An observational study of workflows to support fecal testing for colorectal cancer screening in primary care practices serving Medicaid enrollees.

BACKGROUND: Screening supports early detection and treatment of colorectal cancer (CRC). Provision of fecal immunochemical tests/fecal occult blood tests (FIT/FOBT) in primary care can increase CRC screening, particularly in populations experiencing health disparities. This study was conducted to describe clinical workflows for FIT/FOBT in Oregon primary care practices and to identify specific workflow processes that might be associated (alone or in combination) with higher (versus lower) CRC screening rates. METHODS: Primary care practices were rank ordered by CRC screening rates in Oregon Medicaid enrollees who turned age 50 years from January 2013 to June 2014 (i.e., newly age-eligible). Practices were recruited via purposive sampling based on organizational characteristics and CRC screening rates. Data collected were from surveys, observation visits, and informal interviews, and used to create practice-level CRC screening workflow reports. Data were analyzed using descriptive statistics, qualitative data analysis using an immersion-crystallization process, and a matrix analysis approach. RESULTS: All participating primary care practices (N=9) used visit-based workflows, and four higher performing and two lower performing used population outreach workflows to deliver FIT/FOBTs. However, higher performing practices (n=5) had more established workflows and staff to support activities. Visit-based strategies in higher performing practices included having dedicated staff identify patients due for CRC screening and training medical assistants to review FIT/FOBT instructions with patients. Population outreach strategies included having clinic staff generate lists and check them for accuracy prior to direct mailing of kits to patients. For both workflow types, higher performing clinics routinely utilized systems for patient reminders and follow-up after FIT/FOBT distribution. CONCLUSIONS: Primary care practices with higher CRC screening rates among newly age-eligible Medicaid enrollees had more established visit-based and population outreach workflows to support identifying patients due for screening, FIT/FOBT distribution, reminders, and follow up. Key to practices with higher CRC screening was having medical assistants discuss and review FIT/FOBT screening and instructions with patients. Findings present important workflow processes for primary care practices and may facilitate the implementation of evidence-based interventions into real-world, clinical settings.

Systematic Review of Interventions to Increase Stool Blood Colorectal Cancer Screening in African Americans.

African Americans experience colorectal cancer (CRC) related disparities compared to other racial groups in the United States. African Americans are frequently diagnosed with CRC at a later stage, screening is underutilized, and mortality rates are highest in this group. This systematic review focused on intervention studies using stool blood CRC screening among African Americans in primary care and community settings. Given wide accessibility, low cost, and ease of dissemination of stool-based CRC screening tests, this review aims to determine effective interventions to improve participation rates. This systematic review included intervention studies published between January 1, 2000 and March 16, 2019. After reviewing an initial search of 650 studies, 11 studies were eventually included in this review. The included studies were studies conducted in community and clinical settings, using both inreach and outreach strategies to increase CRC screening. For each study, an unadjusted odds ratio (OR) for the CRC screening intervention compared to the control arm was calculated based on the data in each study to report effectiveness. The eleven studies together recruited a total of 3334 participants. The five studies using two-arm experimental designs ranged in effectiveness with ORs ranging from 1.1 to 13.0 using interventions such as mailed reminders, patient navigation, and tailored educational materials. Effective strategies to increase stool blood testing included mailed stool blood tests augmented by patient navigation, tailored educational materials, and follow-up calls or mailings to increase trust in the patient-provider relationship. More studies are needed on stool blood testing interventions to determine effectiveness in this population.

Comparison of a web-push survey research protocol with a mailed paper and pencil protocol in the Monitoring the Future panel survey.

