Client provideroriented2012 findings


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Client provideroriented2012 findings

  1. 1. Updated Recommendations for Client- and Provider-Oriented Interventions to Increase Breast, Cervical, and Colorectal Cancer Screening Community Preventive Services Task Force Summary: The Community Preventive Services Task Force (Task Force) recommends increasing screening for breast cancer through use of group education, one-on-one education, client reminders, reducing client out-of-pocket costs, and provider assessment and feedback; increasing screening for cervical cancer through use of one-on-one education, client reminders, and provider assessment and feedback; and increasing screening for colorectal cancer through use of one-on-one education, client reminders, reducing structural barriers to screening, and provider assessment and feedback. The Task Force found insuffıcient evidence to determine the effectiveness of increasing screening for breast cancer through use of client incentives, mass media, or provider incentives; for cervical cancer screening through use of group education, client incentives, mass media, reducing client out-of­ pocket costs, reducing structural barriers, or provider incentives; and for colorectal cancer screening through use of group education, client incentives, mass media, reducing client out-of-pocket costs, or provider incentives. Details of these fındings, and some considerations for use, are provided in this article. (Am J Prev Med 2012;43(1):92–96) © 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive MedicineIntroduction access to screening services) and provider-oriented inter­ ventions. Seven client-oriented intervention reviewsI n 2008, the Community Preventive Services Task were updated: group education, one-on-one education, Force (Task Force) published recommendations for client incentives, client reminders, mass media, reducing ten interventions to increase screening for breast, out-of-pocket costs, and reducing structural barriers.cervical, and colorectal cancer.1 Interventions were in Two intervention reviews to increase provider delivery ofthree primary strategic objective areas2: increasing com­munity demand for cancer screening services, increasing cancer screening services were updated: provider assess­community access to screening services, and increasing ment and feedback, and provider incentives.screening service delivery by healthcare providers. The Overall, the new data changed fındings for three inter­Task Force recently updated its recommendations in this ventions: group education to increase breast cancercritical area, based on an expanded review of the litera­ screening is now recommended on the basis of suffıcientture (through October 2008) and systematic reviews of all evidence of effectiveness (previously, insuffıcient evi­evidence. dence to determine effectiveness had been found); one- These updated recommendations cover nine inter­ on-one education to increase colorectal cancer screeningventions to increase screening for breast, cervical, and is now recommended on the basis of suffıcient evidencecolorectal cancer. These fall into two strategic areas: client- of effectiveness (previously, insuffıcient evidence to de­oriented interventions (combining increasing commu­ termine effectiveness had been found); and client re­nity demand for screening and increasing community minders to increase colorectal cancer screening are now recommended on the basis of strong evidence of effec­ tiveness (previously, this intervention was recommendedNames and affıliations of the Task Force members can be found at on the basis of suffıcient evidence of effectiveness). Find­ Address correspondence to: Susan A. Sabatino, MD, MPH, Division ings, by intervention and cancer site, are presented below,of Cancer Prevention and Control, CDC, 4770 Buford Highway (K-55), and the evidence on which these fındings are based isAtlanta GA 30341. E-mail: 0749-3797/$36.00 provided in the accompanying article in this issue of the American Journal of Preventive Medicine.392 Am J Prev Med 2012;43(1):92–96 © 2012 Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
