This document summarizes the results of a study that assessed whether increased cancer screening rates observed after implementing a clinic intervention called Cancer Screening Office Systems (Cancer SOS) were maintained after 24 months when clinics were expected to sustain the intervention without external support. The study found that at 24 months of follow-up, patients who received the intervention had received more cancer screening tests on average compared to the control group. Specifically, the intervention slightly increased rates of mammography screening but did not significantly impact rates of fecal occult blood tests or Pap smears compared to the control group. The effects on screening rates were more modest at 24 months compared to results seen at 12 months, indicating the effects of the intervention had diminished over time.
Optimising the Model of Care for Patient Management at The Tweed Cancer Care ...Cancer Institute NSW
The commonly understood model of shift to shift nursing handover does not apply to most ambulatory day treatment units. Nonetheless, ‘handover’ of patient clinical information remains quintessential to safe clinical practice. Of considerable interest is how EMR may aid the transfer of patient clinical information in these circumstances and address the question: does this facilitate improved patient care?
Rapid review of current service provision following cancer treatmentNHS Improvement
NHS Improvement carried out a rapid review of current provision of services for breast, prostate and colorectal cancer patients following treatment during the summer of 2009 at the request of the National Cancer Survivorship Initiative (NCSI). This publication shares the findings from this review.
(Published September 2010)
Optimising the Model of Care for Patient Management at The Tweed Cancer Care ...Cancer Institute NSW
The commonly understood model of shift to shift nursing handover does not apply to most ambulatory day treatment units. Nonetheless, ‘handover’ of patient clinical information remains quintessential to safe clinical practice. Of considerable interest is how EMR may aid the transfer of patient clinical information in these circumstances and address the question: does this facilitate improved patient care?
Rapid review of current service provision following cancer treatmentNHS Improvement
NHS Improvement carried out a rapid review of current provision of services for breast, prostate and colorectal cancer patients following treatment during the summer of 2009 at the request of the National Cancer Survivorship Initiative (NCSI). This publication shares the findings from this review.
(Published September 2010)
Anti-cancer therapy is big business. In Australia alone between 2000 and 2009, cancer-related pharmaceutical expenditure has risen over 200% to over half a billion dollars per annum.
MEDICAL AUDIT
Evaluation of data, documents, and resources to check performance of systems meets specified standards
PRESCRIPTION MONITORING, ADR, DRUG RELATED PROBLEMS, staff safety, data,defining standards,
collecting data,
identifying areas for improvement,
making necessary changes
back round to defining new standards.
The Lung Cancer Demonstration Project: Implementation and evaluation of a lun...Cancer Institute NSW
The Royal Prince Alfred Hospital lung MDT was established in 1984. Historically, information about MDT decision making was captured as free text in the electronic medical record, including patient investigation and staging. This information was accessible to clinical staff; however, it was not routinely distributed to GPs involved in the patient's care. We identified a potential gap in the current reporting and communication processes.
Objective: To evaluate the utility of a targeted lecture in improving FP awareness amongst clinicians.
Design: This is a dual institution, prospective survey-based study assessing if an educational lecture can increase the likelihood of FP consideration, discussion, and referral.
Comparative efficacy of interventions to promote hand hygiene
in hospital: systematic review and network meta-analysis
Nantasit Luangasanatip,1, 2 Maliwan Hongsuwan,1 Direk Limmathurotsakul,1, 3 Yoel Lubell,1, 4
Andie S Lee,5, 6 Stephan Harbarth,5 Nicholas P J Day,1, 4 Nicholas Graves,2, 7 Ben S Cooper1, 4
Human Papillomavirus Immunization completion rates increased by the use of th...inventionjournals
Human Papillomavirus is the most common sexually transmitted infection in the United States and world wide. Vaccination is a critical public health measure for lowering the risk of cervical genital and anal cancers. Overall vaccination rates in the United States are low. This study highlights the need to change practices in primary care clinics to increase Human Papillomavirus vaccination rates. The study compares vaccination rates before and after the introduction of the American Academy of Pediatrics Tool Kit and a staff training session.
Four strategies to upgrade clinical trial quality in this computerized world ...Pubrica
• Biostatistics Services is important for collecting, reviewing, presenting, and interpreting data in clinical research.
• Applications of clinical biostatistics services are in different areas, such as epidemiology, clinical trials, population genetics, the biology of structures, and more.
Reference : https://pubrica.com/services/research-services/biostatistics-and-statistical-programming-services/
Continue Reading: http://bit.ly/36nwtcs
Why Pubrica?
When you order our services, Plagiarism free|onTime|outstanding customer support|Unlimited Revisions support|High-quality Subject Matter Experts.
Contact us :
Web: https://pubrica.com/
Blog: https://pubrica.com/academy/
Email: sales@pubrica.com
WhatsApp : +91 9884350006
United Kingdom: +44- 74248 10299
Expediting Colonoscopy for Patients with + Faecal Occult Blood Test in a Publ...Cancer Institute NSW
Colon cancer is the commonest cancer in Australia. The Federal Gov. has recently accelerated the rollout of the National Bowel Cancer Screening Program to 2nd yearly after age 50 by 2018. We anticipate up to 1000 extra colonoscopies on the public system at NSLHD.