AIMS: The experiment tested the effects of a web-push survey research protocol, compared with the standard mailed paper-and-pencil protocol, among young adults aged 19-30 years in the 'Monitoring the Future' (MTF) longitudinal study. DESIGN, SETTING AND PARTICIPANTS: The US-based MTF study has measured substance use trends among young adults in panel samples followed biennially, using consistent mailed survey procedures from 1977 to 2017. In 2018, young adult participants in the MTF longitudinal component scheduled to be surveyed at ages 19-30 in 2018 (from high school senior cohorts of 2006-17, n = 14 709) were randomly assigned to receive the standard mail/paper survey procedures or new web-push procedures. MEASUREMENTS: Primary outcomes were responding to the survey and prevalence estimates for past 30-day use of alcohol, cigarettes, marijuana and illicit drugs. FINDINGS: The web-push response rate was 39.07% [95% confidence interval (CI) = 37.889, 40.258]; this was significantly better than the standard MTF response rate of 35.12% (95% CI = 33.964, 36.285). After adjusting for covariates, the web-push condition was associated with a 19% increase in the odds of responding compared with standard MTF (adjusted odds ratio = 1.188; 95% CI = 1.096, 1.287). Substance use prevalence estimates were very similar and differences became negligible when using attrition weights and controlling for socio-demographic characteristics. CONCLUSIONS: The web-push protocol produced a higher response rate than the mailed pencil and paper protocol in the Monitoring the Future panel study, without substantially affecting estimates of substance use once attrition weights and socio-demographic variables were factored in.

Outreach to new mothers through direct mail and email: recruitment in the Early Check research study.

Meeting recruitment targets for clinical trials and health research studies is a notable challenge. Unsuccessful efforts to recruit participants from traditionally underserved populations can limit who benefits from scientific discovery, thus perpetuating inequities in health outcomes and access to care. In this study, we evaluated direct mail and email outreach campaigns designed to recruit women who gave birth in North Carolina for a statewide research study offering expanded newborn screening for a panel of rare health conditions. Of the 54,887 women who gave birth in North Carolina from September 28, 2018, through March 19, 2019, and were eligible to be included on the study's contact lists, we had access to a mailing address for 97.9% and an email address for 6.3%. Rural women were less likely to have sufficient contact information available, but this amounted to less than a one percentage point difference by urbanicity. Native American women were less likely to have an email address on record; however, we did not find a similar disparity when recruitment using direct-mail letters and postcards was concerned. Although we sent letters and emails in roughly equal proportion by urbanicity and race/ethnicity, we found significant differences in enrollment across demographic subgroups. Controlling for race/ethnicity and urbanicity, we found that direct-mail letters and emails were effective recruitment methods. The enrollment rate among women who were sent a recruitment letter was 4.1%, and this rate increased to 5.0% among women who were also sent an email invitation. Study Highlights WHAT IS THE CURRENT KNOWLEDGE ON THE TOPIC? Under-representation by traditionally underserved populations in clinical trials and health research is a challenge that may in part reflect inequitable opportunities to participate. WHAT QUESTION DID THIS STUDY ADDRESS? Are direct-mail and email outreach strategies effective for reaching and recruiting women from traditionally underserved and rural populations to participate in large-scale, population-based research? WHAT DOES THIS STUDY ADD TO OUR KNOWLEDGE? Despite sending recruitment letters and email invitations in roughly equal proportion by urbanicity and race/ethnicity, women living in rural areas were less likely to enroll (2.8%) than women from urban areas (4.2%). Additionally, enrollment rates decreased as the probability that women were members of a racial or ethnic minority group increased. HOW MIGHT THIS CHANGE CLINICAL PHARMACOLOGY OR TRANSLATIONAL SCIENCE? Results from this study might encourage researchers to take a holistic and participant-centered view of barriers to study enrollment that may disproportionately affect underserved communities, including differences in willingness to participate, trust, and access to resources needed for uptake.

Dynamics of COVID-19 transmission including indirect transmission mechanisms: a mathematical analysis.

The outbreak of the novel coronavirus severe acute respiratory syndrome-coronavirus-2 has raised major health policy questions and dilemmas. Whilst respiratory droplets are believed to be the dominant transmission mechanisms, indirect transmission may also occur through shared contact of contaminated common objects that is not directly curtailed by a lockdown. The conditions under which contaminated common objects may lead to significant spread of coronavirus disease 2019 during lockdown and its easing is examined using the susceptible-exposed-infectious-removed model with a fomite term added. Modelling the weekly death rate in the UK, a maximum-likelihood analysis finds a statistically significant fomite contribution, with 0.009 ± 0.001 (95% CI) infection-inducing fomites introduced into the environment per day per infectious person. Post-lockdown, comparison with the prediction of a corresponding counterfactual model with no fomite transmission suggests fomites, through enhancing the overall transmission rate, may have contributed to as much as 25% of the deaths following lockdown. It is suggested that adding a fomite term to more complex simulations may assist in the understanding of the spread of the illness and in making policy decisions to control it.