  2. 2. Community Preventive Services Task Force / Am J Prev Med 2012;43(1):92–96 93 An updated review for small media interventions is vical, and colorectal cancer screening services and to in­underway. An initial review of provider reminders re­ crease provider referral for and delivery of cancercently was published.4 The current updated recommen­ screening. Effectiveness of client-oriented interventionsdations represent the work of the independent, nonfed­ was studied separately for increasing breast cancereral Community Preventive Services Task Force (Task screening by mammography, cervical cancer screeningForce). The Task Force is developing the Guide to Com­ by Pap test, and colorectal cancer screening by fecal oc­munity Preventive Services (the Community Guide) with cult blood test (FOBT), flexible sigmoidoscopy, orthe support of DHHS in collaboration with public and colonoscopy; effectiveness of provider-oriented inter­private partners. The CDC provides staff support to the ventions was studied across all three cancer sites.Task Force for development of the Community Guide, butthe opinions and recommendations resulting from the Client-Oriented Interventionsreviews are those of the Task Force. General methods forconducting Community Guide evidence reviews, and spe­ Group education. Group education conveys informa­cifıc methods for conducting cancer screening reviews, tion on indications for, benefıts of, and ways to overcomehave been published elsewhere.5,6 barriers to screening with the goal of informing, encour­ The selected community and healthcare system inter­ aging, and motivating participants to seek recommendedventions on which this report is based were developed, in screening. Group education usually is conducted bypart, to help meet goals of lowering cancer mortality set health professionals or by trained lay people who useby Healthy People 2020 ( presentations or other teaching aids in a lecture or inter­topicsobjectives2020/overview.aspx?topicid=5). The active format, and often incorporate role-modeling orcancer objectives for Healthy People 2020 reflect the im­ other methods. Group education can be given to a varietyportance of increasing screening for breast, cervical, and of groups, in various settings, and by various types ofcolorectal cancer by measuring use of effective screening educators with various backgrounds and styles.tests identifıed in the U.S. Preventive Services Task Force The Task Force recommends group education (www.(USPSTF) recommendations (see below). RRgroupeducation_a.html) on the basis of suffıcient evi­ dence that these interventions are effective in increasingInformation from Other Advisory Groups screening for breast cancer. There was insuffıcient evi­The U.S. Preventive Services Task Force issues recom­ dence, however, to determine the effectiveness of groupmendations for screening of breast, cervical, and colorec­ education in increasing screening for cervical cancer andtal cancer. USPSTF recommendations for breast cancer colorectal cancer, based on small numbers of studies withscreening were updated in December 2009 (www. methodologic limitations and inconsistent fı One-on-one education. One-on-one education con­USPSTF recommendations for cervical cancer screening were veys information by telephone or in person on indica­updated in March 2012 (www.uspreventiveservicestaskforce. tions for, benefıts of, and ways to overcome barriers toorg/uspstf/uspscerv.htm). The USPSTF made its most recent screening with the goal of informing, encouraging, andrecommendations on colorectal cancer screening (www. motivating people to seek recommended These messages are delivered by healthcare workers orin 2008. other health professionals, lay health advisors, or volun­ teers and are conducted by telephone or in person inIntervention Recommendations medical, community, worksite, or household settings. In­A Community Preventive Services Task Force recom­ terventions can be untailored to address the overall targetmendation is based primarily on effectiveness of the in­ population or tailored, based on individual assessmentstervention as determined by the systematic literature re­ to address the recipient’s individual characteristics, be­view process. In making a recommendation, however, the liefs, or perceived barriers to screening. As defıned by thisTask Force balances information on effectiveness with review, one-on-one education may be accompanied by ainformation on other potential benefıts or harms of the small media or client reminder component.intervention. The Task Force also considers the applica­ The Task Force recommends the use of one-on-onebility of effective interventions to various settings and education ( in determining the scope of the intervention. client-oriented/RROneonOneEducation_a.html) Here, the Task Force presents the recommendations to increase screening for breast and cervical cancers onfrom updated reviews on interventions designed to in­ the basis of strong evidence of effectiveness. The Taskcrease community demand for and access to breast, cer­ Force also recommends the use of one-on-one educationJuly 2012