An integrated model of psychosocial cancer care: a work in progress…Cancer Institute NSW
Cancer patients are faced with a multitude of stressors, from diagnosis, through treatment, at recurrence, in the stages following treatment completion, and in the terminal phase. Psychosocial care has been highlighted as a critical aspect of providing comprehensive patient-focused care. Specifically, one of the goals of The NSW Cancer Plan 2011-2015 is to improve the quality of life of people with cancer and their carers. This project was initiated to improve the current psychosocial model of care at The Kinghorn Cancer Centre (TKCC), to better reflect an integrated, holistic and comprehensive model of patient-centred care.
Decision makers in the healthcare field like doctors, patients and policy makers need access to clinical evidence to address issues that have bearing on the health of the population and the treatment prescribed and thereby on the financials implications of the healthcare industry.
Predictors of MDT review and the impact on lung cancer survival for HNELHD re...Cancer Institute NSW
Review by a Multidisciplinary Team (MDT) has been shown to lead to increased rates of surgical resection, radiotherapy, chemotherapy and timeliness of care. Most recently, the Victorian lung cancer patterns of care study have found that MDT review is an independent predictor of lung cancer survival.
Anti-cancer therapy is big business. In Australia alone between 2000 and 2009, cancer-related pharmaceutical expenditure has risen over 200% to over half a billion dollars per annum.
MEDICAL AUDIT
Evaluation of data, documents, and resources to check performance of systems meets specified standards
PRESCRIPTION MONITORING, ADR, DRUG RELATED PROBLEMS, staff safety, data,defining standards,
collecting data,
identifying areas for improvement,
making necessary changes
back round to defining new standards.
The Lung Cancer Demonstration Project: Implementation and evaluation of a lun...Cancer Institute NSW
The Royal Prince Alfred Hospital lung MDT was established in 1984. Historically, information about MDT decision making was captured as free text in the electronic medical record, including patient investigation and staging. This information was accessible to clinical staff; however, it was not routinely distributed to GPs involved in the patient's care. We identified a potential gap in the current reporting and communication processes.
Objective: To evaluate the utility of a targeted lecture in improving FP awareness amongst clinicians.
Design: This is a dual institution, prospective survey-based study assessing if an educational lecture can increase the likelihood of FP consideration, discussion, and referral.
Comparative efficacy of interventions to promote hand hygiene
in hospital: systematic review and network meta-analysis
Nantasit Luangasanatip,1, 2 Maliwan Hongsuwan,1 Direk Limmathurotsakul,1, 3 Yoel Lubell,1, 4
Andie S Lee,5, 6 Stephan Harbarth,5 Nicholas P J Day,1, 4 Nicholas Graves,2, 7 Ben S Cooper1, 4
Human Papillomavirus Immunization completion rates increased by the use of th...inventionjournals
Human Papillomavirus is the most common sexually transmitted infection in the United States and world wide. Vaccination is a critical public health measure for lowering the risk of cervical genital and anal cancers. Overall vaccination rates in the United States are low. This study highlights the need to change practices in primary care clinics to increase Human Papillomavirus vaccination rates. The study compares vaccination rates before and after the introduction of the American Academy of Pediatrics Tool Kit and a staff training session.
Four strategies to upgrade clinical trial quality in this computerized world ...Pubrica
• Biostatistics Services is important for collecting, reviewing, presenting, and interpreting data in clinical research.
• Applications of clinical biostatistics services are in different areas, such as epidemiology, clinical trials, population genetics, the biology of structures, and more.
Reference : https://pubrica.com/services/research-services/biostatistics-and-statistical-programming-services/
Continue Reading: http://bit.ly/36nwtcs
Why Pubrica?
When you order our services, Plagiarism free|onTime|outstanding customer support|Unlimited Revisions support|High-quality Subject Matter Experts.
Contact us :
Web: https://pubrica.com/
Blog: https://pubrica.com/academy/
Email: sales@pubrica.com
WhatsApp : +91 9884350006
United Kingdom: +44- 74248 10299
Expediting Colonoscopy for Patients with + Faecal Occult Blood Test in a Publ...Cancer Institute NSW
Colon cancer is the commonest cancer in Australia. The Federal Gov. has recently accelerated the rollout of the National Bowel Cancer Screening Program to 2nd yearly after age 50 by 2018. We anticipate up to 1000 extra colonoscopies on the public system at NSLHD.
An integrated model of psychosocial cancer care: a work in progress…Cancer Institute NSW
Cancer patients are faced with a multitude of stressors, from diagnosis, through treatment, at recurrence, in the stages following treatment completion, and in the terminal phase. Psychosocial care has been highlighted as a critical aspect of providing comprehensive patient-focused care. Specifically, one of the goals of The NSW Cancer Plan 2011-2015 is to improve the quality of life of people with cancer and their carers. This project was initiated to improve the current psychosocial model of care at The Kinghorn Cancer Centre (TKCC), to better reflect an integrated, holistic and comprehensive model of patient-centred care.
Decision makers in the healthcare field like doctors, patients and policy makers need access to clinical evidence to address issues that have bearing on the health of the population and the treatment prescribed and thereby on the financials implications of the healthcare industry.
Predictors of MDT review and the impact on lung cancer survival for HNELHD re...Cancer Institute NSW
Review by a Multidisciplinary Team (MDT) has been shown to lead to increased rates of surgical resection, radiotherapy, chemotherapy and timeliness of care. Most recently, the Victorian lung cancer patterns of care study have found that MDT review is an independent predictor of lung cancer survival.
6 Reasons Why Building a Personal Brand Can Land You Your Dream JobKayla Joy Mele
Companies these days want to know if you can go 'digital'. Resume's can show what you have done in words, why not share a hands-on experience? In 16 slides I share with you why you should have a personal brand and portfolio site and how to get started.
