Economic Evaluation of Interventions to Increase Colorectal Cancer Screening at Federally Qualified Health Centers.

The Centers for Disease Control and Prevention (CDC) has a long-standing commitment to increase colorectal cancer (CRC) screening for vulnerable populations. In 2005, the CDC began a demonstration in five states and, with lessons learned, launched a national program, the Colorectal Cancer Control Program (CRCCP), in 2009. The CRCCP continues today and its current emphasis is the implementation of evidence-based interventions to promote CRC screening. The purpose of this article is to provide an overview of four CRCCP awardees and their federally qualified health center partners as an introduction to the accompanying series of research briefs where we present individual findings on impacts of evidence-based interventions on CRC screening uptake for each awardee. We also include in this article the conceptual framework used to guide our research. Our findings contribute to the evidence base and guide future program implementation to improve sustainability, increase CRC screening, and address disparities in screening uptake.

The effect of delivery structure on costs, screening and health promotional services in state level National Breast and Cervical Cancer Early Detection Programs.

PURPOSE: We estimated the costs and effectiveness of state programs in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) based on the type of delivery structure. METHODS: Programs were classified into three delivery structures: (1) centralized, (2) decentralized, and (3) mixed. Centralized programs offer clinical services in satellite offices, but all other program activities are performed centrally. Decentralized programs contract with other entities to fully manage and provide screening and diagnostic services and other program activities. Programs with mixed service delivery structures have both centralized and decentralized features. Programmatic costs were averaged over a 3 year period (2006-2007, 2008-2009, and 2009-2010). Effectiveness was defined in terms of the average number of women served over the 3 years. We report costs per woman served by program activity and delivery structure and incremental cost effectiveness by program structure and by breast/cervical services. RESULTS: Average costs per woman served were lowest for mixed program structures (breast = $225, cervical = $216) compared to decentralized (breast = cervical = $276) and centralized program structures (breast = $259, cervical = $251). Compared with decentralized programs, for each additional woman served, centralized programs saved costs of $281 (breast) and $284 (cervical). Compared with decentralized programs, for each additional woman served, mixed programs added an additional $109 cost for breast but saved $1,777 for cervical cancer. CONCLUSIONS: Mixed program structures were associated with the lowest screening and diagnostic costs per woman served and had generally favorable incremental costs relative to the other program structures.

Awardee-specific economic costs of providing cancer screening and health promotional services to medically underserved women eligible in the National Breast and Cervical Cancer Early Detection Program.

OBJECTIVES: To estimate awardee-specific costs of delivering breast and cervical cancer screening services in their jurisdiction and to assess potential variation in the cost of key activities across awardees. METHODS: We developed the cost assessment tool to collect resource use and cost data from the National Breast and Cervical Cancer Early Detection Program awardees for 3 years between 2006 and 2010 and generated activity-based cost estimates. We estimated awardee-specific cost per woman served for all activities, clinical screening delivery services, screening promotion interventions, and overarching program support activities. RESULTS: The total cost per woman served by the awardees varied greatly from $205 (10th percentile) to $499 (90th percentile). Differences in the average (median) cost per person served for clinical services, health promotion interventions, and overarching support activities ranged from $51 to $125. CONCLUSIONS: The cost per woman served varied across awardee and likely reflected underlying differences across awardees in terms of screening infrastructure, population served, and barriers to screening uptake. Collecting information on contextual factors at the awardee, health system, provider, and individual levels may assist in understanding this variation in cost.

Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program: Increasing Access to Screening.

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screening and diagnostic services to low-income, uninsured, and underinsured women across the nation. Although the program has provided services to more than 5 million women since 1991, there remains a significant burden of breast and cervical cancer with inequities among certain populations. To reduce this burden and improve health equity, the NBCCEDP is expanding its scope to include population-based strategies to increase screening in health systems and communities through the implementation of patient and provider evidence-based interventions, connecting women in communities to clinical services, increasing opportunities to access screening, and enhancing the targeting of women in need of services. The goal is to reach more women and make sure women are getting the right screening test at the right time.

Identifying optimal approaches to scale up colorectal cancer screening: an overview of the centers for disease control and prevention (CDC)'s learning laboratory.

