Automated Digital Notification of COVID-19 Diagnoses Through Text and Email Messaging - North Carolina, December 2020-January 2021.

During October 3, 2020-January 9, 2021, North Carolina experienced a 400% increase in daily reported COVID-19 cases (1). To handle the increased number of cases and rapidly notify persons receiving a positive SARS-CoV-2 test result (patients), North Carolina state and local health departments moved from telephone call notification only to telephone call plus automated text and email notification (digital notification) beginning on December 24, 2020. Overall, among 200,258 patients, 142,975 (71%) were notified by telephone call or digital notification within the actionable period (10 days from their diagnosis date)* during January 2021, including at least 112,543 (56%) notified within 24 hours of report to North Carolina state and local health departments, a significantly higher proportion than the 25,905 of 175,979 (15%) notified within 24 hours during the preceding month (p<0.001). Differences in text notification by age, race, and ethnicity were observed. Automated digital notification is a feasible, rapid and efficient method to support timely outreach to patients, provide guidance on how to isolate, access resources, inform close contacts, and increase the efficiency of case investigation staff members.

The Supply and Distribution of the Preventive Medicine Physician Workforce.

CONTEXT: Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since. OBJECTIVE: The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce. DESIGN: Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile. SETTING: The 50 US states and District of Columbia. PARTICIPANTS: Board-certified and self-designated preventive medicine physicians in the United States. MAIN OUTCOME MEASURES: Number, demographics, and location of preventive medicine physicians in United States. RESULTS: From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing. CONCLUSIONS: The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty.

Preventive Medicine Physicians' Role in Health Care Organizations' Pursuit of the Triple Aim.

CONTEXT: The Institute for Healthcare Improvement's Triple Aim is rooted in improving population health and therefore requires a focus on prevention as well as management of disease. Preventive medicine (PM) physicians are uniquely trained in clinical medicine as well as health care delivery and systems-based practice, thus potentially positioning them to lead population health and contribute to the Triple Aim. OBJECTIVE: The objectives of this study were to (1) describe PM physicians' contributions related to the Triple Aim and (2) describe PM physician satisfaction with these activities. DESIGN: A survey was administered to physicians graduating from a single Preventive Medicine Residency program between 1975 and 2015. Physicians were asked about work in 3 specific emerging areas that relate to the Triple Aim's focus on population health improvement: population health; health system transformation; and integration between primary care and public health. PM physicians were also asked about their job, career, and specialty satisfaction. RESULTS: Most respondents (74%) practiced population health, with the majority (63%) defining this as improving the health of the population at large versus for a defined clinical population (37%). Approximately half (59%) of PM physicians are involved in health system transformation leadership. Most respondents practice both public health and primary care, but only 32% report having had positions that involve integration of these activities. PM physicians reported high specialty satisfaction levels, particularly among those involved in population health and health care transformation. CONCLUSION: PM physicians already make substantial contributions to population health and lead work related to the Triple Aim. High satisfaction among PM physicians suggests that they can contribute to a stable and sustainable population health workforce.

Characteristics of Population Health Physicians and the Needs of Healthcare Organizations.

INTRODUCTION: Healthcare organizations are transitioning from fee-for-service, volume-based care toward value-based care and the Triple Aim. Physicians have critical roles as leaders and practitioners in this emerging field of population health management; however, the competencies required of these physicians are not well described. The purpose of this study is to explore the approaches of healthcare systems to population health-related functions, the competencies needed, and the characteristics of physicians who lead or staff these functions. METHODS: Investigators conducted semistructured interviews with a convenience sample of 14 healthcare executives and 15 Preventive Medicine physicians and a focus group with 9 healthcare executives. Interviews and the focus group were recorded, transcribed, and coded. Themes and notable quotes were identified. Data were collected and analyzed in 2019. RESULTS: Population health was variously defined by the healthcare executives, often naming specific components or activities. The typical population health activities described by healthcare executives (e.g., quality measurement and process improvement) were reported along with the skills of physicians performing these functions (e.g., data analysis, informatics, leadership, business acumen). A total of 2 types of population health physicians were described: the clinician leader and the population health specialist. CONCLUSIONS: This exploratory study identified several useful competencies for population health physicians in healthcare systems. Findings point to opportunities to promote a more systematic approach to population health and to prepare Preventive Medicine and other physicians for population health management positions.