A Dartmouth Microsystem Assessment was conducted to examine a hospital unit\\’s functionality and to highlight opportunities for improvement. To enhance the gathering of data, a statistical tool was created to measure a wider sample population. The CNL student implemented a more reliable and valid data gathering system. The nurse educator asked to use the graduate student’s tool on the unit and throughout the hospital.
Traditionally, physicians recruited clinical trial subjects, but pharmaceutical companies have become ever more involved through centralized campaigns. Physicians are vital to a trial and the pharmaceutical effort helps shift some of the recruitment demands away from the site to allow them to focus on the subjects. Thus, it is practical to understand if different recruitment methods could change or skew the study population. This study determines if differences or similarities occurred between subjects recruited by physicians and pharmaceutical companies. It discovered that some of both occurred. The pharmaceutical company efforts helped recruit potential subjects from the general population that were similar to subjects recruited by the physicians, but this particular campaign was limited by language which affected recruitment of Hispanic subjects. The social impact of this study provides insight about pharmaceutical company recruitment. Since the National Library of Medicine has indicated that clinical trials should reflect the broader diseased population, the efforts of the pharmaceutical company can help support the physicians’ efforts by recruiting from the broader population. Together, both efforts can create a global good by allowing the trial to reflect the population of post-approval use. These findings still raise a question about the proper balance between the two recruitment groups so that the intended characteristics of the diseased population are maintained. Because differences between physician and pharmaceutical recruited subjects can exist, the potential of one group to bias the trial results exist. As such, some analysis by recruitment method can help ensure that variations in the study population are minimal without skewing the data to create positive study results.
Incorporating the Patient Voice to Improve Ulcerative Colitis Recruitment Cas...Covance
Dr. Joan Meyer, Covance Executive Director of Strategy & Planning for iiGM, recently discussed her team's efforts to understand patients' opinions about inflammatory bowel disease trials and develop patient-centered clinical strategies to improve study recruitment.
Evidence TableEvidence TablePICOT Question
[Insert here]APA Source Reference
(Include the DOI or URL. Use the source URL, not the library link.) Indicate: Peer Reviewed,
Clinical Guideline, or
Best Practice GuidelineAim, Hypothesis,
or Research QuestionConceptual or
Theoretical FrameworkResearch Design/MethodologyMeasurement
MethodSample Population
or SettingResearch Variables Data AnalysisFindingsGaps in ResearchSignificant Findings from a Critical Appraisal of the Evidence
(level, quality of the evidence)Good QuotesAdditional NotesEnd of Worksheet
Role of Clinical Trial Participation in Cancer Research: Barriers,
Evidence, and Strategies
Joseph M. Unger, Ph.D.1, Elise Cook, M.D.2, Eric Tai, M.D.3, and Archie Bleyer, M.D.4
1Fred Hutchinson Cancer Research Center, Seattle, Washington
2The University of Texas MD Anderson Cancer Center, Houston, Texas
3Centers for Disease Control and Prevention, Atlanta, Georgia
4St Charles Health System, Quality Department, Bend, Oregon
OVERVIEW
Fewer than 1 in 20 adult cancer patients enroll in cancer clinical trials. But although barriers to
trial participation have been the subject of frequent study, the rate of trial participation has not
changed substantially over time. Barriers to trial participation are structural, clinical, and
attitudinal, and differ according to demographic and socioeconomic factors. In this paper, we
characterize the nature of cancer clinical trial barriers, and we consider global and local strategies
for reducing barriers. We also consider the specific case of adolescents with cancer, and show that
the low rate of trial enrollment in this age group strongly correlates with limited improvements in
cancer population outcomes compared to other age groups. Our analysis suggests that a clinical
trial system that enrolls patients at higher rates produces treatment advances at a faster rate and
corresponding improvements in cancer population outcomes. Viewed in this light, the issue of
clinical trial enrollment is foundational, lying at the heart of the cancer clinical trial endeavor.
Fewer barriers to trial participation would allow trials to be completed more quickly and would
improve the generalizability of trial results. Moreover, increased accrual to trials is important to
patients, since trials provide patients the opportunity to receive the newest treatments. In an era of
increasing emphasis on a treatment decision-making process that incorporates the patient
perspective, the opportunity for patients to choose trial participation for their care is vital.
INTRODUCTION
The path from initial development of a new cancer drug to diffusion of the new therapy into
the cancer treatment community relies, crucially, on clinical trials, which represent the final
step in evaluating the efficacy of new therapeutic approaches for malignancy. It has been
repeatedly estimated that <5% of adult cancer patients enroll in cancer clinical trials.1,2
...
Cropped Paperbag Encompassing both comfort and style,.docxmydrynan
Cropped Paperbag: Encompassing both comfort and style, the paperbag is the perfect statement trouser without losing commercial viability. Cropped lengths are key. Also great with business causal.
o r i g i n a l a r t i c l e
Preventing Central Line–Associated Bloodstream Infections: A
Qualitative Study of Management Practices
Ann Scheck McAlearney, ScD, MS;1,2 Jennifer L. Hefner, PhD, MPH;1 Julie Robbins, PhD, MHA;1 Michael I. Harrison, PhD;3
Andrew Garman, PsyD, MS4,5
objective. To identify factors that may explain hospital-level differences in outcomes of programs to prevent central line–associated
bloodstream infections.
design. Extensive qualitative case study comparing higher- and lower-performing hospitals on the basis of reduction in the rate of central
line–associated bloodstream infections. In-depth interviews were transcribed verbatim and analyzed to determine whether emergent themes
differentiated higher- from lower-performing hospitals.