Are patients more adherent to newer drugs?

The annual preventable cost from non-adherence in the US health care system amounts to $100 billion. While the relationship between adherence and the health system, the condition, patient characteristics and socioeconomic factors are established, the role of the heterogeneous productivity of drug treatment remains ambiguous. In this study, we perform cross-sectional retrospective analyses to study whether patients who use newer drugs are more adherent to pharmacotherapy than patients using older drugs within the same therapeutic class, accounting for unobserved heterogeneity at the individual level (e.g. healthy adherer bias). We use US Marketscan commercial claims and encounters data for 2008-2013 on patients initiating therapy for five chronic conditions. Productivity is captured by a drug's earliest Food and Drug Administration (FDA) approval year ("drug vintage") and by FDA" therapeutic potential" designation. We control for situational factors as promotional activity, copayments and distribution channel. A 10-year increase in mean drug vintage is associated with a 2.5 percentage-point increase in adherence. FDA priority status, promotional activity and the share of mail-order prescription fills positively influenced adherence, while co-payments had a negative effect. Newer drugs not only may be more effective in terms of clinical benefits, on average. They provide means to ease drug therapy to increase adherence levels as one component of drug quality, a notion physicians and pharmacy benefit managers should be aware of.

Harnessing health plan enrollee data to boost membership in patient-powered research networks.

BACKGROUND: Patient-powered research networks (PPRNs) have been employing and exploring different methods to engage patients in research activities specific to their conditions. One way to intensify patient engagement is to partner with payer stakeholders. The objective of this study was to evaluate the effectiveness of two common payer-initiated outreach methods (postal mail versus email) for inviting prospective candidates to participate in their initiatives. METHODS: This descriptive study linked members of a nationally-representative private insurance network to four disease-specific PPRN registries. Eligible members meeting diagnostic criteria who were not registered in any of the four PPRNs by 02/28/2018 were identified, and randomly assigned to either the mail or email group. They were contacted in two outreach efforts: first on 04/23/2018, and one follow-up on 05/23/2018. New registration rates by outreach method as of 8/31/2018 were determined by relinking. We compared registrants and non-registrants using bivariate analysis. RESULTS: A total of 14,571 patients were assigned to the mail group, and 14,574 to the email group. Invitations were successfully delivered to 13,834 (94.9%) mail group and 10,205 (70.0%) email group members. A small but significantly larger proportion of mail group members, (n = 78; 0.54, 95% Confidence Interval [CI] {0.42-0.67%}) registered in PPRNs relative to the email group (n = 24; 0.16, 95% CI {0.11-0.25%}), p < 0.001. Members who registered had more comorbidities, were more likely to be female, and had marginally greater medical utilization, especially emergency room visits, relative to non-registrants (52.0% vs. 42.5%, p = 0.05). CONCLUSION: A health plan outreach to invite members to participate in PPRNs was modestly effective. Regular mail outperformed less costly email. Providing more value-add to participants may be a possible way to increase recruitment success.

Early investments in state capacity promote persistently higher levels of social capital.

Social capital has been shown to positively influence a multitude of economic, political, and social outcomes. Yet the factors that affect long-run social capital formation remain poorly understood. Recent evidence suggests that early state formation, especially investments in state capacity, are positively associated with higher levels of contemporary social capital and other prosocial attitudes. The channels by which early state capacity leads to greater social capital over time are even less understood. We contribute to both questions using the spatial and temporal expansion of the US postal network during the 19th century. We first show that county-level variation in post office density is highly correlated with a bevy of historical and contemporary indicators of social capital (e.g., associational memberships, civic participation, health, and crime). This finding holds even when controlling for historical measures of development and contemporary measures of income, inequality, poverty, education, and race. Second, we provide evidence of an informational mechanism by which this early investment in infrastructural capacity affected long-run social capital formation. Namely, we demonstrate that the expansion of the postal network in the 19th century strongly predicts the historical and contemporary location of local newspapers, which were the primary mode of impersonal information transmission during this period. Our evidence sheds light on the role of the state in both the origins of social capital and the channels by which it persists. Our findings also suggest that the consequences of the ongoing decline in local newspapers will negatively affect social capital.

