Social Needs Screening and Referral Program at a Large US Public Hospital System, 2017.

Many health care providers and systems are developing and implementing processes to screen patients for social determinants of health and to refer patients to appropriate nonclinical and community-based resources. The largest public health care system in the United States, New York City Health + Hospitals, piloted such a program in 2017. A qualitative evaluation yielded insights into the implementation and feasibility of such screening and referral programs in health care systems serving low-income, minority, immigrant, and underserved populations.

Impact of a Citywide Benchmarking Intervention on Colonoscopy Quality Performance.

INTRODUCTION: There is marked variability in colonoscopy quality, limiting its effectiveness in colorectal cancer prevention. Multiple indicators have been established as markers for colonoscopy quality; however, there are conflicting data on the effects of quality reporting programs on endoscopist performance. In this study, we investigate the impact of a multicenter quarterly report card initiative on colonoscopy quality metric performance. METHODS: Data were collected from 194 endoscopists at 10 participating sites throughout New York City using a Qualified Clinical Data Registry from January 2013 to December 2014. Adenoma detection rate (ADR), cecal intubation rate, withdrawal time, bowel preparation quality and appropriate interval recommendations were tracked. Report cards were distributed to each site on a quarterly basis and technical assistance was provided as needed. Performance trends were analyzed using the Cochran-Armitage trend and analysis of variance tests. RESULTS: 37,258 screening colonoscopies were performed during the study period. There was a positive performance trend for ADR over time from the first quarter of 2013 to the last quarter of 2014 (15.6-25.7%; p < 0.001). There were also increases in cecal intubation rates (78.2-92.6%; p < 0.001), bowel preparation adequacy rates (77.5-92.8%; p < 0.001), and adherence to appropriate screening intervals (28.0-55.0%; p < 0.001). There was no clinically significant change in mean withdrawal time. CONCLUSIONS: The implementation of a quarterly report card initiative resulted in statistically significant improvements in adenoma detection, cecal intubation, bowel preparation adequacy rates, and appropriate recommended screening intervals.

New York Citywide Colon Cancer Control Coalition: A public health effort to increase colon cancer screening and address health disparities.

BACKGROUND: Although screening for colorectal cancer (CRC) is a widely accepted concept nationally and screening rates are increasing, there are differences in screening rates between states and within states. METHODS: In an effort to increase screening rates and ensure equal access with respect to race/ethnicity, the New York City Department of Health and Mental Hygiene formed a coalition of stakeholders in 2003, with its primary focus on colonoscopy, to develop and implement strategies across the city to achieve this goal. RESULTS: From a screening colonoscopy rate of only 42% in 2003, these concerted efforts contributed to achieving a screening rate of 62% by 2007 and a screening rate of almost 70% in 2014 with the elimination of racial and ethnic disparities. CONCLUSIONS: This article provides details of how this program was successfully conceived, implemented, and sustained in the large urban population of New York City. The authors hope that by sharing the many elements involved and the lessons learned, they may help other communities to adapt these experiences to their own environments so that CRC screening rates can be maximized. Cancer 2016;122:269-277. © 2015 American Cancer Society.

The economic impact of a patient navigator program to increase screening colonoscopy.

BACKGROUND: Patient navigation can increase colorectal cancer screening rates. The net economic impact of a colonoscopy patient navigator program was evaluated in an urban public hospital setting. METHODS: Cost, cost-effectiveness, and cost-benefit analyses were performed of a colonoscopy patient navigation program at 3 urban public hospitals in the period from 2003 to 2007. Program effectiveness was assessed in a 2-group, pre- and post-program, nonrandomized evaluation, comparing program hospitals with comparison hospitals that served similar populations. Costs were assessed from the provider's perspective. Outcomes included colonoscopy volume, colonoscopy completion rate, program cost, incremental cost-effectiveness, and net monetary benefit. RESULTS: Patient navigation was associated with a 61% increase in average monthly colonoscopy volume at program hospitals, from 114 procedures to 184 procedures, compared with a 12% increase at comparison hospitals. Adjusted for other factors, the navigator program increased colonoscopy volume by 44 to 67 additional procedures per month. Average program cost varied from $50 to $300 per patient referred to a navigator. Incremental cost-effectiveness varied from $200 to $700 per additional colonoscopy. At 2 hospitals, net revenue associated with increased colonoscopy volume exceeded the program cost per additional colonoscopy, yielding a net financial benefit; at the third hospital, the program yielded a net cost. Variation between hospitals in the program's economic impact was primarily attributable to differences in personnel costs. CONCLUSIONS: Economic evaluation of this colonoscopy patient navigator program in an urban public hospital setting suggests that such programs can be a cost-effective use of limited resources and yield a net financial benefit for providers.