setting. Eight US hospitals that had participated in the federally funded On the CUSP—Stop BSI initiative.
participants. One hundred ninety-four interviewees including administrative leaders, clinical leaders, professional staff, and frontline
physicians and nurses.
results. A main theme that differentiated higher- from lower-performing hospitals was a distinctive framing of the goal of “getting
to zero” infections. Although all sites reported this goal, at the higher-performing sites the goal was explicitly stated, widely embraced, and
aggressively pursued; in contrast, at the lower-performing hospitals the goal was more of an aspiration and not embraced as part of the strategy
to prevent infections. Five additional management practices were nearly exclusively present in the higher-performing hospitals: (1) top-level
commitment, (2) physician-nurse alignment, (3) systematic education, (4) meaningful use of data, and (5) rewards and recognition.
We present these strategies for prevention of healthcare-associated infection as a management “bundle” with corresponding suggestions for
implementation.
conclusions. Some of the variance associated with CLABSI prevention program outcomes may relate to specific management practices.
Adding a management practice bundle may provide critical guidance to physicians, clinical managers, and hospital leaders as they work to
prevent healthcare-associated infections.
Infect Control Hosp Epidemiol 2015;36(5):557–563
Central line–associated bloodstream infections (CLABSIs)
increase risk of prolonged hospitalization, morbidity, and
death, and result in substantial financial and nonfinancial
costs to health systems and society.1–3 CLABSI rates can be
significantly reduced by implementing a “bundle” of 5 clinical
practices: full-barrier precautions, chlorhexidine antiseptic
and sterile dressing, optimal vein selection, improved hand
hygiene, and prompt removal of unnecessary central line
catheters.2,4,5 This bundle, combined with dedicated line
insertio.
Recruitment Metrics from TogetherRA: A Study in Rheumatoid Arthritis Patients...John Reites
DIA poster presentation on May, 30, 2013 for a direct-to-patient RA patient study that collected ePRO, medical chart data and a biologic lab sample from 23andMe with integration for final analysis.
Measuring to Improve Medication Reconciliationin a Large Sub.docxalfredacavx97
Measuring to Improve Medication Reconciliation
in a Large Subspecialty Outpatient Practice
Elizabeth Kern, MD, MS; Meg B. Dingae, MHSA; Esther L. Langmack, MD; Candace Juarez, MT; Gary Cott, MD;
Sarah K. Meadows, MS
Background: To assess performance in medication reconciliation (med rec)—the process of comparing and reconciling
patients’ medication lists at clinical transition points—and demonstrate improvement in an outpatient setting, sustainable
and valid measures are needed.
Methods: An interdisciplinary team at National Jewish Health (Denver) attempted to improve med rec in an ambulatory
practice serving patients with respiratory and related diseases. Interventions, which were aimed at physicians, nurses (RNs),
and medical assistants, involved changes in practice and changes in documentation in the electronic health record (EHR).
New measures designed to assess med rec performance, and to validate the measures, were derived from EHR data.
Results: Across 18 months, electronic attestation that med rec was completed at clinic visits increased from 9.8% to 91.3%
(p < 0.0001). Consistent with this improvement, patients with medication lists missing dose/frequency for at least one prescription-
type medication decreased from 18.1% to 15.8% (p < 0.0001). Patients with duplicate albuterol inhalers on their list decreased
from 4.0% to 2.6% (p < 0.0001). Percentages of patients increased for printing of the medication list at the visit (18.7% to
94.0%; p < 0.0001) and receipt of the printed medication list at the visit (52.3% to 67.0%; p = 0.0074). Documentation
that patient education handouts were offered increased initially then declined to an overall poor performance of 32.4% of
clinic visits. Investigation of this result revealed poor buy-in and a highly redundant process.
Conclusion: Deriving measures reflecting performance and quality of med rec from EHR data is feasible and sustainable
over the time periods necessary to demonstrate change. Concurrent, complementary measures may be used to support the
validity of summary measures.
Medication reconciliation (med rec) is the process of sys-tematically and comprehensively reviewing the
medications a patient is taking, to ensure that medications
added, changed, or discontinued are evaluated for poten-
tial safety concerns. One of the three current Joint
Commission National Patient Safety Goals (NPSGs) on med-
ication safety (Goal 3), concerns medication reconciliation,
which ambulatory care organizations have been expected to
perform since 2005. The current version of the goal
(NPSG.03.06.01), effective July 1, 2011, stipulates that am-
bulatory care organizations maintain and communicate
accurate patient medication information.1 One require-
ment is that the organization obtain the patient’s medication
information at the beginning of an episode of care, with the
information to be updated when the patient’s medications
change. Ideally, med rec should occur at each transition of
care or han.
Clearing the Error: Patient Participation in Reducing Diagnostic ErrorJefferson Center
To generate new, patient-centered insights into diagnostic error, we convened diverse groups in public deliberation to recommend and evaluate actions that patients and/or their advocates would be willing and able to perform to improve diagnostic quality.
2016 indicator reference guide viral load suppression at 12 months
2005 Cancer SOS paper
1. Long-term Results From a Randomized
Controlled Trial to Increase Cancer
Screening Among Attendees of
Community Health Centers
ABSTRACT
PURPOSE We assessed whether increased cancer screening rates that were
observed with Cancer Screening Office Systems (Cancer SOS) could be maintained
at 24 months’ follow-up, a period in which clinics were expected to be largely
self-sufficient in maintaining the intervention.