Proactively Offered Text Messages and Mailed Nicotine Replacement Therapy for Smokers in Primary Care Practices: A Pilot Randomized Trial.

INTRODUCTION: Proactive, population health cessation programs can guide efforts to reach smokers outside of the clinic to encourage quit attempts and treatment use. AIMS AND METHODS: This study aimed to measure trial feasibility and preliminary effects of a proactive intervention offering text messages (TM) and/or mailed nicotine replacement therapy (NRT) to smokers in primary care clinics. From 2017 to 2019 we performed a pilot randomized trial comparing brief telephone advice (control: BA), TM, 2 weeks of mailed NRT, or both interventions (TM + NRT). Patients were identified using electronic health records and contacted proactively by telephone to assess interest in the study. We compared quit attempts, treatment use, and cessation in the intervention arms with BA. RESULTS: Of 986 patients contacted, 153 (16%) enrolled (mean age 53 years, 57% female, 76% white, 11% black, 8% Hispanic, 52% insured by Medicaid) and 144 (94%) completed the 12-week assessment. On average, patients in the TM arms received 159 messages (99.4% sent, 0.6% failed), sent 19 messages, and stayed in the program for 61 days. In all groups, a majority of patients reported quit attempts (BA 67% vs. TM 86% [p = .07], NRT 81% [p = .18], TM + NRT 79% [p = .21]) and NRT use (BA 51% vs. NRT 83% [p = .007], TM 65% [p = .25], TM + NRT 76% [p = .03]). Effect estimates for reported 7-day abstinence were BA 10% versus TM 26% (p = .09), NRT 28% (p = .06), and TM + NRT 23% (p = .14). CONCLUSIONS: Proactively offering TM or mailed nicotine medications was feasible among primary care smokers and a promising approach to promote quit attempts and short-term abstinence. IMPLICATIONS: Proactive intervention programs to promote quit attempts outside of office visits among smokers enrolled in primary care practices are needed. TM have potential to engage smokers not planning to quit or to support smokers to make a planned quit attempt. This pilot study demonstrates the feasibility of testing a proactive treatment model including TM and/or mailed NRT to promote quit attempts, treatment use, and cessation among nontreatment-seeking smokers in primary care. CLINICALTRIALS.GOV IDENTIFIER: NCT03174158.

Survey Item Response Rates by Survey Modality, Language, and Sociodemographic Factors in a Large U.S. Cohort.

BACKGROUND: Large-scale prospective cohorts traditionally use English, paper-based, mailed surveys, but Web-based surveys can lower costs and increase data quality, and multi-language surveys may aid in capturing diverse populations. Little evidence exists examining item response for multiple survey modalities or languages in epidemiologic cohorts. METHODS: A total of 254,475 men and women completed a comprehensive lifestyle and medical survey at enrollment (2006-2013) for the Cancer Prevention Study-3, a U.S.-based prospective cohort. Web-based (English only) or paper (Spanish or English) surveys were offered. Using generalized linear models, differences in item response rates overall and by topical areas (e.g., reproductive history) by modality and language were examined. We further examined whether differences in response quality by sociodemographic characteristics within each survey modality existed. RESULTS: Overall, English Web-based surveys had the highest average item response rate (97.6%), followed by English paper (95.5%) and Spanish paper (83.1%). Lower item response rates were seen among nonwhite, lower income, or less-educated participants. When examining individual survey sections by topic, results varied the most for residential history, with the lowest item response rate among Spanish language respondents (women, 62.7% and men, 64.3%) and the highest in English language Web-based, followed by paper respondents (women, 94.6% and men, 95.3%; and women, 92.8% and men, 92.1%, respectively). CONCLUSIONS: This study supports that utilizing multimodal survey approaches in epidemiologic studies does not differentially affect data quality. However, for some topic areas, further analysis should be considered for assessing data quality differences in Spanish language surveys. IMPACT: Multimodal survey administration is effective in nondifferentially capturing high-quality data.See all articles in this CEBP Focus section, "Modernizing Population Science."