Increased screening colonoscopy rates and reduced racial disparities in the New York Citywide campaign: an urban model.

OBJECTIVES: In 2003, in response to low colonoscopy screening rates and significant sociodemographic disparities in colonoscopy screening in New York City (NYC), the NYC Department of Health and Mental Hygiene, together with the Citywide Colon Cancer Control Coalition, launched a multifaceted campaign to increase screening. We evaluated colonoscopy trends among adult New Yorkers aged 50 years and older between 2003 and 2007, the first five years of this campaign. METHODS: Data were analyzed from the NYC Community Health Survey, an annual, population-based surveillance of New Yorkers. Annual prevalence estimates of adults who reported a timely colonoscopy, one within the past 10 years, were calculated. Multivariate models were used to analyze changes over time in associations between colonoscopy screening and sociodemographic characteristics. RESULTS: Overall, from 2003 to 2007 the proportion of New Yorkers aged 50 years and older who reported timely colonoscopy screening increased from 41.7% to 61.7%. Racial/ethnic and sex disparities observed in 2003 were eliminated by 2007: prevalence of timely colonoscopy was similar among non-Hispanic whites, non-Hispanic blacks, Hispanics, men, and women. However, Asians, the uninsured, and those with lower education and income continued to lag in receipt of timely colonoscopies. CONCLUSIONS: The increased screening colonoscopy rate and reduction of racial/ethnic disparities observed in NYC suggest that multifaceted, coordinated urban campaigns can improve low utilization of clinical preventive health services and reduce public-health disparities.

Effect of a patient navigator program on the volume and quality of colonoscopy.

BACKGROUND AND GOALS: To increase colorectal cancer screening among urban minorities, New York Presbyterian Hospital/Columbia University, with support from the New York City Department of Health and the Citywide Colon Cancer Control Coalition (C5), instituted a patient navigation and direct endoscopic referral system. We assessed the effect of this program on the volume of colonoscopy in this institution, which caters to a socioeconomically diverse patient population. STUDY: We compared colonoscopy volume during the first year of the navigator program with the volume during the year before this program. We stratified on Medicaid status to assess the secular trend of screening rates. To assess quality during this period, we measured cecal intubation rates, preparation quality, and adenoma detection rates. RESULTS: Of the 749 patients assessed by the patient navigators, 678 (91%) underwent colonoscopy. Colonoscopy volume among the Medicaid outpatients increased by 56% (957 to 1489). Adenoma detection was 27% and the cecal intubation rate was 97%. Comparing navigated patients with the nonnavigated Medicaid outpatients, preparation quality was superior (34% vs. 40% suboptimal, P=0.0282), although preparation quality remained inferior to that of private patients (20% suboptimal, P<0.0001). CONCLUSIONS: Volume of the colonoscopy increased, coinciding with the onset of the patient navigation program. This increase was nearly entirely owing to a rise in the colonoscopies among Medicaid outpatients, the principal focus of the navigator program. This increase in quantity was accomplished while maintaining an overall high level of quality as measured by cecal intubation rates and adenoma detection, although preparation quality requires further efforts at improvement.

A public health approach to winning the war against cancer.

The "war on cancer" in the United States has been viewed primarily as an effort to develop and disseminate cancer cures, but cancer is far more easily prevented than cured. There are three major approaches to cancer prevention: Primary prevention, through reduction in risk factors and changes to the environment that reduce human exposure to widely-consumed cancer-promoting agents. The most important actions for primary prevention of cancer are those that reduce tobacco use through taxation, smoke-free environment policies, advertising restrictions, counter-advertising, and cessation programs. The World Health Organization's MPOWER package outlines these actions, each of which covered less than 5% of people in the world in 2007. Similarly, cancer can be prevented by reducing alcohol consumption through policies such as alcohol taxes and limits on alcohol sales, and restoring caloric balance through policies such as creating healthier food environments and engineering the built environment to increase opportunities for physical activity. Vaccination is an effective approach to preventing specific virus-associated cancers, such as using human papillomavirus vaccine to prevent cervical cancer and hepatitis B virus vaccine to prevent hepatocellular cancer. Secondary prevention reduces cancer mortality through screening and early treatment; this approach has been used successfully for breast and cervical cancer but is still underused against colon cancer. Progress can be made in all three approaches to cancer prevention, but will require a greater emphasis on public health programs and public policy. Winning the war on cancer will require a much larger investment in prevention to complement efforts to improve treatment.