METHODS Eight primary care clinics serving disadvantaged populations in Hills-
borough County, Fla, agreed to take part in a cluster-randomized experimental
trial. Charts of independent samples of established patients aged 50 to 75 years
were abstracted, with data collected at baseline (n = 1,196) and at 24 months’
follow-up (n = 1,296). Papanicolaou (Pap) smears, mammography, and fecal
occult blood testing were assessed.
RESULTS At 24 months of follow-up, intervention patients had received a greater
number of cancer screening tests (mean 1.17 tests vs 0.94 tests, t test = 4.42,
P <.0001). In multivariate analysis that controlled for baseline screening rates,
secular trends, and other patient and clinic characteristics, the intervention
increased the odds of mammograms slightly (odds ratio [OR]) = 1.26; 95% con-
fidence interval [CI], 1.02-1.55; P = .03) but had no effect on fecal occult blood
tests (OR = 1.17; 95% CI, 0.92-1.48; P =0.19) or Pap smears (OR = 0.88; 95%
CI, 0.0.68-1.15; P = .34).
CONCLUSIONS The Cancer SOS intervention had persistent, although modest,
effects on screening at 24 months’ follow-up, an effect that had clearly dimin-
ished from results reported at 12 months’ follow-up. Further study is needed to
develop successful intervention strategies that are either self-sustaining or that are
able to produce long-term changes in screening behavior.
Ann Fam Med 2005;3:109-114. DOI: 10.1370/afm.240.
INTRODUCTION
P
atients belonging to a racial or ethnic minority are more likely to
have poor cancer outcomes.1-7
Patients of low socioeconomic sta-
tus and those who are uninsured or insured by Medicaid are also at
greater risk of poor cancer outcomes.4,6,8-14
The reasons why these groups
have less favorable cancer outcomes is not certain but has been attributed
to lower rates of screening.15-24
In an attempt to address these health disparities, we developed the
Cancer Screening Office System (Cancer SOS), a low-cost office systems
intervention to promote screening in primary care clinics serving disad-
vantaged populations. The intervention is not computerized and relies on
personnel and resources that are available to most primary care clinics.
The intervention attempted to change systematically the behaviors of all
Richard G. Roetzheim, MD, MSPH1,2
Lisa K. Christman, BS1
Paul B. Jacobsen, PhD2
Jennifer Schroeder, BS1
Rania Abdulla, BS 1
Seft Hunter, BS1
1
Department of Family Medicine,
University of South Florida., Tampa, Fla
2
H. Lee Moffitt Cancer Center
& Research Institute, Tampa, Fla
Conflicts of interest: none reported
CORRESPONDING AUTHOR
Richard Roetzheim, MD
Department of Family Medicine
University of South Florida
12901 Bruce B. Downs Blvd. MDC 13
Tampa, FL 33612
rroetzhe@hsc.usf.edu
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2. TRIAL TO INCREASE CANCER SCREENING
office staff (including physicians) to accomplish cancer
screening and is modeled after similarly successful inter-
ventions.25,26
We tested the efficacy of the Cancer SOS
among patients attending community health centers, a
representative setting of care for the target population.
The effectiveness of the intervention at 12 months’
follow-up has been previously reported.27
In multivari-
ate analysis that controlled for baseline screening rates,
secular trends, and other patient and clinic character-
istics, the intervention increased the odds of screening
with mammograms (adjusted odds ratio [OR] = 1.62,
P = .023) and fecal occult blood tests (OR = 2.5,
P <.0001), with a trend toward greater use of Papani-
colaou (Pap) smears (OR = 1.57, P = .096). Left unan-
swered, however, was whether the increased rates of
screening that were observed could be sustained with-
out ongoing support from research staff.
To assess whether the effectiveness of the interven-
tion could be sustained, we assessed screening outcomes
after an additional 12 months of follow-up, a period in
which clinics were largely self-sufficient in regard to the
intervention. During the first intervention year, office
staff were taught how to maintain the intervention and
how to train new employees in the intervention proce-
dures. Training manuals were provided to all interven-
tion clinics, and a person from each clinic (usually the
office manager) assumed responsibility for maintaining
the intervention structure. During the second follow-up
year, intervention clinics were given all necessary sup-
plies and materials but were expected to maintain the
intervention themselves, without ongoing support from
research staff. The durability of the intervention was
assessed by chart reviews conducted at 24 months’ fol-
low-up, the results of which are reported here.
METHODS
To target an underserved population, clinics were
recruited from among 16 clinics participating in a
county-funded health insurance plan in Hillsborough
County, Fla. Clinics were eligible for the randomized
trial if (1) they provided primary medical care 5 days a
week, (2) the majority of physician and other clinicians
agreed to participate, and (3) the clinic was expected
to continue operating in the same fashion for the next
24 months. Each clinic individually decided whether to
participate in the intervention, and none was obligated
to join the study . We performed a cluster-randomized
experimental trial in which 8 clinics meeting eligibil-
ity criteria were randomized to either intervention or
control conditions. Together the clinics provided more
than 3,000 patient visits per week.