Exercise and cardiovascular load in workers with high occupational physical activity.

This study investigated the association between exercise and cardiovascular load in Korean mail carriers with high occupational physical activity (OPA). A total of 36 subjects completed a questionnaire, and their heart rates were measured for 3 consecutive days. Treadmill tests were used determine maximal oxygen uptake (VO2max). The subjects' relative heart rate (RHR) was 25.6%±4.5%, which was higher than the recommended RHR (24.5%). Daily working hours were 11.1 ± 0.9 hours, which was longer than the maximum acceptable work time (7.8 ± 1.7 hours). Multiple regression analysis showed that daily working hours were positively associated with RHR, but exercise did not show any significant association. According to the results of this study, exercise may not be of benefit to workers with high OPA, suggesting that exercise should be cautiously considered for workers with high OPA.

Effect of Mailed Human Papillomavirus Test Kits vs Usual Care Reminders on Cervical Cancer Screening Uptake, Precancer Detection, and Treatment: A Randomized Clinical Trial.

Importance: In the United States, more than 50% of cervical cancers are diagnosed in underscreened women. Cervical cancer screening guidelines now include primary human papillomavirus (HPV) testing as a recommended strategy. Home-based HPV self-sampling is a viable option for increasing screening compliance and effectiveness; however, US data are needed to inform health care system implementation. Objective: To evaluate effectiveness of mailed HPV self-sampling kits vs usual care reminders for in-clinic screening to increase detection and treatment of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and uptake of cervical cancer screening. Design, Setting, and Participants: Randomized clinical trial conducted in Kaiser Permanente Washington, a US integrated health care delivery system. Women aged 30 to 64 years with health plan enrollment for 3 years and 5 months or more, a primary care clinician, no Papanicolaou test within 3 years and 5 months, and no hysterectomy were identified through electronic medical records and enrolled from February 25, 2014, to August 29, 2016, with follow-up through February 26, 2018. Interventions: The control group received usual care (annual patient reminders and ad hoc outreach from primary care clinics). The intervention group received usual care plus a mailed HPV self-sampling kit. Main Outcomes and Measures: Two primary outcomes were (1) CIN2+ detection within 6 months of screening and (2) treatment within 6 months of CIN2+ detection. Screening uptake within 6 months of randomization was a secondary outcome. Results: A total of 19 851 women (mean [SD] age, 50.1 [9.5] years) were included, with 9960 randomized to the intervention group and 9891 randomized to the control group. All women randomized were included in analysis. In the intervention group, 12 participants with CIN2+ were detected compared with 8 in the control group (relative risk, 1.49; 95% CI, 0.61-3.64) and 12 cases were treated vs 7 in the control group (relative risk, 1.70; 95% CI, 0.67-4.32). Screening uptake was higher in the intervention group (2618 participants [26.3%] vs 1719 participants [17.4%]; relative risk, 1.51; 95% CI, 1.43-1.60). Conclusions and Relevance: Mailing HPV kits to underscreened women increased screening uptake compared with usual care alone, with no significant differences in precancer detection or treatment. Results support the feasibility of mailing HPV kits to women who are overdue for screening as an outreach strategy to increase screening uptake in US health care systems. Efforts to increase kit uptake and follow-up of positive results are warranted to maximize detection and treatment of CIN2+. Trial Registration: ClinicalTrials.gov identifier: NCT02005510.

Financial Incentives to Increase Colorectal Cancer Screening Uptake and Decrease Disparities: A Randomized Clinical Trial.

