Implementing Mailed Colorectal Cancer Fecal Screening Tests in Real-World Primary Care Settings: Promising Implementation Practices and Opportunities for Improvement.

Colorectal cancer (CRC) screening reduces morbidity and mortality, but screening rates in the USA remain suboptimal. The Colorectal Cancer Control Program (CRCCP) was established in 2009 to increase screening among groups disproportionately affected. The CRCCP utilizes implementation science to support health system change as a strategy to reduce disparities in CRC screening by directing resources to primary care clinics to implement evidence-based interventions (EBIs) proven to increase CRC screening. As COVID-19 continues to impede in-person healthcare visits and compel the unpredictable redirection of clinic priorities, understanding clinics' adoption and implementation of EBIs into routine care is crucial. Mailed fecal testing is an evidence-based screening approach that offers an alternative to in-person screening tests and represents a promising approach to reduce CRC screening disparities. However, little is known about how mailed fecal testing is implemented in real-world settings. In this retrospective, cross-sectional analysis, we assessed practices around mailed fecal testing implementation in 185 clinics across 62 US health systems. We sought to (1) determine whether clinics that do and do not implement mailed fecal testing differ with respect to characteristics (e.g., type, location, and proportion of uninsured patients) and (2) identify implementation practices among clinics that offer mailed fecal testing. Our findings revealed that over half (58%) of clinics implemented mailed fecal testing. These clinics were more likely to have a CRC screening policy than clinics that did not implement mailed fecal testing (p = 0.007) and to serve a larger patient population (p = 0.004), but less likely to have a large proportion of uninsured patients (p = 0.01). Clinics that implemented mailed fecal testing offered it in combination with EBIs, including patient reminders (92%), provider reminders (94%), and other activities to reduce structural barriers (95%). However, fewer clinics reported having the leadership support (58%) or funding stability (29%) to sustain mailed fecal testing. Mailed fecal testing was widely implemented alongside other EBIs in primary care clinics participating in the CRCCP, but multiple opportunities for enhancing its implementation exist. These include increasing the proportion of community health centers/federally qualified health centers offering mailed screening; increasing the proportion that provide pre-paid return mail supplies with the screening kit; increasing the proportion of clinics monitoring both screening kit distribution and return; ensuring patients with abnormal tests can obtain colonoscopy; and increasing sustainability planning and support.

Multi-component interventions and change in screening rates in primary care clinics in the Colorectal Cancer Control Program.

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality. Implementation of evidence-based interventions (EBIs) increases CRC screening. The purpose of this analysis is to determine which combinations of EBIs or strategies led to increases in clinic-level screening rates among clinics participating in CDC's Colorectal Cancer Control Program (CRCCP). Data were collected from CRCCP clinics between 2015 and 2018 and the analysis was conducted in 2020. The outcome variable was the annual change in clinic level CRC screening rate in percentage points. We used first difference (FD) estimator of linear panel data regression model to estimate the associations of outcome with independent variables, which include different combinations of EBIs and intervention strategies. The study sample included 486 unique clinics with 1156 clinic years of total observations. The average baseline screening rate was 41 % with average annual increase of 4.6 percentage points. Only two out of six combinations of any two EBIs were associated with increases in screening rate (largest was 6.5 percentage points, P < 0.001). Any combinations involving three EBIs or all four EBIs were significantly associated with the outcome with largest increase of 7.2 percentage points (P < 0.001). All interventions involving 2-3 strategies led to increases in rate with largest increase associated with the combination of increasing community demand and access (6.1 percentage points, P < 0.001). Clinics implementing combinations of these EBIs, particularly those including three or more EBIs, often were more likely to have impact on screening rate change than those implementing none.

Development of a Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions in Primary Care Clinics.