The intervention targeted 3 cancer screening tests:
mammograms, Pap smears, and fecal occult blood test
(FOBT). Key components of the intervention included
a cancer screening checklist that was completed by
patients indicating whether patients were due for
screening and a series of red, yellow, and green stickers
that indicated whether recommended screening tests
had been ordered and completed. Additional details
about the about the clinics that participated and addi-
tional details about the intervention itself have been
reported previously.27
Data Collection
During data collection periods, research assistants
assembled sampling frames of all patient visits using
office billing and scheduling records. Patient’s records
were eligible to be abstracted if both of the following
criteria were met: (1) the patient was 50 to 75 years
of age and (2) the patient was established in the clinic
(defined as having had at least 1 visit 12 months or
more before the sampled visit). Based on sample size
requirements for the intervention (the intervention was
structured to provide 80% power to detect increases in
screening rates of 20% or more), independent random
samples of 150 charts were selected for each clinic at
baseline and again at 12 and 24 months after the inter-
vention had been fully implemented in the clinic. Thus
the samples were cross-sectional and did not assess the
same patients during the 24-month period, as would
occur in a cohort study. We also assessed compliance
with the system at 6 months and again at 24 months by
determining the percentage of intervention charts that
contained a Cancer SOS checklist.
To prevent medical record reviews from influencing
patient- or clinician-screening behavior, and to allow
adequate time for recommended screening tests to be
completed, we abstracted charts 3 months after study
patients had visited the clinic. Neither patients nor staff
were aware of the period during which chart abstrac-
tions would occur. For each of the targeted cancer
screening tests, the date the procedure was completed
was recorded to determine whether the patient was
up-to-date on screening. We defined being up-to-date
as having completed the targeted screening test dur-
ing either the 12 months before the audited visit or
the 3 months after the audited visit. The use of a grace
period has been applied in other studies25,28-32
and
allows sufficient time for screening tests that were rec-
ommended at an audited visit to have been completed
by the patient.
Chart abstracters used a standardized method and
instrument to abstract chart information and were
trained by the project manager. Relevant clinical data,
including progress notes, laboratory reports, radiology
reports, consultation letters, and hospital records, were
abstracted from all sections of the chart. Before begin-
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TRIAL TO INCREASE CANCER SCREENING
ning data collection, inter-rater reliability for chart
abstractors was assessed for the 3 cancer screening tests
by a second review of a sample of 30 charts and cal-
culating the κ statistic. The following values of κ were
obtained when assessing whether a patient was up-to-
date on cancer screening: Pap smear κ= 1.00, mammo-
gram κ= 1.00, FOBT κ= 0.91.
We assessed whether the patient was up-to-date on
one or more of the following cancer screening tests:
mammogram, Pap smear, or FOBT. Women who had a
personal history of breast cancer were excluded from
our analysis of mammograms. Women with a personal
history of cervical cancer or those who had had a
hysterectomy were excluded from our analysis of Pap
smear screening. Patients with a personal history of
colon cancer and those who had received a colonos-
copy or double-contrast barium enema in the previous
10 years were excluded from the analysis of FOBT. We
defined being up-to-date on FOBT as having completed
3 home-collected specimens, not testing a stool speci-
men obtained in the physician’s office. For all screening
outcomes, we considered only the actual completion of
the screening test, not a physician’s recommendation
or patient refusal to be screened. Finally, all outcomes
were assessed strictly by chart review, not patient’s self-
report of screening on their checklist.
Approximately 850 of the charts reviewed at base-
line and at 24 months did not meet eligibility criteria.
For this analysis, the final data set consisted of the
combined abstracted records of eligible patients from
the 2 independent samples collected at baseline (n
= 1,196) and 24 months after the intervention (n =
1,296). To adjust simultaneously for potential con-
founders, we performed generalized linear models anal-
ysis using PROC GENMOD in SAS (SAS Version 8,
SAS Institute Inc., Cary, NC). The following variables
were included in regression models: age, sex, race-eth-
nicity, marital status, smoking status, health insurance,
comorbidity (using the Charlson Comorbidity Index),
number of chronic illnesses, number of prescribed med-
ications, number of health care visits in the previous
year, clinic attended, primary language spoken, family
history of targeted cancers, and for women, estrogen
replacement therapy and history of benign breast dis-
ease. Increasing scores on the Charlson Comorbidity
Index reflect a greater burden of comorbid illness.33,34
Indicator variables were also created for clinic type
(control vs intervention) and for survey year (baseline,
or 24-month follow-up). We also included an interac-
tion term for the 2 variables of clinic type and survey
year. The interaction term estimates the effect of the
intervention controlling for any baseline screening
differences and secular trends in screening rates while
adjusting for other covariates. Because of the clustered
nature of the data, we obtained parameter estimates
and 95% confidence intervals (CIs) using the method
of generalized estimating equations.35,36
Finally, we
repeated our analysis comparing patients who had a
Cancer SOS screening checklist in their chart (indicat-
ing the intervention had actually been implemented
for that patient) with those who did not, to assess the
potential effectiveness of the intervention strategy
when it was actually implemented. This study was
approved by the University of South Florida Institu-
tional Review Board.