Importance: Colorectal cancer screening rates are suboptimal, particularly among sociodemographically disadvantaged groups. Objective: To examine whether guaranteed money or probabilistic lottery financial incentives conditional on completion of colorectal cancer screening increase screening uptake, particularly among groups with lower screening rates. Design, Setting, and Participants: This parallel, 3-arm randomized clinical trial was conducted from March 13, 2017, through April 12, 2018, at 21 medical centers in an integrated health care system in western Washington. A total of 838 age-eligible patients overdue for colorectal cancer screening who completed a questionnaire that confirmed eligibility and included sociodemographic and psychosocial questions were enrolled. Interventions: Interventions were (1) mail only (n = 284; up to 3 mailings that included information on the importance of colorectal cancer screening and screening test choices, a fecal immunochemical test [FIT], and a reminder letter if necessary), (2) mail and monetary (n = 270; mailings plus guaranteed $10 on screening completion), or (3) mail and lottery (n = 284; mailings plus a 1 in 10 chance of receiving $50 on screening completion). Main Outcomes and Measures: The primary outcome was completion of any colorectal cancer screening within 6 months of randomization. Secondary outcomes were FIT or colonoscopy completion within 6 months of randomization. Intervention effects were compared across sociodemographic subgroups and self-reported psychosocial measures. Results: A total of 838 participants (mean [SD] age, 59.7 [7.2] years; 546 [65.2%] female; 433 [52.2%] white race and 101 [12.1%] Hispanic ethnicity) were included in the study. Completion of any colorectal screening was not significantly higher for the mail and monetary group (207 of 270 [76.7%]) or the mail and lottery group (212 of 284 [74.6%]) than for the mail only group (203 of 284 [71.5%]) (P = .11). For FIT completion, interventions had a statistically significant effect (P = .04), with a net increase of 7.7% (95% CI, 0.3%-15.1%) in the mail and monetary group and 7.1% (95% CI, -0.2% to 14.3%) in the mail and lottery group compared with the mail only group. For patients with Medicaid insurance, the net increase compared with mail only in FIT completion for the mail and monetary or the mail and lottery group was 37.7% (95% CI, 11.0%-64.3%) (34.2% for the mail and monetary group and 40.4% for the mail and lottery group) compared with a net increase of only 5.6% (95% CI, -0.9% to 12.2%) among those not Medicaid insured (test for interaction P = .03). Conclusions and Relevance: Financial incentives increased FIT uptake but not overall colorectal cancer screening. Financial incentives may decrease screening disparities among some sociodemographically disadvantaged groups. Trial Registration: ClinicalTrials.gov identifier: NCT00697047.

Opportunities to encourage mail order pharmacy delivery service use for diabetes prescriptions: a qualitative study.

BACKGROUND: Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional "brick and mortar" pharmacies to refill prescriptions. METHODS: We conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. RESULTS: A total of 28 diabetes patients participated. Participants' average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of 'Opportunity.' Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions. CONCLUSIONS: This study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.

The Danish health and morbidity surveys: study design and participant characteristics.

BACKGROUND: Reliable data from health surveys are essential to describe the status and trends in health indicators by means of information not available from official registers. In Denmark, nationally representative health surveys (the Danish Health and Morbidity Surveys) have been carried out among adults during the past three decades by the Danish National Institute of Public Health, University of Southern Denmark. The aim of the present study is to describe the study design of the three most recent surveys in 2010, 2013, and 2017, including the survey mode and response rates. METHODS: In 2010, 2013, and 2017, the samples (n = 25,000 each) were based on random sampling of individuals aged 16 years or older with a permanent residence in Denmark. A subsample of previously invited respondents was also re-invited in subsequent survey waves. Data were collected through self-administered questionnaires, yet with a concurrent mixed-mode approach, allowing for the invited individuals to complete either a web questionnaire or an identical paper questionnaire. In 2010 and 2013, survey invitations were sent by regular postal mail, whereas a secure electronical mail service, Digital Post, was used to invite the majority (90.1%) of the sample in 2017. RESULTS: The overall response rate decreased from 60.7% in 2010 to 57.1% in 2013 and 56.1% in 2017. Between 2010 and 2017 the response mode distribution for the web questionnaire increased markedly from 31.7 to 73.8%. The largest increase in the proportion which completed the web questionnaire was found in the oldest age group. CONCLUSIONS: Data from the Danish Health and Morbidity Surveys reveal an increasing proportion of the respondents to complete web questionnaires instead of paper questionnaires. Even though the response rate remained relatively stable in 2017, declining response rates is a major concern in health surveys. As the generalizability to the Danish population may be compromised by a low response rate, efforts to increase the response rate or keep it stable are crucial in future surveys. Thus, efforts should be made to ensure convenience and feasibility in relation to access to and the completion of survey (web) questionnaires.