  3. 3. 94 Community Preventive Services Task Force / Am J Prev Med 2012;43(1):92–96to increase colorectal cancer screening with FOBT based evaluated the effectiveness of mass media used alone, oron suffıcient evidence of effectiveness. Evidence is insuf­ its individual contribution to the effectiveness of multi-fıcient, however, to determine the effectiveness of one- component interventions.on-one education in increasing colorectal cancer screen­ The Task Force fınds insuffıcient evidence to deter­ing with other tests, because only two studies assessed mine the effectiveness of mass media interventionscolonoscopy, with inconsistent results, and one study for (­flexible sigmoidoscopy found no effect. oriented/RRmassmedia_a.html) in increasing screeningClient incentives. Client incentives are small, noncoer­ for breast, cervical, or colorectal cancers. Although ad­cive rewards (e.g., cash or coupons) to motivate people to ditional studies were found during the updated re­seek cancer screening for themselves or to encourage view,3 there continue to be too few studies to determineothers (e.g., family members, close friends) to seek effectiveness for breast, cervical, or colorectal cancerscreening. Incentives are distinct from interventions de­ screening.signed to improve access to services (e.g., transportation, Reducing out-of-pocket costs. These interventions at­child care, reducing client out-of-pocket costs). The Task tempt to minimize or remove economic barriers thatForce fınds insuffıcient evidence to determine the effec­ impede client access to cancer screening services. Coststiveness of using client incentives (www.thecommunity can be reduced through a variety of approaches, includ­ ing vouchers, reimbursements, reduction in copays, orhtml) to increase screening for breast, cervical, or colo­ adjustments in federal or state insurance coverage. Ef­rectal cancers because only one study for breast cancer forts to reduce client costs may be combined with mea­and no studies for cervical and colorectal cancers were sures to provide client education, information about pro­identifıed. gram availability, or measures to reduce structuralClient reminders. Client reminders are textual (letter, barriers.postcard, e-mail) or telephone messages advising people The Task Force recommends reducing client out-that they are due (reminder) or overdue (recall) for of-pocket costs ( Client reminders may be enhanced by one or screening/client-oriented/RRoutofpocket_a.html) tomore of the following: follow-up printed or telephone increase screening for breast cancer on the basis of suffı­reminders; additional text or discussion with information cient evidence of effectiveness. There is insuffıcient evi­about indications for, benefıts of, and ways to overcome dence to determine the effectiveness of reducing out-of­barriers to screening; and/or assistance in scheduling ap­ pocket costs in increasing screening for cervical orpointments. Interventions can be untailored to address colorectal cancer because too few (cervical cancer) or nothe overall target population or tailored with the intent to (colorectal cancer) studies were identifıed. Nonetheless,reach one specifıc person, based on characteristics unique the consistent, favorable results for interventions thatto that person, related to the outcome of interest, and reduce costs for breast cancer screening and several otherderived from an individual assessment. preventive services suggest that such interventions are The Task Force recommends the use of client remin­ likely to be effective for increasing cervical and colorectalders ( cancer screening as well.client-oriented/RRreminders_a.html) to increase screen­ Reducing structural barriers. Structural barriers areing for breast and cervical cancers on the basis of strong non-economic burdens or obstacles that impede access toevidence of effectiveness. The Task Force also recom­ screening. Interventions designed to reduce these barri­mends the use of client reminders to increase colorectal ers may facilitate access by reducing time or distancecancer screening with FOBT based on strong evidence of between service delivery settings and target populations;effectiveness. Evidence is insuffıcient, however, to deter­ modifying hours of service to meet client needs; offeringmine effectiveness of client reminders in increasing colo­ services in alternative or nonclinical settings (e.g., mobilerectal cancer screening with other tests (colonoscopy, mammography vans at worksites or in residential com­flexible sigmoidoscopy) because of inconsistent evidence. munities); and eliminating or simplifying administrativeMass media. Mass media—including TV, radio, news­ procedures and other obstacles (e.g., scheduling assis­papers, magazines, and billboards—are used to commu­ tance or patient navigators, transportation, dependentnicate educational and motivational information in com­ care, translation services, limiting the number of clinicmunity or larger-scale intervention campaigns. Mass visits). Such interventions often include one or moremedia interventions, however, almost always include secondary supporting measures, such as printed or tele­other components or attempt to capitalize on existing phone reminders; education about cancer screening; in­interventions and infrastructure. The updated review3 formation about cancer screening availability (e.g., group