RESULTS
The clinical characteristics of patients attending con-
trol clinics compared with those attending intervention
clinics have been previously summarized.27
Patients
attending intervention clinics were more likely to be
African American and married and were generally more
ill, as evidenced by a greater number of comorbid ill-
nesses, greater number of prescribed medications, and
greater number of health care visits. Compliance with
the Cancer SOS intervention decreased during the
course of the intervention, with 334 of 615 (54.3%)
charts showing evidence of the Cancer SOS cancer
screening checklist at a 24-months follow-up, com-
pared with 74% at the 6-month follow-up. Cancer
screening rates at baseline, 12 months, and 24 months
are reported in Table 1. For all 3 targeted tests, screen-
ing differences observed between control and inter-
vention clinics were less prominent at the 24-month
follow-up compared with the 12-month follow-up. We
Table 1. Cancer Screening at Baseline,
12 Months’, and 24 Months’ Follow-up
Variable
Percentage of Patients
Up-To-Date
Baseline 12 Months 24 Months
Papanicolaou smears
Control 57.6 48.2 45.3
Intervention 61.9 62.4 47.3
Mammograms
Control 75.9 71.1 64.5
Intervention 71.4 75.7 67.0
Fecal occult blood tests
Total sample
Control 22.1 11.9 12.6
Intervention 35.9 40.1 28.2
Men
Control 22.5 12.2 11.0
Intervention 28.3 41.4 27.3
Women
Control 22.1 11.9 13.0
Intervention 38.1 39.7 28.5
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also assessed the total number of targeted screening
tests that were up-to-date. At 24 months, patients in
control clinics were, on average, up-to-date on 0.94
cancer screening tests compared with an average of
1.17 tests for patients in intervention clinics (t test =
4.42, P <.0001). Among women who were eligible for
all 3 screening tests, the percentage completing screen-
ing tests at 24 months was as follows: for the control
group, the mean number of tests was 1.22, 25.6% had
0 tests, 34.9% had 1 test, 31.0% had 2 tests, and 8.5%
had all 3 tests; for the intervention group, mean num-
ber of tests was 1.37, 24.0% had 0 tests, 29.8% had 1
test, 31.5 had 2 tests, and 14.7% had all 3 tests.
Multivariate analysis was used to assess the effective-
ness of the intervention on individual screening tests by
determining the odds ratio for the interaction term pre-
viously described (Table 2). The intervention increased
the odds of mammography but had no significant effect
on the other 2 targeted screening tests. When results
were repeated comparing patients having a Cancer SOS
screening checklist with those who did not, presence of
a checklist was associated with increased odds of Pap
smear screening (OR = 2.03; 95% CI, 1.14-3.61; P =
.014) and FOBT screening (OR = 3.28; 95% CI, 2.05-
5.23; P <.0001), with a trend of increased odds of mam-
mography screening (OR = 1.42; 95% CI, 0.98-2.07;
P = .06). Finally, in a subgroup analysis, we found no
significant difference in the effects of the Cancer SOS
intervention among patients having a health mainte-
nance visit (data not shown).
DISCUSSION
The Cancer SOS intervention had persistent, although
modest, effects on screening at 24 months’ follow-up.
Patients who received care at intervention clinics were
up-to-date on a greater number of targeted screening
tests at 24 months’ follow-up and had 26% greater odds
of mammography screening compared with patients
in control clinics. Although still apparent, interven-
tion effects on screening at 24 months’ follow-up had
clearly diminished relative to effects observed at 12
months follow-up.
Some evidence suggests that
the decline in effectiveness of the
intervention with time was more
the result of decreased compliance
with the system than then a system
that became ineffective with time.
For example, compliance with the
Cancer SOS system, as determined
by the presence of a Cancer SOS
screening checklist in the patient’s
chart, declined from about 75% at
6 months’ follow-up to just more than 50% at the 24-
month mark. Furthermore, patients having a checklist
in the chart had increased odds of screening relative to
patients not receiving the intervention.
Although we were unable to assess rigorously the
reasons for diminished compliance with the Cancer SOS
system, there are several explanations. First, all interven-
tion clinics had some degree of staff turnover during
the course of the study. At site visits for data collection,
for example, it was not uncommon to find newly hired
personnel who were not familiar with the Cancer SOS
system. Although the Cancer SOS intervention had pro-
visions for training new staff (training manuals, assigned
responsibilities for training, etc), it appeared that train-
ing did not always occur in practice. In addition, the
enthusiasm with which a new program is implemented
would likely diminish as its novelty wanes. Although the
Cancer SOS system was purposely designed for ease of
implementation and maintenance, it would appear that
even such relatively simple interventions as Cancer SOS
may require ongoing support from an outside entity to
insure full implementation.
Few studies have assessed the durability of office
systems interventions. Dietrich and colleagues found
that intervention effects on FOBT and self-breast
examination persisted 24 months after an office sys-
tems intervention was completed but that effects
declined for mammography and clinical breast exami-
nation.31
Margolis and colleagues reported sustained
improvements in preventive care for children at 30
months of follow-up with an office systems interven-
tion.37
Stange and colleagues also found that improve-
ments in preventive care among intervention clinics
were maintained at 24 months’ follow-up.38
Goodson
and colleagues reported some success in the ablility of
the clinic to maintain an office intervention even up
to 6 years after implementation; effects on screening
rates were not reported, however.39
While not specifi-
cally assessing ongoing effectiveness, other studies
have assessed primary outcomes of office systems
interventions at a point greater than 12 months after
the intervention was implemented. Results were less
encouraging in these studies.26,40
Table 2. Results of Multivariate Analyses on Intervention Effects
Variable Odds Ratio 95% CI P Value
Papanicolaou smears (n = 1,103) 0.88 0.68-1.15 .34
Mammograms (n = 1,844) 1.26 1.02-1.55 .03
FOBT (n = 2,009) 1.17 0.92-1.48 .19
Men 1.33 0.78-2.27 .30
Women 1.13 0.87-1.46 .37
CI = confidence interval; FOBT = fecal occult blood test.