The impact of survey mode on the response rate in a survey of the factors that influence Minnesota physicians' disclosure practices.

BACKGROUND: There is evidence that the physician response rate is declining. In response to this, methods for increasing the physician response rate are currently being explored. This paper examines the response rate and extent of non-response bias in a mixed-mode study of Minnesota physicians. METHODS: This mode experiment was embedded in a survey study on the factors that influence physicians' willingness to disclose medical errors and adverse events to patients and their families. Physicians were randomly selected from a list of licensed physicians obtained from the Minnesota Board of Medical Practice. Afterwards, they were randomly assigned to either a single-mode (mail-only or web-only) or mixed-mode (web-mail or mail-web) design. Differences in response rate and nonresponse bias were assessed using Fischer's Exact Test. RESULTS: The overall response rate was 18.60%. There were no statistically significant differences in the response rate across modes (p - value = 0.410). The non-response analysis indicates that responders and non-responders did not differ with respect to speciality or practice location. CONCLUSIONS: The mode of administration did not affect the physician response rate.

Methods to increase response rates to a population-based maternity survey: a comparison of two pilot studies.

BACKGROUND: Surveys are established methods for collecting population data that are unavailable from other sources; however, response rates to surveys are declining. A number of methods have been identified to increase survey returns yet response rates remain low. This paper evaluates the impact of five selected methods on the response rate to pilot surveys, conducted prior to a large-scale National Maternity Survey in England. METHODS: The pilot national maternity surveys were cross-sectional population-based questionnaire surveys of women who were three months postpartum selected at random from birth registrations. Women received a postal questionnaire, which they could complete on paper, online or verbally over the telephone. An initial pilot survey was conducted (pilot 1, n = 1000) to which the response rate was lower than expected. Therefore, a further pilot survey was conducted (pilot 2, n = 2000) using additional selected methods with the specific aim of increasing the response rate. The additional selected methods used for all women in pilot 2 were: pre-notification, a shorter questionnaire, more personable survey materials, an additional reminder, and inclusion of quick response (QR) codes to enable faster access to the online version of the survey. To assess the impact of the selected methods, response rates to pilot surveys 1 and 2 were compared. RESULTS: The response rate increased significantly from 28.7% in pilot 1 to 33.1% in pilot 2 (+ 4.4%, 95%CI:0.88-7.83, p = 0.02). Analysis of weekly returns according to time from initial and reminder mail-outs suggests that this increase was largely due to the additional reminder. Most respondents completed the paper questionnaire rather than taking part online or over the telephone in both pilot surveys. However, the overall response to the online questionnaire almost doubled from 1.8% in pilot 1 to 3.5% in pilot 2, corresponding to an absolute difference of 1.7% (95%CI:0.45-2.81, p = 0.01), suggesting that QR codes might have facilitated online participation. CONCLUSIONS: Declining survey response rates may be ameliorated with the use of selected methods. Further studies should evaluate the effectiveness of each of these methods using randomised controlled trials and identify novel strategies for engaging populations in survey research.

A Retrospective Database Study Comparing Diabetes-Related Medication Adherence and Health Outcomes for Mail-Order Versus Community Pharmacy.