Evidence-based interventions, including provider assessment and feedback, provider reminders, patient reminders, and reduction of structural barriers, improve colorectal cancer screening rates. Assessing primary care clinics' readiness to implement these interventions can help clinics use strengths, identify barriers, and plan for success. However, clinics may lack tools to assess readiness and use findings to plan for successful implementation. To address this need, we developed the Field Guide for Assessing Readiness to Implement Evidence-Based Cancer Screening Interventions (Field Guide) for the Centers for Disease Control and Prevention's (CDC's) Colorectal Cancer Control Program (CRCCP). We conducted a literature review of evidence and existing tools to measure implementation readiness, reviewed readiness tools from selected CRCCP award recipients (n = 35), and conducted semi-structured interviews with key informants (n = 8). We sought feedback from CDC staff and recipients to inform the final document. The Field Guide, which is publicly available online, outlines 4 assessment phases: 1) convene team members and determine assessment activities, 2) design and administer the readiness assessment, 3) evaluate assessment data, and 4) develop an implementation plan. Assessment activities and tools are included to facilitate completion of each phase. The Field Guide integrates implementation science and practical experience into a relevant tool to bolster clinic capacity for implementation, increase potential for intervention sustainability, and improve colorectal cancer screening rates, with a focus on patients served in safety net clinic settings. Although this tool was developed for use in primary care clinics for cancer screening, the Field Guide may have broader application for clinics and their partners for other chronic diseases.

Evaluating Uptake of Evidence-Based Interventions in 355 Clinics Partnering With the Colorectal Cancer Control Program, 2015-2018.

PURPOSE AND OBJECTIVES: Colorectal cancer screening rates remain suboptimal in the US. The Colorectal Cancer Control Program (CRCCP) of the Centers for Disease Control and Prevention (CDC) seeks to increase screening in health system clinics through implementation of evidence-based interventions (EBIs) and supporting activities (SAs). This program provided an opportunity to assess the uptake of EBIs and SAs in 355 clinics that participated from 2015 to 2018. INTERVENTION APPROACH: The 30 funded awardees of CRCCP partnered with clinics to implement at least 2 of 4 EBIs that CDC prioritized (patient reminders, provider reminders, reducing structural barriers, provider assessment and feedback) and 4 optional strategies that CDC identified as SAs (small media, professional development and provider education, patient navigation, and community health workers). EVALUATION METHODS: Clinics completed 3 annual surveys to report uptake, implementation, and integration and perceived sustainability of the priority EBIs and SAs. RESULTS: In our sample of 355 clinics, uptake of 4 EBIs and 2 SAs significantly increased over time. By year 3, 82% of clinics implemented patient reminder systems, 88% implemented provider reminder systems, 82% implemented provider assessment and feedback, 76% implemented activities to reduce structural barriers, 51% implemented provider education, and 84% used small media. Most clinics that implemented these strategies (>90%) considered them fully integrated into the health system or clinic operations and sustainable by year 3. Fewer clinics used patient navigation (30%) and community health workers (19%), with no increase over the years of the study. IMPLICATIONS FOR PUBLIC HEALTH: Clinics participating in the CRCCP reported high uptake and perceived sustainability of EBIs that can be integrated into electronic medical record systems but limited uptake of patient navigation and community health workers, which are uniquely suited to reduce cancer disparities. Future research should determine how to promote uptake and assess cost-effectiveness of CRCCP interventions.

Use of the prostate-specific antigen test in the U.S. for men age 30 to 64 in 2011 to 2017 using a large commercial claims database: Implications for practice interventions.