Use of recommended screening tests can reduce new colorectal cancers (CRC) and deaths, but screening uptake is suboptimal in the United States (U.S.). The Centers for Disease Control and Prevention (CDC) funded a second round of the Colorectal Cancer Control Program (CRCCP) in 2015 to increase screening rates among individuals aged 50-75 years. The 30 state, university, and tribal awardees supported by the CRCCP implement a range of multicomponent interventions targeting health systems that have low CRC screening uptake, including low-income and minority populations. CDC invited a select subset of 16 CRCCP awardees to form a learning laboratory with the goal of performing targeted evaluations to identify optimal approaches to scale-up interventions to increase uptake of CRC screening among vulnerable populations. This commentary provides an overview of the CRCCP learning laboratory, presents findings from the implementation of multicomponent interventions at four FQHCs participating in the learning laboratory, and summarizes key lessons learned on intervention implementation approaches. Lessons learned can support future program implementation to ensure scalability and sustainability of the interventions as well as guide future implementation science and evaluation studies conducted by the CRCCP learning laboratory.

A conceptual framework and metrics for evaluating multicomponent interventions to increase colorectal cancer screening within an organized screening program.

BACKGROUND: Multicomponent, evidence-based interventions are viewed increasingly as essential for increasing the use of colorectal cancer (CRC) screening to meet national targets. Multicomponent interventions involve complex care pathways and interactions across multiple levels, including the individual, health system, and community. METHODS: The authors developed a framework and identified metrics and data elements to evaluate the implementation processes, effectiveness, and cost effectiveness of multicomponent interventions used in the Centers for Disease Control and Prevention's Colorectal Cancer Control Program. RESULTS: Process measures to evaluate the implementation of interventions to increase community and patient demand for CRC screening, increase patient access, and increase provider delivery of services are presented. In addition, performance measures are identified to assess implementation processes along the continuum of care for screening, diagnosis, and treatment. Series of intermediate and long-term outcome and cost measures also are presented to evaluate the impact of the interventions. CONCLUSIONS: Understanding the effectiveness of multicomponent, evidence-based interventions and identifying successful approaches that can be replicated in other settings are essential to increase screening and reduce CRC burden. The use of common framework, data elements, and evaluation methods will allow the performance of comparative assessments of the interventions implemented across CRCCP sites to identify best practices for increasing colorectal screening, particularly among underserved populations, to reduce disparities in CRC incidence and mortality.

The history and use of cancer registry data by public health cancer control programs in the United States.

Because cancer registry data provide a census of cancer cases, registry data can be used to: 1) define and monitor cancer incidence at the local, state, and national levels; 2) investigate patterns of cancer treatment; and 3) evaluate the effectiveness of public health efforts to prevent cancer cases and improve cancer survival. The purpose of this article is to provide a broad overview of the history of cancer surveillance programs in the United States, and illustrate the expanding ways in which cancer surveillance data are being made available and contributing to cancer control programs. The article describes the building of the cancer registry infrastructure and the successful coordination of efforts among the 2 federal agencies that support cancer registry programs, the Centers for Disease Control and Prevention and the National Cancer Institute, and the North American Association of Central Cancer Registries. The major US cancer control programs also are described, including the National Comprehensive Cancer Control Program, the National Breast and Cervical Cancer Early Detection Program, and the Colorectal Cancer Control Program. This overview illustrates how cancer registry data can inform public health actions to reduce disparities in cancer outcomes and may be instructional for a variety of cancer control professionals in the United States and in other countries. Cancer 2017;123:4969-76. Published 2017. This article is a U.S. Government work and is in the public domain in the USA.

CDC Grand Rounds: the future of cancer screening.

Cancer is the second leading cause of death in the United States, with 52% of deaths caused by cancers of the lung and bronchus, female breast, uterine cervix, colon and rectum, oral cavity and pharynx, prostate, and skin (melanoma). In the 1930s, uterine cancer, including cancer of the uterine cervix, was the leading cause of cancer deaths among women in the United States. With the advent of the Papanicolaou (Pap) test in the 1950s to detect cellular level changes in the cervix, cervical cancer death rates declined significantly. Since this first cancer screening test, others have been developed that detect the presence of cancer through imaging procedures (e.g., mammography, endoscopy, and computed tomography) and laboratory tests (e.g., fecal occult blood tests).