Multiple COVID-19 Clusters on a University Campus - North Carolina, August 2020.

Preventing transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), in institutes of higher education presents a unique set of challenges because of the presence of congregate living settings and difficulty limiting socialization and group gatherings. Before August 2020, minimal data were available regarding COVID-19 outbreaks in these settings. On August 3, 2020, university A in North Carolina broadly opened campus for the first time since transitioning to primarily remote learning in March. Consistent with CDC guidance at that time (1,2), steps were taken to prevent the spread of SARS-CoV-2 on campus. During August 3-25, 670 laboratory-confirmed cases of COVID-19 were identified; 96% were among patients aged <22 years. Eighteen clusters of five or more epidemiologically linked cases within 14 days of one another were reported; 30% of cases were linked to a cluster. Student gatherings and congregate living settings, both on and off campus, likely contributed to the rapid spread of COVID-19 within the university community. On August 19, all university A classes transitioned to online, and additional mitigation efforts were implemented. At this point, 334 university A-associated COVID-19 cases had been reported to the local health department. The rapid increase in cases within 2 weeks of opening campus suggests that robust measures are needed to reduce transmission at institutes of higher education, including efforts to increase consistent use of masks, reduce the density of on-campus housing, increase testing for SARS-CoV-2, and discourage student gatherings.

Building a Viable Weight Management Program in a Patient-Centered Medical Home.

BACKGROUND AND OBJECTIVES: The growing prevalence of obesity in the United States and globally highlights the need for innovative strategies to provide obesity treatment in primary care settings. This report describes and evaluates the Weight Management Program (WMP), an interprofessional program in an academic family medicine clinic delivering intensive behavioral therapy (IBT) following evidenced-based guidelines. METHODS: We extracted WMP participant health data from the electronic health record and evaluated retrospectively. Eligible participants completed at least four WMP visits and had a baseline weight, blood pressure, and hemoglobin A1c (HbA1c) recorded within 1 year prior to their first visit. Paired t tests were used to assess changes in, weight, HbA1c and systolic and diastolic blood pressures from baseline. RESULTS: WMP counseled 673 patients over 3,895 visits from September 2015 to June 2019. Of these, 186 met eligibility criteria (at least four visits), with a median of eight visits (mean=11.3, SD=8.1). Participants saw an average weight decrease during program participation of 9.7 lbs (P<.001), an average decrease in HbA1c of 0.2 points (P=.004), and an average blood pressure reduction of 2.8 mmHg systolic (P=.002) and 1.9 mmHg diastolic (P=.03). One-third of participants (n=60) achieved clinically significant weight loss (>5%) at 18 months. The program has become financially sustainable through billing for preventive counseling services and a $125 out-of-pocket enrollment fee. CONCLUSIONS: WMP provides one model for primary care practices to develop a financially sustainable and evidence-based behavioral therapy weight management program for their patients with obesity. Future work will include assessment of longer-term program benefits, quality metrics, and health care costs.

Using a RE-AIM framework to identify promising practices in National Diabetes Prevention Program implementation.

BACKGROUND: The National Diabetes Prevention Program (National DPP) is rapidly expanding in an effort to help those at high risk of type 2 diabetes prevent or delay the disease. In 2012, the Centers for Disease Control and Prevention funded six national organizations to scale and sustain multistate delivery of the National DPP lifestyle change intervention (LCI). This study aims to describe reach, adoption, and maintenance during the 4-year funding period and to assess associations between site-level factors and program effectiveness regarding participant attendance and participation duration. METHODS: The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide the evaluation from October 2012 to September 2016. Multilevel linear regressions were used to examine associations between participant-level demographics and site-level strategies and number of sessions attended, attendance in months 7-12, and duration of participation. RESULTS: The six funded national organizations increased the number of participating sites from 68 in 2012 to 164 by 2016 across 38 states and enrolled 14,876 eligible participants. By September 2016, coverage for the National DPP LCI was secured for 42 private insurers and 7 public payers. Nearly 200 employers were recruited to offer the LCI on site to their employees. Site-level strategies significantly associated with higher overall attendance, attendance in months 7-12, and longer participation duration included using self-referral or word of mouth as a recruitment strategy, providing non-monetary incentives for participation, and using cultural adaptations to address participants' needs. Sites receiving referrals from healthcare providers or health systems also had higher attendance in months 7-12 and longer participation duration. At the participant level, better outcomes were achieved among those aged 65+ (vs. 18-44 or 45-64), those who were overweight (vs. obesity), those who were non-Hispanic white (vs. non-Hispanic black or multiracial/other races), and those eligible based on a blood test or history of gestational diabetes mellitus (vs. screening positive on a risk test). CONCLUSIONS: In a time of rapid dissemination of the National DPP LCI the findings of this evaluation can be used to enhance program implementation and translate lessons learned to similar organizations and settings.