BACKGROUND: Given the public health relevance of PSA-based screening, various professional organizations have issued recommendations on the use of the PSA test to screen for prostate cancer in different age groups. AIM: Using a large commercial claims database, we aimed to determine the most recent rates of PSA testing for privately insured men age 30 to 64 in the context of screening recommendations. METHODS AND RESULTS: Data from employer plans were from MarketScan commercial claims database. Annual PSA testing rate was the proportion of men with ≥1 paid test(s) per 12 months of continuous enrollment. Men with diagnosis of any prostate-related condition were excluded. Annual percent change (APC) in PSA test use was estimated using joinpoint regression analysis. In 2011 to 2017, annual testing rate encompassing 5.02 to 5.53 million men was approximately 1.4%, age 30 to 34; 3.4% to 4.1%, age 35 to 39; 11% to 13%, age 40 to 44; 18% to 21%, age 45 to 49; 31% to 33%, age 50 to 54; 35% to 37%, age 55 to 59; and 38% to 41%, age 60 to 64. APC for 2011 to 2017 was -0.5% (P = .11), age 30 to 34; -3.0% (P = .001), age 35-39; -3.1% (P < .001), age 40 to 44; -2.4% (P = .001), age 45 to 49; -0.2% (P = .66), age 50 to 54; 0.0% (P = .997), age 55 to 59; and -3.3% (P = .054) from 2011 to 2013 and 1.2% (P = .045) from 2013 to 2017, age 60 to 64. PSA testing rate decreased from 2011 to 2017 for age groups between 35 and 49 by 13.4% to 16.9%. CONCLUSIONS: Based on these data, PSA testing rate has modestly decreased from 2011 to 2017. These results, however, should be considered in view of the limitation that MarketScan claims data may not be equated to actual PSA testing practices in the entire U.S. population age 30 to 64. Future research should be directed to understand why clinicians continue ordering PSA test for men younger than 50.

Use of the prostate-specific antigen (PSA) test in the United States for men age ≥65, 1999-2015: Implications for practice interventions.

BACKGROUND: Various professional organizations have issued recommendations on use of the PSA test to screen for prostate cancer in different age groups. AIMS: Using Medicare claims databases, we aimed to determine rates of PSA testing in the context of screening recommendations during 1999-2015 for US men age ≥65, stratified by age group and census regions, after excluding claims relating to all prostate-related conditions. METHODS AND RESULTS: Medicare claims databases encompassed 9.71-11.12 million men for the years under study. PSA testing rate was the proportion of men with ≥1 test(s) per 12 months of continuous enrollment. Men diagnosed with any prostate-related condition were excluded. Annual percent change (APC) in PSA test use was estimated using joinpoint regression analysis. In 1999-2015, annual testing rate was 10.1%-23.1%, age ≥85; 16.6%-31.0%, age 80-84; 23.8%-35.8%, age 75-79; 28.3%-36.9%, age 70-74; and 26.4%-33.6%, age 65-69. From 1999 to 2015, PSA testing rate decreased 40.7%, 29.9%, 13.9%, and 2.9%, respectively, for men age ≥85, 80-84, 75-79, and 70-74. For men age 65-69, test use increased by 0.3%. Significant APC trends were: APC1999-2002  = +8.1%, P = .029 and APC2008-2015  = -9.0%, P < .001 for men age ≥85; APC2008-2015  = -7.1%, P = .001 for men age 80-84; APC2001-2015  = -2.5%, P < .001 for men age 75-79; APC2008-2015  = -3.3%, P = .007 for men age 70-74; and APC2010-2015  = -5.2%, P = .014 for men age 65-69. COCLUSION: Although decreased from 1999 to 2015, PSA testing rates remained high for men age ≥70. Further research could help understand why PSA testing continues inconsistent with recommendations.

Evidence-Based Interventions and Colorectal Cancer Screening Rates: The Colorectal Cancer Screening Program, 2015-2017.

