibers to dramatically increase the prevalence of pleural changes 25 years after cessation of exposure at low CFE levels is a concern in view of the wide national distribution of this ore for commercial and residential use.

Cervical Cancer Burden and Opportunities for Prevention in a Safety-Net Healthcare System.

BACKGROUND: The high prevalence of cervical cancer at safety-net health systems requires careful analysis to best inform prevention and quality improvement efforts. We characterized cervical cancer burden and identified opportunities for prevention in a U.S. safety-net system. METHODS: We reviewed tumor registry and electronic health record (EHR) data of women with invasive cervical cancer with ages 18+, diagnosed between 2010 and 2015, in a large, integrated urban safety-net. We developed an algorithm to: (i) classify whether women had been engaged in care (≥1 clinical encounter between 6 months and 5 years before cancer diagnosis); and (ii) identify missed opportunities (no screening, no follow-up, failure of a test to detect cancer, and treatment failure) and associated factors among engaged patients. RESULTS: Of 419 women with cervical cancer, more than half (58%) were stage 2B or higher at diagnosis and 40% were uninsured. Most (69%) had no prior healthcare system contact; 47% were diagnosed elsewhere. Among 122 engaged in care prior to diagnosis, failure to screen was most common (63%), followed by lack of follow-up (21%), and failure of test to detect cancer (16%). Tumor stage, patient characteristics, and healthcare utilization differed across groups. CONCLUSIONS: Safety-net healthcare systems face a high cervical cancer burden, mainly from women with no prior contact with the system. To prevent or detect cancer early, community-based efforts should encourage uninsured women to use safety-nets for primary care and preventive services. IMPACT: Among engaged patients, strategies to increase screening and follow-up of abnormal screening tests could prevent over 80% of cervical cancer cases.

Cervical cancer screening among HIV-infected women in an urban, United States safety-net healthcare system.

OBJECTIVE: Little is known about cervical cancer screening and results patterns among HIV-infected (HIV+) women in real-world healthcare settings. We characterized two periods of screening opportunity. DESIGN: Retrospective cohort. SETTING: US safety-net healthcare system in Dallas County, Texas. PARTICIPANTS: We analyzed data from electronic medical records (EMR) of 1490 HIV+ women receiving care 2010-2014. MAIN OUTCOME MEASURES: At baseline, we categorized a woman's Pap status 15 months prior to index date as under-screened (vs. screened), and cytology result (normal vs. abnormal). Then, we examined screening completion and results, and colposcopy uptake and results after an abnormal screen, in the subsequent 15-month period. RESULTS: More than half of women (56%) had no evidence of a Pap test (i.e. under-screened) at baseline. Under-screened women were more likely to be older (50-64 years), have diabetes, and unknown viral load; they were less likely to be Black, Hispanic, have Medicaid, recently pregnant, have a HIV clinic visit, or a CD4 cell count at least 200 cells/µl. Nearly half of under-screened women (46%, n = 383) remained under-screened in the subsequent 15 months. Among women under-screened at baseline who later completed screening and follow-up during the study period, 21 high-grade dysplasia and three cancers were diagnosed. Overall, 40% of women did not receive colposcopy when needed, with most failures to follow-up occurring in women who were under-screened at baseline. CONCLUSION: Most HIV+ women receiving care in a safety-net system did not receive sufficient screening for cervical cancer and remained at exceptionally high risk of developing high-grade dysplasia.

HRCT/CT and associated spirometric effects of low Libby amphibole asbestos exposure.

OBJECTIVE: Evaluate the relationship between cumulative fiber exposure and high-resolution or conventional chest computed tomography (HRCT/CT) changes and spirometry of workers with Libby amphibole asbestos exposure. METHODS: Of the original 1980 cohort (n = 513), 431 were living and asked to participate. Images were evaluated for localized pleural thickening (LPT), diffuse pleural thickening (DPT), and parenchymal changes. RESULTS: A total of 306 participants provided either HRCT/CT scans (n = 191) or chest radiographs (n = 115). Of the 191 with HRCT/CT, 52.9% had pleural changes and 13.1% had parenchymal changes. Those with LPT only, LPT and/or DPT, or DPT and/or parenchymal changes had mean 6.1, 8.0, and 18.0 loss in percent predicted forced vital capacity, respectively. CONCLUSIONS: Exposure to vermiculite containing amphibole fibers is associated with pleural and parenchymal HRCT/CT changes at low cumulative fiber exposure; these changes are associated with spirometric decrements.

Asbestos-related radiographic findings among household contacts of workers exposed to Libby vermiculite: impact of workers' personal hygiene practices.

OBJECTIVE: To explore the potential impact of worker hygiene by determining the prevalence of radiographic changes consistent with asbestos exposure among household contacts of workers exposed to Libby vermiculite that contained amphibole fibers. METHODS: Workers and household contacts had chest radiographs and completed questionnaires regarding hygiene and potential exposure pathways. RESULTS: Participants included 191 household contacts of 118 workers. One household contact (0.5%) had localized pleural thickening, and three (1.6%) had irregular opacities at profusion category 1/0 or greater. Worker radiographs demonstrated pleural changes in 45% and irregular opacities at profusion category 1/0 or greater in 8%. CONCLUSIONS: Libby vermiculite-exposed workers demonstrated an elevated prevalence of pleural and interstitial chest radiographic changes. There was, however, no increased prevalence of similar changes among household contacts, likely because of personal hygiene measures taken by the majority of workers.

Exposure estimates for workers in a facility expanding Libby vermiculite: updated values and comparison with original 1980 values.