Alignment of Preventive Medicine Physicians' Residency Training With Professional Needs.

Preventive medicine (PM) physicians promote population-based approaches to health care with training that emphasizes public health, epidemiology, and policy. PM physicians use these skills in varied, often nonclinical, practice settings. PM career diversity challenges educators when designing residency curricula. Input from PM physicians about workforce environments is needed to ensure that residency requirements match skills needed post-residency. Graduates of one PM residency were sent a cross-sectional survey in 2016. Questions included professional experience, importance of 18 Accreditation Council for Graduate Medical Education sub-competencies and 13 leadership/management skills to current position, and residency training adequacy in those sub-competencies/skills. Responses were rated on 3-point Likert scales. Analyses were completed in 2017. Pearson's chi-square tests examined relationships between position type (academic/government) and perception of competencies' importance and training adequacy. Eighty PM physicians responded (46%): 44% worked in academia and 25% in federal/state/local government. Half (53%) were PM board certified. A total of 88% completed clinical residency prior to PM. Thirteen of 18 competencies were important to work, and respondents felt well trained in 16 of 18 competencies. Respondents did not feel well trained in emergency preparedness and surveillance systems during residency and their opinions about the importance of these sub-competencies varied based on where they worked. Respondents rated all 13 leadership/management skills as important, but reported inadequate residency training. In conclusion, respondents rated most Accreditation Council for Graduate Medical Education sub-competencies as important to current work and felt well trained, indicating good alignment between residency training and professional needs. Respondents also reported leadership/management training deficiencies. PM residencies might consider incorporating formal leadership training into curricula.

Evaluation of a Quality Improvement Resource for Public Health Practitioners.

OBJECTIVES: Quality improvement is a critical mechanism to manage public health agency performance and to strengthen accountability for public funds. The objective of this study was to evaluate a relatively new quality improvement resource, the Public Health Quality Improvement Exchange (PHQIX), a free online communication platform dedicated to making public health quality improvement information accessible to practitioners. METHODS: We conducted an internet-based survey of registered PHQIX users (n = 536 respondents) in 2013 and key informant interviews with PHQIX frequent users (n = 21) in 2014, in the United States. We assessed use of the PHQIX website, user engagement and satisfaction, communication and knowledge exchange, use of information, and impact on quality improvement capacity and accreditation readiness. RESULTS: Of 462 respondents, 369 (79.9%) browsed quality improvement initiatives, making it the most commonly used site feature, and respondents described PHQIX as a near-unique source for real-world quality improvement examples. Respondents were satisfied with the quality and breadth of topics and relevance to their settings (average satisfaction scores, 3.9-4.1 [where 5 was the most satisfied]). Of 407 respondents, 237 (58.2%) said that they had put into practice information learned on PHQIX, and 209 of 405 (51.6%) said that PHQIX had helped to improve quality improvement capacity. Fewer than half of respondents used the commenting function, the Community Forum, and the Ask an Expert feature. CONCLUSIONS: Findings suggest that PHQIX, particularly descriptions of the quality improvement initiatives, is a valued resource for public health practitioners. Users reported sharing information with colleagues and applying what they learned to their own work. These findings may relate to other efforts to disseminate quality improvement knowledge.

Measuring public health practice and outcomes in chronic disease: a call for coordination.

A strategic opportunity exists to coordinate public health systems and services researchers' efforts to develop local health department service delivery measures and the efforts of divisions within the Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to establish outcome indicators for public health practice in chronic disease. Several sets of outcome indicators developed by divisions within NCCDPHP and intended for use by state programs can be tailored to assess outcomes of interventions within smaller geographic areas or intervention settings. Coordination of measurement efforts could potentially allow information to flow from the local to the state to the federal level, enhancing program planning, accountability, and even subsequent funding for public health practice.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan.