Preventing premature deaths from breast and cervical cancer among underserved women in the United States: insights gained from a national cancer screening program.

This commentary highlights some of the valuable insights gained from a special collection of papers that utilized data from the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and appear in this special issue. The data and experiences of the NBCCEDP can inform the identification of new opportunities and directions for meeting the cancer screening needs of underserved women in a complex and changing health care environment.

Implementation of the National Breast and Cervical Cancer Early Detection Program: the beginning.

In 1990, Congress passed the Breast and Cervical Cancer Mortality Prevention Act because of increases in the number of low-income and uninsured women being diagnosed with breast cancer. This act authorized the Centers for Disease Control and Prevention (CDC) to establish the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to provide high-quality and timely breast and cervical cancer screening and diagnostic services to low-income, uninsured women. The program started in 1991, and, in 1993, Congress amended the act to allow the CDC to fund American Indian and Alaska Native tribes and tribal organizations. By 1996, the program was providing cancer screening across the United States. To ensure appropriate delivery and monitoring of services, the program adopted detailed policies on program management, evidence-based guidelines for clinical services, a systematized clinical data system to track service quality, and key partnerships that expand the program's reach. The NBCCEDP currently funds 67 programs, including all 50 states, the District of Columbia, 5 US territories, and 11 tribes or tribal organizations.

The Influence of the VERB campaign on children's physical activity in 2002 to 2006.

OBJECTIVES: We evaluated physical activity outcomes for children exposed to VERB, a campaign to encourage physical activity in children, across campaign years 2002 to 2006. METHODS: We examined the associations between exposure to VERB and (1) physical activity sessions (free time and organized) and (2) psychosocial outcomes (outcome expectations, self-efficacy, and social influences) for 3 nationally representative cohorts of children. Outcomes among adolescents aged 13 to 17 years (cohort 1, baseline) and children aged 9 to 13 years from cohorts 2 and 3 were analyzed for dose-response effects. Propensity scoring was used to control for confounding influences. RESULTS: Awareness of VERB remained high across campaign years. In 2006, reports of children aged 10 to 13 years being active on the day before the survey increased significantly as exposure to the campaign increased. Psychosocial outcomes showed dose-response associations. Effects lessened as children aged out of the campaign target age range (cohort 1, baseline), but dose-response associations persisted in 2006 for outcome expectations and free-time physical activity. CONCLUSIONS: VERB positively influenced children's physical activity outcomes. Campaign effects persisted as children grew into their adolescent years.

It's what you do! Reflections on the VERB campaign.

This article shares the first-hand experiences of the CDC's VERB team in planning, executing, and evaluating a campaign that used social marketing principles, which involved paid media advertising, promotions, and national and community partnerships to increase physical activity among children aged 9-13 years (tweens). VERB staff gained valuable experience in applying commercial marketing techniques to a public health issue. This article describes how marketing, partnership, and evaluation activities were implemented to reach a tween audience. In doing so, fundamental differences in marketing between public health and the private sector were revealed.

The VERB campaign: applying a branding strategy in public health.

A branding strategy was an integral component of the VERB Youth Media Campaign. Branding has a long history in commercial marketing, and recently it has also been applied to public health campaigns. This article describes the process that the CDC undertook to develop a physical activity brand that would resonate with children aged 9-13 years (tweens), to launch an unknown brand nationally, to build the brand's equity, and to protect and maintain the brand's integrity. Considerations for branding other public health campaigns are also discussed.

The VERB campaign's strategy for reaching African-American, Hispanic, Asian, and American Indian children and parents.

The VERB campaign promoted physical activity to U.S. children aged 9-13 years (tweens) by surrounding them with appealing messages that were associated with the VERB brand and tag line It's what you do! To maximize the impact of the campaign, VERB had a two-level strategy for its marketing. One level was designed to reach a general audience of tweens (i.e., most tweens who use mainstream media). The second level was designed specifically to reach four racial or ethnic audiences: African Americans, Hispanics, Asian Americans, and American Indians as an augmentation to the first level. This article focuses on VERB's market segmentation strategy and reports how messages for the general audience were adapted to reach specific racial or ethnic segments of the U.S. population. Findings are reported from qualitative studies conducted with tweens and the parents of tweens from these ethnic groups, and the marketing strategies used to reach each ethnic group and the results of evaluations of those strategies are also described.