INTRODUCTION: The Centers for Disease Control and Prevention administers the Colorectal Cancer Control Program to increase colorectal cancer screening rates among people aged 50-75 years in areas where rates are lower than state or national levels. The aim of this study is to better understand the effectiveness of specific Colorectal Cancer Control Program components. METHODS: The study population included clinics enrolled in the Colorectal Cancer Control Program during Years 1 and 2. Clinic data collected by the Centers for Disease Control and Prevention annually from 2015 to 2017 for program evaluation were used. The outcome variable was screening rate change through Program Year 2, and predictor variables were a new implementation or enhancement of evidence-based interventions and other program components. The analysis, conducted in 2020, used ordinary least square and generalized estimating equations regressions and first difference models to estimate the associations of independent variables with the outcome. RESULTS: Of the total 336 clinics, 50%-70% newly implemented or enhanced different evidence-based interventions. Among these, client reminders were most highly associated with the increase in screening rates (8.0 percentage points). Provider reminder was not significantly associated with any change in screening rates. Among all program components, having a colorectal cancer screening champion was most highly (8.4 percentage points) associated with screening rate change. Results from different models were slightly different but in agreement. CONCLUSIONS: Client reminders, provider assessment and feedback, and colorectal cancer screening champions were associated with increased clinic-level colorectal cancer screening rates. Universal implementation of these strategies can substantially increase colorectal cancer screening rates in the U.S.

Occurrence of Echinococcusgranulosussensulato and Other Taeniids in Bhutan.

The present research shows the results of a national study documenting the occurrence and genetic diversity of Echinococcus and Taenia species across Bhutan. Environmental dog faecal samples (n = 953) were collected from 2016 to 2018 in all 20 Bhutanese districts, mainly in urbanised areas. Cystic echinococcosis cysts were isolated from 13 humans and one mithun (Bos frontalis). Isolation of taeniid eggs from faeces was performed by sieving/flotation technique, followed by DNA isolation, PCR and sequence analyses for species identification (gene target: small subunit of ribosomal RNA). Genetic diversity of E. granulosuss.s. was based on the sequence (1609 bp) of the cox1 gene. A total of 67 out of 953 (7%) dog faecal samples were positive for at least one taeniid species. From the 670 free-roaming dog faecal samples, 40 (5.9%) were positive for taeniid DNA, 22 (3.2%) of them were identified as E. granulosuss.s. and four (0.5%) as E. ortleppi (G5). From the 283 faecal samples originating from yak-grazing areas, 27 (9.5%) were taeniid positive, including eight (2.8%) infected with E. granulosuss.s. and four (1.4%) with E. ortleppi. E. granulosuss.s. was identified in all isolates from human and the cyst from mithun. A haplotype network (cox1 gene) from E. granulosuss.s, including isolates from 12 dogs, two human and one mithun, revealed eight different haplotypes. The most common cox1 haplotype was the globally distributed Eg01, followed by Eg40 and Eg37 (previously described in China). Five new cox1 haplotypes (EgBhu1-5) originated from human, dogs, and a mithun were identified. The study indicated the contamination of urban areas and pastures with Echinococcus eggs in seven districts in Bhutan. The molecular characterisation of E. granulosuss.l. revealed different E. granulosuss.s. haplotypes as well as E. ortleppi. The transmission of T. multiceps was documented only in the western part of the country. Considering the zoonotic feature of E. granulosus s.s. and E. ortleppi and the economic impact of coenurosis caused by T. multiceps (also known as gid) in Bhutan, the findings of this study represent a significant contribution towards an epidemiological baseline for the establishment of a national control programme.