OBJECTIVES: We conducted a literature review and environmental scan to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts. METHODS: We searched 4 major health services and social science electronic databases and conducted an Internet search to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity. RESULTS: We identified 49 interventions, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics. CONCLUSIONS: An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Linkages between clinical practices and community organizations for prevention: a literature review and environmental scan.

CONTEXT: A literature review and environmental scan were conducted to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts. EVIDENCE ACQUISITION: A search was made of four major health services and social science electronic databases and an Internet search was conducted to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity. EVIDENCE SYNTHESIS: In all, 49 interventions were identified, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics. CONCLUSIONS: An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Cancer Plan Index: a measure for assessing the quality of cancer plans.

OBJECTIVE: To (1) conduct an in-depth assessment of the content of comprehensive cancer control plans and (2) obtain data that can be used to provide guidance to grantees supported by the Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) as they refine their plans, and to other health professionals as similar planning is done. DESIGN: Through an iterative development process, a workgroup of subject matter experts from NCCCP and Research Triangle Institute International (RTI International) identified 11 core or essential components that should be considered in cancer plans on the basis of their professional experience and expertise. They also developed a tool, the Cancer Plan Index (CPI), to assess the extent to which cancer plans addressed the 11 core components. SETTING: Sixty-five comprehensive cancer control programs in states, tribes, territories, and jurisdictions funded by the NCCCP. DATA SOURCE: Raters reviewed and abstracted all available cancer plans (n = 66), which included plans from 62 funded programs and 4 states of the Federated States of Micronesia funded by Centers for Disease Control and Prevention as a subcontractor of one funded program. Of the 66 plans, 3 plans were used to pilot test the CPI and the remaining 63 plans were subsequently reviewed and abstracted. MAIN OUTCOME MEASURE(S): The primary outcome measures are national-level component scores for 11 defined domains (global involvement of stakeholders, developing the plan, presentation of data on disease burden, goals, objectives, strategies, reduction of cancer disparities, implementation, funds for implementation of plan, evaluation, usability of plan), which represent an average of the component scores across all available cancer plans. RESULTS: To aid in the interpretation and usability of findings, the components were segmented into 3 tiers, representing a range high (average score = 2.01-4.00), moderate (average score = 1.01-2.00), and low (average score = 0-1.00) levels of description of the component. Programs overall provided relatively comprehensive descriptions of goals, objectives, and strategies; moderate description of the plan development process, presentation of data on disease burden, and plans on the reduction of cancer disparities; and little to no description of stakeholder involvement plans for implementation, funds for implementation, and evaluation of the plan. CONCLUSIONS: Areas of the CPI with low average component scores should stimulate technical assistance to the funded programs, either to increase program activities or to increase discussion of key activities in the plan.

Piloting performance measurement for Comprehensive Cancer Control programs.

OBJECTIVE: To implement a pilot test of performance measures for National Comprehensive Cancer Control (CCC) programs funded by the Centers for Disease Control and Prevention (CDC). DESIGN: A cross-sectional assessment conducted in 2008. SETTING: A total of 65 CCC-funded entities (51 states, 7 tribes, and 7 territories or jurisdictions) representing 69 CCC programs. PARTICIPANTS: Comprehensive Cancer Control program staff. MAIN OUTCOME MEASURES: In a process that involved stakeholders from funded programs, academia, and nonprofit organizations, the CDC developed a framework for evaluation and a performance measures worksheet containing 11 performance measures for CCC programs that assessed grantee attainment of key components of CCC as required in the funding announcement. The framework was based on a CCC logic model. The performance measures worksheet contained detailed description of the measures, definitions, and suggested data sources for the 11 measures. RESULTS: Of the 69 programs, 61 completed the worksheets. The median time reported to complete the worksheet was 10 hours (interquartile range = 6-20). Almost all programs reported having representation of relevant populations in their coalition and having conducted a recent assessment of the burden of cancer. Less frequently, programs reported having a written evaluation plan or having enacted policy changes. Additional performance measures described non-CDC funding, the percentage of partners implementing CCC activities, and the percentage of implemented interventions that were evidence-based. CONCLUSIONS: This pilot test of the performance measures worksheet established the feasibility of conducting a standardized survey of CCC programs to identify issues of importance to developing and implementing the CCC program at national and program levels. The performance measures provided unique data on CCC grantees to the CDC funders and feedback on performance measures for improving questions on future surveys. Refinement of the performance measures will provide a tool for monitoring processes of action and accountability of grantees and will encourage a culture of quality improvement through systematic evaluation.