Evaluation of a national physical activity intervention for children: VERB campaign, 2002-2004.

BACKGROUND: Amid concern for the consequences of physical inactivity among children, the Centers for Disease Control and Prevention started a campaign using commercial marketing methods to promote physical activity to children. DESIGN: Longitudinal study using a telephone survey to assess physical activity behaviors and attitudes at baseline and for 2 years of follow-up. Relationships of campaign awareness to behavioral and psychosocial effects were analyzed with use of propensity scoring. PARTICIPANTS: Nationally representative cohort of 2257 parent-child dyads. INTERVENTION: Marketing campaign (VERB) directed to all U.S. children aged 9 to 13 years. Components included general market and ethnic-specific advertisements on television and radio, in print, and through promotions in communities, schools, and on the Internet. Advertising ran nationally at consistent levels from June 2002 through June 2004. MAIN OUTCOME MEASURES: Psychosocial measures and self-reports of free-time and organized physical activity during nonschool hours in the week before the interview and on the day before the interview. RESULTS: After 2 years, a dose-response effect was detected in the study population. The more children who reported seeing VERB messages, the more physical activity they reported and the more positive their attitudes were about the benefits of being physically active. Children aware of VERB reported engaging in significantly more physical activity than children unaware of VERB. These results were considerably stronger than the effects after Year 1, which were only for physical activity among subpopulations. CONCLUSIONS: The VERB campaign continued to positively influence children's attitudes about physical activity and their physical activity behaviors and expanded the effects to more children. With adequate and sustained investment, health marketing shows promise to affect the attitudes and behavior of children.

Effects of a mass media campaign to increase physical activity among children: year-1 results of the VERB campaign.

OBJECTIVE: To determine the effects of a mass media campaign on the levels of physical activity among children 9 to 13 years of age. DESIGN: A prospective, longitudinal, quasi-experimental design was used. A baseline survey was conducted in April to June 2002, before the launch of VERB advertising. Random-digit-dialing methods were used to survey a nationally representative sample of children and parents. The follow-up survey was repeated with the same cohort of children and parents in April to June 2003. Propensity scoring was used to determine the campaign's effects on awareness and physical activity behaviors. SETTING: United States. PARTICIPANTS: A total of 3120 parent-child dyads. Intervention. The VERB campaign is a multiethnic campaign that combines paid advertisements with school and community promotions and Internet activities to encourage children 9 to 13 years of age to be physically active every day. Launched in 2002 by the Centers for Disease Control and Prevention, VERB uses commercial marketing methods to advertise being physically active as cool, fun, and a chance to have a good time with friends. Using the VERB brand, paid advertising ran nationally from June 2002 through June 2003, targeting 9- to 13-year-old youths. MAIN OUTCOME MEASURES: Children's awareness of the campaign and self-reported estimates of free-time and organized physical activity sessions during nonschool hours in the week before the interview. RESULTS: After 1 year, 74% of children surveyed were aware of the VERB campaign. Levels of reported sessions of free-time physical activity increased for subgroups of children 9 to 13 years of age. A pattern of effects across 2 measures was observed for younger children (9-10 years of age), girls, children whose parents had less than a high school education, children from urban areas that were densely populated, and children who were low active at baseline. These subgroups engaged in more median weekly sessions of free-time physical activity than did children who were unaware of VERB and, as the children's level of VERB awareness was incrementally higher, the children engaged in incrementally more free-time physical activity sessions. The average 9- to 10-year-old youth engaged in 34% more free-time physical activity sessions per week than did 9- to 10-year-old youths who were unaware of the campaign. A pattern of effects for organized activity was found only for children classified as low active at baseline. CONCLUSIONS: The VERB campaign achieved high levels of awareness in 1 year. Higher levels of physical activity were reported for subgroups of US children. Promoting physical activity with child-focused commercial advertising shows promise.