OBJECTIVE: Low cumulative fiber exposure (CFE) has been associated with health effects in a cohort exposed to Libby vermiculite. This study refines the original 1980 exposure estimates and compares the CFE results. METHODS: Cumulative fiber exposure estimates were developed using three times more industrial hygiene measurements and long-term workers' input. New adjustments included vermiculite ore source, seasonal overtime hours, time spent in various tasks, and recollection of historical dustiness. RESULTS: The overall mean (95% confidence interval) CFE (n = 513) in 1980 (0.80 [0.69 to 0.93]) was statistically similar to the overall mean (95% confidence interval) CFE in 2010 (0.74 [0.61 to 0.90]). The mean CFE in the lowest exposure category (<2 fiber-years/cm) decreased from 0.36 to 0.22 fiber-years/cm (P < 0.05). The 2010 CFE estimate extended the upper bound of the range of previous estimates from 28.10 to 106.31 fiber-years/cm. CONCLUSIONS: The range of CFE values was expanded. These estimates may impact the understanding of Libby vermiculite health outcomes.

Biopersistence of refractory ceramic fiber in human lung tissue and a 20-year follow-up of radiographic pleural changes in workers.

OBJECTIVE: The biopersistence of refractory ceramic fiber (RCF) in human lung tissue is unknown and may contribute to an association between cumulative fiber exposure and radiographic changes. METHODS: Lung tissue fiber was analyzed for a case series of 10 RCF workers and a 20-year longitudinal chest radiograph study of 1323 workers was conducted. RESULTS: Within lung tissue, RCF comprised 14% to 100% of fibers 5 µm or more in length and was identified up to 20 years after RCF employment. Among workers with no reported asbestos exposure, cumulative exposure of more than 63 to 110 and more than 110 fiber-months/cm was associated with radiographic pleural changes of 8.5% (odds ratio, 7.2; 95% confidence interval, 1.4 to 36.8) and 11.6% (odds ratio, 10.3; 95% confidence interval, 2.1 to 49.9), respectively. CONCLUSIONS: Refractory ceramic fiber can persist in human lung tissue for up to 20 years and may contribute to the significant association between cumulative fiber exposure and radiographic pleural changes.

Mesothelioma associated with commercial use of vermiculite containing Libby amphibole.

OBJECTIVES: To describe asbestos-related mortality among manufacturing workers who expanded and processed Libby vermiculite that contained amphibole fiber. METHODS: Standardized mortality ratio was calculated for 465 white male workers 31 years after last Libby vermiculite exposure. RESULTS: Two workers died from mesothelioma, resulting in a significantly increased standardized mortality ratio of 10.5 (95% confidence interval, 1.3 to 38.0). These workers were in the upper 10th percentile of cumulative fiber exposure, that is, 43.80 and 47.23 fiber-years/cm, respectively. One additional worker with cumulative fiber exposure of 5.73 fiber-years/cm developed mesothelioma but is not deceased. There were no other significantly increased standardized mortality ratios. CONCLUSIONS: Workers expanding and processing Libby vermiculite in a manufacturing setting demonstrated an increased risk for the development of mesothelioma following exposure to the amphibole fiber contained within this vermiculite ore source.

Functional impairment and quality of life in retired workers of the construction trades.

This cross-sectional study compared the quality of life and physical health of retirees from the construction industry to that of retirees from more sedentary occupations. The feasibility of cooperation from the unions and their retirees for a larger health study was also examined. The mailed health survey assessed current physical functioning, role limitations as a result of poor health, pain, and past and current problems with falls and injuries. The survey was completed by 77 construction and 174 nonconstruction retirees. Results were striking with 42.1% of the construction retirees, compared to 12.9% of the male and 14.3% of female nonconstruction retirees reporting significantly poorer health. A multiple regression analysis comparing male construction to male nonconstruction retirees showed male construction retirees were almost five times more likely to report their health as being fair or poor. Further, significantly more male construction, versus male nonconstruction retirees, reported that their physical health reduced the time they were able to spend on daily activities. Almost one in five (19.4%) construction retirees described themselves as having severe to very severe pain versus 3.1% of the male nonconstruction retirees. Construction retirees reported significantly greater problems with their vision, neck and shoulders, hands and wrists, hips, knees, and ankle/feet joints. These findings suggest that with our rapidly aging population, there will be enormous physical, emotional, and financial costs related to construction work and that prevention and intervention measures are needed for current employees in this profession.

Exposures to refractory ceramic fibers in manufacturing and related operations: a 10-year update.

Refractory ceramic fiber (RCF) is a man-made vitreous fiber used for its insulating properties. Since 1987, the work environment of approximately 800 persons employed in fiber manufacture or production operations directly related to manufacturing has been monitored to evaluate exposure levels. Samples were collected quarterly from the breathing zones of randomly selected workers. The measurements from those working in areas of similar activities and exposure controls (dust zones or homogeneous exposure groups) were used to calculate a mean exposure during identified time periods. Persons who spent all of their work time in one zone/group were assigned this mean exposure; those with responsibilities in more than one area were assigned an exposure based on a time-weighted formula. A total of 3213 measurements were used to estimate exposure for 130 job titles; because of the mobile jobs, many samples contribute to the estimates of exposure for multiple job titles. The majority of exposure estimates (53%) have remained stable over the operational history of the plant reported here. For 32 job titles (25%) exposures have decreased, and for 28 job titles (22%) exposures have increased. Of the 122 job titles active in 2001, 97 (79%) exposures were estimated to be at 0.25 f/cc or lower; 8 (7%) had an exposure exceeding 0.5 f/cc (range 0.51-0.80) and 17 (14%) of these exposure estimates were in the range of > 0.25 f/cc to 0.5 f/cc. The continuing program to measure exposure supports a respiratory health surveillance program in these facilities.