Public health case studies in diabetes prevention and control: innovation, partnerships, and funding.

BACKGROUND: In 2006, we conducted case studies of 4 North Carolina local health departments (LHDs) that scored highly on an index of diabetes prevention and control performance, to explore characteristics that may serve as barriers or facilitators of diabetes prevention and control services. METHODS: Case studies involving in-depth interviews were conducted at 4 LHDs. Sites were selected on the basis of 2 variables, known external funding for diabetes services and population size, that were associated with performance in diabetes prevention and control in a 2005 survey of all North Carolina LHDs. Fourteen interviews (individual and group) were conducted among 17 participants from the 4 LHDs. The main outcome measures were LHD characteristics that facilitate or hinder the performance of diabetes programs and services. RESULTS: Interviews revealed that all 4 high-performing LHDs had received some sort of funding from a source external to the LHD. Case study participants indicated that barriers to additional service delivery included low socioeconomic status of the population and lack of financial resources. Having a diabetes self-management education program that was recognized by the American Diabetes Association appeared to be a facilitator of diabetes services provision. Other facilitators were leadership and staff commitment, which appeared to facilitate the leveraging of partnerships and funding opportunities, leading to enhanced service delivery. LIMITATIONS: The small number of LHDs participating in the study and the cross-sectional study design were limitations. CONCLUSION: Leadership, staff commitment, partnership leveraging, and funding appear to be associated with LHD performance in diabetes prevention and control services. These factors should be further studied in future public health systems and services research.

Enhancing the use and quality of colorectal cancer screening.

OBJECTIVES: To conduct a systematic review of the use and quality (including underuse, overuse, and misuse) of appropriate colorectal cancer (CRC) screening, including factors associated with screening, effective interventions to improve screening rates, current capacity, and monitoring and tracking the use and quality. Trends in the use and quality of CRC screening tests is also presented. DATA SOURCES: We searched MEDLINE, the Cochrane Library, and the Cochrane Central Trials Registry, supplemented by handsearches, for studies published in English from January 1998 through September 2009. REVIEW METHODS: We used standard Evidence-based Practice Center methods of dual review of abstracts, full text articles, abstractions, quality rating, and quality grading. We resolved disagreements by consensus. RESULTS: We found multiple problems of underuse, overuse, and misuse of CRC screening. We identified a total of 116 articles for inclusion into the systematic review, including a total of 72 studies qualified for inclusion for key question (KQ) 2, 21 for KQ 3, 12 for KQ 4, and 8 for KQ 5. A number of patient-level factors are associated with lower screening rates, including having low income or less education, being uninsured or of Hispanic or Asian descent, not being acculturated into the United States, and having less or reduced access to care. Being insured, of higher income or education, and non-Hispanic white, participating in other cancer screenings, having a family history of CRC or personal history of another cancer, as well as receiving a physician recommendation to be screened, are associated with higher screening rates. Interventions that effectively increased CRC screening with high strength of evidence include patient reminders, one-on-one interactions, eliminating structural barriers, and system-level changes. The largest magnitude of improvement came from one-on-one interactions and eliminating barriers. Purely educational small-media interventions do not improve screening rates. Evidence is mixed for decision aids, although certain designs may be effective. No studies tested interventions to reduce overuse or misuse of CRC screening. We found no studies that assessed monitoring systems for underuse, overuse, and misuse of CRC screening. Modeling studies, using various assumptions, show that if the United States were to adopt a colonoscopy-only approach to CRC screening and everyone were to agree to be screened in this way, it is likely that colonoscopy capacity would need to be substantially increased. CONCLUSIONS: Both CRC screening and patient-physician discussions of CRC screening are underused, and important problems of overuse and misuse also exist. Some interventions hold promise for improvement. The research priority is to design and test interventions to increase screening and CRC screening discussions, building on the effective approaches identified in this review, and tailored to specific population needs. In addition, new interventions to reduce overuse and misuse should be designed and tested, along with studies of ongoing monitoring systems that are linked to feedback and continued improvement efforts.