  4. 4. Community Preventive Services Task Force / Am J Prev Med 2012;43(1):92–96 95education, pamphlets, or brochures); or measures to re­ suffıcient because of a small magnitude of effect acrossduce client out-of-pocket costs. Interventions principally studies and because data from healthcare systems thatdesigned to reduce client costs are considered to be a include provider incentives as part of their strategies forseparate class of approaches. administration and provider compensation have not The Task Force recommends reducing structural bar­ been published.riers to increase screening ( Using the Recommendations andbarriers_a.html) for breast and colorectal cancers (by Findingsmammography and FOBT, respectively) on the basis of These recommendations are intended to highlight effec­strong evidence of effectiveness. Evidence is insuffıcient, tive interventions, which should be considered over alter­however, to determine whether reducing structural bar­ natives without documented effectiveness when decidingriers is effective in increasing colorectal cancer screening among possible approaches to increasing cancer screen­by flexible sigmoidoscopy or colonoscopy because only ing. These recommendations are neither intended norone study using these screening procedures was identi­ expected to be applicable in all situations. Decision mak­fıed. Evidence is also insuffıcient to determine the effec­ ers and implementers should bear in mind that an under­tiveness of the intervention in increasing screening for standing of local context—including known barriers tocervical cancer because only three relevant studies were screening in the target population(s), available resources,identifıed, and these had methodologic limitations. and what can be implemented effectively—is essential to the process of identifying appropriate strategies and se­Increasing Provider Delivery lecting feasible intervention approaches for a specifıc set­Provider assessment and feedback. Provider assess­ ting or population.ment and feedback interventions both evaluate provider The systematic collection of qualitative and quantita­performance in offering and/or delivering screening to tive data can be an extremely helpful tool for developing aclients (assessment) and present providers with informa­ more thorough understanding of the local context. Oncetion about their performance in providing screening ser­ that context is understood clearly, the recommendationsvices (feedback). Feedback may describe the performance presented here and the evidence on applicability in theof a group of providers (e.g., mean performance for a accompanying evidence review3 can be used to help selectpractice) or individual providers, and may be compared appropriate interventions. Some key considerations inwith a goal or standard. using recommended interventions are noted below. The Task Force recommends provider assessment andfeedback interventions ( Choosing Interventions to Meetcancer/screening/provider-oriented/RRpaf_a.html) on Community Needsthe basis of suffıcient evidence of effectiveness in increas­ It is important to consider the characteristics of the targeting screening for breast cancer (mammography); cervical population carefully when considering implementingcancer (Pap); and colorectal cancer (FOBT). Evidence any intervention, and this need is particularly strong forremains insuffıcient, however, to determine effectiveness interventions intended to educate and increase awarenessof this intervention in increasing colorectal cancer about cancer screening (e.g., one-on-one education,screening using methods other than FOBT. group education, mass media). For example, when base­Provider incentives. Provider incentives are direct or line screening rates are high, group education or massindirect rewards intended to motivate providers to per­ media campaigns directed at the general population mayform cancer screening or make appropriate referral for not be the most appropriate intervention. Such interven­their patients to receive these services. Rewards are often tions may be most appropriate when directed at popula­monetary, but can include nonmonetary incentives also tions or subpopulations with relatively low screening(e.g., continuing medical education credit). Because some rates, and when their messages are directed at the mostform of assessment is needed to determine whether pro­ relevant issues for the specifıc group or individualviders receive rewards, an assessment component may be addressed.included in the intervention. Considering the specifıc characteristics of the target The Task Force fınds insuffıcient evidence to deter­ population is also important for implementing appropri­mine the effectiveness of provider incentives (www. ate interventions to increase cancer screening by reduc­­ ing structural barriers. Many options for reducing struc­oriented/RRincentives_a.html) in increasing screening tural barriers are available, and questions remain aboutfor breast, cervical, or colorectal cancers. Evidence is in­ whether some of these approaches are more or less effec-July 2012