Characterizing clinics with differential changes in the screening rate in the Colorectal Cancer Control Program of the Centers for Disease Control and Prevention.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) funds the Colorectal Cancer Control Program (CRCCP) to increase colorectal cancer (CRC) screening rates in primary care clinics by implementing evidence-based interventions (EBIs). This study examined differences in clinic characteristics and implementation efforts among clinics with differential changes in screening rates over time. METHODS: CRCCP clinic data collected by the CDC were used. The outcome was the clinic status (highest quartile [Q4] vs lowest quartile [Q1]), which was based on the absolute screening rate change between the first and second program years. Five clinic characteristic variables and 12 clinic-level CRCCP variables (eg, EBIs) were assessed in bivariable analyses, and logistic regression was used to determine significant predictors of the outcome. RESULTS: Each group included 78 clinics (N = 156). Clinics with a Q4 status saw a 14.9 percentage point increase in the screening rate, whereas clinics with a Q1 status experienced a 9.1 percentage point decline. Q4s were more likely than Q1s to have a CRC champion, implement 4 EBIs versus fewer EBIs, implement at least 1 new EBI, and increase the number of implemented EBIs. The adjusted odds of Q4 status were 5.3 times greater (95% confidence interval [CI], 1.9-14.9) if a clinic implemented an additional EBI. The adjusted odds of Q4 status increased to 7.1 (95% CI, 2.2-23.1) if a clinic implemented 2 to 4 additional EBIs. CONCLUSIONS: Implementing new EBIs or enhancing existing ones improves CRC screening rates. Additionally, clinics with lower screening rates had greater rate increases and may have benefited more from the CRCCP.

Preventing Breast, Cervical, and Colorectal Cancer Deaths: Assessing the Impact of Increased Screening.

INTRODUCTION: The US Preventive Services Task Force (USPSTF) recommends select preventive clinical services, including cancer screening. However, screening for cancers remains underutilized in the United States. The Centers for Disease Control and Prevention leads initiatives to increase breast, cervical, and colorectal cancer (CRC) screening. We assessed the number of avoidable deaths from increased screening, according to USPSTF recommendations, for CRC and female breast and cervical cancers. METHODS: We used model-based estimates of avoidable deaths for the lifetime of single-year age cohorts under the current and increased use of screening scenarios (data year 2016; analysis, 2018). We calculated prevented cancer deaths for each 1% increase in screening uptake and extrapolated to current level of screening (2016), current level plus 10 percentage points, and increasing screening to 90% and 100% of the eligible population. RESULTS: Increased use of screening from current levels to 100% would prevent an additional 2,821 deaths from breast cancer, 6,834 deaths from cervical cancer, and 35,530 deaths from CRC over a lifetime of the respective single-year cohort. Increasing use of CRC screening would prevent approximately 8.5 times as many deaths as the equivalent increase in use of breast cancer screening (women only), although twice as many people (men and women) would have to be screened for CRC. CONCLUSIONS: A large number of deaths could be avoided by increasing breast, cervical, and CRC screening. Public health programs incorporating strategies shown to be effective can help increase screening rates.

Correlates of colorectal cancer screening rates in primary care clinics serving low income, medically underserved populations.

INTRODUCTION: Screening for colorectal cancer (CRC) is effective in reducing CRC burden. Primary care clinics have an important role in increasing screening. We investigated associations between clinic-level CRC screening rates of the clinics serving low income, medically underserved population, and clinic-level screening interventions, clinic characteristics and community contexts. METHODS: Using data (2015-16) from the Centers for Disease Control and Prevention's (CDC) Colorectal Cancer Control Program, we linked clinic-level data with county-level contextual data from external sources. Analysis variables included clinic-level CRC screening rates, four different evidence-based interventions (EBIs) intended to increase screening, clinic characteristics, and clinic contexts. In the analysis (2018), we used weighted ordinary least square multiple regression analyses to associate EBIs and other covariates with clinic-level screening rates. RESULTS: Clinics (N = 581) had an average screening rate of 36.3% (weighted. Client reminders had the highest association (5.6 percentage points) with screening rates followed by reducing structural barriers (4.9 percentage points), provider assessment and feedback (3.2 percentage points), and provider reminders (<1 percentage point). Increases in the number of EBIs was associated with steady increases in the screening rate (5.4 percentage points greater for one EBI). Screening rates were 16.4 percentage points higher in clinics with 4 EBIs vs. no EBI. Clinic characteristics, contexts (e.g. physician density), and context-EBI interactions were also associated with clinic screening rates. CONCLUSIONS: These results may help clinics, especially those serving low income, medically underserved populations, select individual or combinations of EBIs suitable to their contexts while considering costs.