BACKGROUND: Adherence to oral antihyperglycemic agents (AHAs) is important for managing blood glucose levels and avoiding hospitalizations or diabetes complications. Previous studies have found that use of mail-order pharmacy dispensing channels results in greater adherence than use of community pharmacies, but the link between use of mail-order pharmacies and improved clinical outcomes has not been established. OBJECTIVE: To compare the effect of mail-order and community pharmacy use on adherence to oral AHAs, hemoglobin A1c (A1c) level, and glycemic control, as well as emergency department (ED) and inpatient hospital use. METHODS: This retrospective cohort study of administrative claims data from January 1, 2008, to December 31, 2016, included patients with Medicare Advantage Prescription Drug plan coverage with ≥ 2 claims for the same oral AHA and a diagnosis of type 2 diabetes mellitus (T2DM). Patients were indexed to the start of the most advanced oral AHA identified to begin study observations at the start of a new treatment and assigned to mail-order or community pharmacy cohorts based on which channel dispensed ≥ 80% of their oral AHA claims; all others were excluded. Mail-order and community pharmacy patients were 1:1 propensity score matched. Matched cohorts were compared on proportion of days covered (PDC), adherence (PDC ≥ 0.8), A1c level, glycemic control, and ED and inpatient use for measurement periods of 12, 24, 36, and 48 months post-index. RESULTS: 19,307 mail-order and 19,307 community pharmacy users were matched. PDC was higher for mail-order pharmacy users at 12 months (0.93 vs. 0.82, P < 0.001) and sustainable through 48 months (0.87 vs. 0.77, P < 0.001). Adherence was also greater for mail-order pharmacy patients through 12 months (86% vs. 68%, P < 0.001) and sustainable through 48 months (78% vs. 62%, P < 0.001). Glycemic control as A1c < 7% was not significantly different, but control as A1c < 8% was greater for mail-order pharmacy users at 12 months (91% vs. 89%, P = 0.006) and was greater through 36 months (93% vs. 89%, P = 0.043). Effects on A1c level were not evident. Mail-order pharmacy users were less likely to have an ED visit within 12 months (26% vs. 28%, P < 0.0001), and the difference was observed through 36 months (50% vs. 54%, P < 0.0001). Similarly, fewer mail-order pharmacy users had an inpatient hospitalization within 12 months (17% vs. 19%, P < 0.0001), and the difference was observed through 48 months (43% vs. 47%, P = 0.009). CONCLUSIONS: The results of the study demonstrate a benefit to patients who use mail-order pharmacies for chronic medications to treat T2DM. The study identified greater glycemic control, lower ED use, and lower hospitalization among individuals using mail-order pharmacies. These positive outcomes were evident in the near term and sustained over time. DISCLOSURES: This study received no outside funding but was sponsored by Humana through regular employment activities by Schwab, Racsa, and Worley, who are employed by Humana Healthcare Research (formerly Comprehensive Health Insights). This study found benefits related to using mail-order versus community pharmacies for dispensing antihyperglycemic agents in the treatment of type 2 diabetes. Humana owns mail-order pharmacies under the Humana Pharmacy subsidiary. Mourer and Meah are paid employees of Humana Pharmacy Solutions. Rascati is employed by the University of Texas College of Pharmacy at Austin.

Improving Response Rates and Representation of Hard-to-Reach Groups in Family Experience Surveys.

OBJECTIVE: Most US hospitals conduct patient experience surveys by mail or telephone after discharge to assess patient/family centeredness of care. Pediatric response rates are usually very low, especially for black, Latino, and low-income respondents. We investigated whether day of discharge surveying using tablets improves response rates and respondent representativeness. METHODS: This was a quasi-experimental study of parents of patients discharged from 4 units of a children's hospital. Parents were assigned to receive the Child Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) via an audio-enabled tablet before discharge or via mail at approximately 1 week postdischarge. Intervention and control conditions alternated by week. We compared response rates, child/respondent characteristics, and mean top-box scores between tablet and mail only arms. RESULTS: Administering Child HCAHPS on a tablet was administratively feasible and did not interfere with the discharge process (median completion time, 12.4 minutes). The response rate was 71.1% (424 of 596) for tablet versus 16.3% (96 of 588) for mail only. Although the tablet response rate was higher in every subgroup, tablet respondents were more likely to be fathers (20.4% vs 6.4%; P = .006), more likely to have a high school education or less (17.5% vs 8.4%; P = .002), less likely to be white (56.8% vs 71.9%; P = .006), and more likely to be publicly insured (31.4% vs 19.8%; P = .02). Tablet scores were significantly higher than mail only scores for 3 of 17 measures. CONCLUSIONS: The response rate for day of discharge tablet survey administration was >4-fold higher than with single-wave mail-only administration, with greater participation of hard-to-reach groups. These findings suggest tablet administration before discharge shows great promise for real-time feedback and QI and may transform the field of inpatient survey administration.