  5. 5. 96 Community Preventive Services Task Force / Am J Prev Med 2012;43(1):92–96tive or appropriate for use within specifıc settings or with However, studies of the effects of such strategies were notspecifıc populations—such as with people who have available for evaluation and thus could not contribute tonever been screened or who may be hard to reach for Task Force fındings on their effectiveness.screening. In the absence of such research, specifıc inter­vention approaches should be selected and implemented Additional Information and Assistanceonly after careful consideration of the most importantbarriers to screening for the target population. Additional information and assistance in selecting and implementing appropriate interventions to increase can­Implementing Multiple Interventions cer screening are available through online tools, such as those available at Cancer Control P.L.A.N.E.T. (cancer­In many situations, it may be appropriate to implement two Its links provide helpfulor more interventions, because a single intervention might sources of information for determining cancer controlnot address adequately multiple barriers that contribute to program priorities, identifying potential partners, ex­low screening rates within a community or that prevent ploring various intervention approaches, fınding re­people from adhering to screening recommendations. search-tested intervention programs and products, and The updated reviews found some evidence that imple­ planning and evaluating the intervention program. Al­menting an intervention such as one-on-one education as though such tools can be invaluable resources, it is alsopart of a multicomponent intervention that includes helpful to draw on direct technical assistance and adviceother approaches to increasing cancer screening can pro­ from people with experience in implementing the inter­vide incremental benefıts. Decisions about when to use ventions of interest.such a multicomponent approach, and which specifıccombinations of interventions to implement, should bebased not only on the characteristics of the target popu­ No fınancial disclosures were reported by the authors of thislation and the most important barriers to screening but paper.also on whether adequate resources and infrastructureexist to deliver all components with fıdelity. ReferencesConsidering the Healthcare System Context 1. Task Force on Community Preventive Services. Recommendations forRecent changes in healthcare systems are making it in­ client- and provider-directed interventions to increase breast, cervical,creasingly necessary to consider single-component inter­ and colorectal cancer screening. Am J Prev Med 2008;35(1S):21–5. 2. Breslow RA, Rimer BK, Baron RC, et al. Introducing the Communityventions, such as provider assessment and feedback, Guide’s reviews of evidence on interventions to increase screening forwithin a broader context of how care is delivered in a breast, cervical, and colorectal cancers. Am J Prev Med 2008;35(1S):given healthcare system. Some changes, such as increased 14 –20.integration of computerized medical records into prac­ 3. Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine up­tice, may make it easier to implement and sustain such dated systematic reviews for the Guide to Community Preventive Ser­interventions. Further, it is appropriate to consider the vices. Am J Prev Med 2012;43(1):765–786.role that provider assessment and feedback can play to 4. Baron RC, Melillo S, Rimer BK, et al. Intervention to increase recom­improve the delivery of recommended cancer screenings mendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: a systematic review of provider remind­in relationship to other elements of the specifıc healthcare ers. Am J Prev Med 2010;38(1):110 –7.system, such as provider compensation policies. 5. Briss PA, Zaza S, Pappaioanou M, et al. Developing an evidence-based Although the Task Force found insuffıcient evidence to Guide to Community Preventive Services—methods. The Task Force ondetermine the effectiveness of provider incentives in in­ Community Preventive Services. Am J Prev Med 2000;18(1S):35– 43. 6. Baron RC, Rimer BK, Coates RJ, et al. Methods for conducting system­creasing cancer screening, many healthcare systems in­ atic reviews of evidence on effectiveness and economic effıciency ofclude provider incentives as part of a comprehensive interventions to increase screening for breast, cervical, and colorectalstrategy for administration and provider compensation. cancers. Am J Prev Med 2008;35(1S):26 –33.