The diabetes primary prevention initiative interventions focus area: a case study and recommendations.

BACKGROUND: In 2005, CDC began the Diabetes Primary Prevention Initiative Interventions Focus Area (DPPI-IFA), which funded five state Diabetes Prevention and Control Programs (DPCPs) to translate diabetes primary prevention trials into real-world settings by developing and implementing a framework for state-level diabetes primary prevention. PURPOSE: The purpose of this case study, conducted in 2007, was to describe DPPI-IFA implementation, including facilitators and challenges to the initiative. METHODS: Case studies of the five DPCPs in the DPPI-IFA involving site visits with key informant interviews of state staff and partners and archival record collection. RESULTS: Partners recruited for DPPI-IFA activities included local or state public health agencies (three of five DPCPs); regional or state nonprofit organizations (five DPCPs); businesses or employers (three DPCPs); and healthcare organizations (four DPCPs). The DPCPs implemented a variety of interventions in three main domains: diabetes primary prevention and prediabetes awareness, screening activities and lifestyle interventions, and prediabetes-related health policy efforts. Preliminary outcomes are described at the individual and organization/partnership levels. Results suggest the importance of utilizing preexisting partnerships to extend work into diabetes prevention, providing even small amounts of funding to partners, and prior program planning for diabetes prevention. Challenges for the DPPI-IFA included recruiting participants, establishing links with providers to obtain diagnostic testing for people screened for prediabetes, and offering a lifestyle intervention. CONCLUSIONS: The DPPI-IFA represents a unique effort by state public health programs in the translation of diabetes primary prevention trials into real-world settings. The experiences of the DPPI-IFA programs offer valuable lessons for future community-based diabetes prevention initiatives, especially regarding the need to strengthen clinical-community partnerships for referral of people with prediabetes to evidence-based lifestyle programs.

Systematic review: enhancing the use and quality of colorectal cancer screening.

BACKGROUND: National guideline groups recommend screening and discussion of screening options for persons at average risk for colorectal cancer (CRC). However, emerging evidence suggests that CRC screening is simultaneously underused, overused, and misused and that adequate patient-provider discussions about screening are infrequent. PURPOSE: To summarize evidence on factors that influence CRC screening and strategies that increase the appropriate use and quality of CRC screening and CRC screening discussions. DATA SOURCES: MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were searched for English-language publications describing studies conducted in the United States from January 1998 through September 2009. STUDY SELECTION: Two reviewers independently selected studies that addressed the study questions and met eligibility criteria. DATA EXTRACTION: Information on study design, setting, intervention, outcomes, and quality were extracted by one reviewer and double-checked by another. Reviewers assigned a strength-of-evidence grade for intervention categories by using criteria plus a consensus process. DATA SYNTHESIS: Reviewers found evidence of simultaneous underuse, overuse, and misuse of CRC screening as well as inadequate clinical discussions about CRC screening. Several patient-level factors were independently associated with lower screening rates, including having low income or less education, being uninsured, being Hispanic or Asian, being less acculturated into the United States, or having limited access to care. Evidence that interventions that included patient reminders or one-on-one interactions (that is, between patients and nonphysician clinic staff), eliminated structural barriers (for example, simplifying access to fecal occult blood test cards), or made system-level changes (for example, using systematic screening as opposed to opportunistic screening) were effective in enhancing use of CRC screening was strong. Evidence on how best to enhance discussions about CRC screening options is limited. No studies focused on reducing overuse, and very few focused on misuse. LIMITATIONS: Reporting and publication bias may have affected our findings. The independent effect of individual elements of multicomponent interventions was often uncertain. CONCLUSION: Although CRC screening is underused overall, important problems of overuse and misuse also exist. System- and policy-level interventions that target vulnerable populations are needed to reduce underuse. Interventions aimed at reducing barriers by making the screening process easier are likely to be effective. Studies aimed at reducing overuse and misuse and at enhancing the quality and frequency of discussions about CRC screening options are needed. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.