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Although a great number of interventions have
found significant effects on screening rates in the short
term,41,42
few have proven long-term durability. It is not
known whether office systems interventions have bet-
ter durability than other approaches to improve cancer
screening. Improved long-term outcomes (beyond
12 months) have been reported in studies of tailored
telephone counseling, for example.43,44
Other studies
reporting primary outcomes more than 12 months after
intervention implementation were not as successful.45-51
In conclusion, the Cancer SOS intervention had
persistent, although modest, effects on screening at 24
months’ follow-up. Effectiveness of the intervention
strategy had clearly diminished from results reported
at 12 months’ follow-up, most likely because of dimin-
ished compliance with the system. Further study is
needed to develop successful intervention strategies
that are either self-sustaining or that are able to pro-
duce long-term changes in screening behavior. Cancer
SOS materials and methods are freely available for use
at the following Web site (http://www.hsc.usf.edu/FAM-
ILY/research/index.htm).
To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/3/2/109.
Key words: Mass screening; mammography; vaginal smears; occult
blood; breast neoplasms; colorectal neoplasms; community health cen-
ters; primary health care
Submitted July 8, 2004; submitted, revised, August 25, 2004; accepted
September 8, 2004.
Funding support: This research was supported by National Cancer Insti-
tute grant R01 CA77282.
References
1. Miller B, Ries L, Hankey B, Kosary C, Edwards B. Cancer Statistics
Review: 1973-1989. Washington, DC: National Cancer Institute;
1992;9. NIH Publication 92-278.
2. Mandelblatt J, Andrews H, Kao R, Wallace R, Kerner J. The late-stage
diagnosis of colorectal cancer: demographic and socioeconomic fac-
tors. Am J Public Health. 1996;86:1794-1797.
3. Ndubuisi SC, Kofie VY, Andoh JY, Schwartz EM. Black-white differ-
ences in the stage at presentation of prostate cancer in the District of
Columbia. Urology. 1995;46:71-77.
4. Roetzheim RG, Pal N, Tennant C, et al. Effects of health insur-
ance and race on early detection of cancer. J Natl Cancer Inst.
1999;91:1409-1415.
5. Roetzheim RG, Pal N, Gonzalez EC, Ferrante JM, Van Durme DJ,
Krischer JP. Effects of health insurance and race on colorectal cancer
treatments and outcomes. Am J Public Health. 2000;90:1746-1754.
6. Roetzheim RG, Gonzalez EC, Ferrante JM, Pal N, Van Durme DJ,
Krischer JP. Effects of health insurance and race on breast carcinoma
treatments and outcomes. Cancer. 2000;89:2202-2213.
7. Richardson JL, Langholz B, Bernstein L, Burciaga C, Danley K, Ross
RK. Stage and delay in breast cancer diagnosis by race, socioeco-
nomic status, age and year. Br J Cancer. 1992;65:922-926.
8. Farley TA, Flannery JT. Late-stage diagnosis of breast cancer in
women of lower socioeconomic status: public health implications. Am
J Public Health. 1989;79:1508-1512.
9. Wells BL, Horm JW. Stage at diagnosis in breast cancer: race and
socioeconomic factors. Am J Public Health. 1992;82:1383-1385.
10. Bassett M, Krieger N. Social class and black-white differences in
breast cancer survival. Am J Public Health. 1986;76:1400-1403.
11. Mandelblatt J, Andrews H, Kerner J, Zauber A, Burnett W. Deter-
minants of late stage diagnosis of breast and cervical cancer: the
impact of age, race, social class, and hospital type. Am J Public Health.
1991;81:646-649.
12. Hunter C, Redmond C, Chen V, et al. Breast cancer: factors associ-
ated with stage at diagnosis in black and white women. J Natl Cancer
Inst. 1993;85:1129-1137.
13. Eley JW, Hill HA, Chen VW, et al. Racial differences in survival from
breast cancer. Results of the National Cancer Institute Black/White
Cancer Survival Study. JAMA. 1994;272:947-954.
14. Ayanian J, Kohler B, Abe T, Epstein A. The relation between health
insurance coverage and clinical outcomes among women with breast
cancer. N Engl J Med. 1993;329:326-331.
15. Stein J, Fox S. Language preference as an indicator of mammography
use among Hispanic women. J Natl Cancer Inst. 1990;82:1715-1716.
16. Calle E, Flanders W, Thun M, Martin L. Demographic predictors of
mammography and Pap smear screening in US women. Am J Public
Health. 1993;83:53-60.
17. Anderson L, May D. Has the use of cervical, breast, and colorectal
cancer screening increased in the United States? Am J Public Health.
1995;85:840-842.
18. Lee J, Vogel V. Who uses screening mammography regularly? Cancer
Epidemiol Biomarkers Prev. 1995;4:901-906.
19. Harlan L, Bernstein A, Kessler L. Cervical cancer screening: who is
not screened and why? Am J Public Health. 1991;81:885-891.
20. Burns R, McCarthy E, Freund K, et al. Black women receive less
mammography even with similar primary care. Ann Intern Med.
1996;125:173-182.
21. National Cancer Institute Breast Cancer Screening Consortium.
Screening mammography: a missed clinical opportunity? JAMA.
1990;264:54-58.
22. Anonymous. Breast and cervical cancer screening among under-
served women. Baseline survey results from six states. The National
Cancer Institute Screening Consortium for Underserved Women. Arch
Fam Med. 1995;4:617-624.
23. Hayward R, Shapiro M, Freeman H, Corey C. Who gets screened for
cervical and breast cancer? Results from a new national survey. Arch
Intern Med. 1988:1177-1181.
24. Breen N, Kessler L. Changes in the use of screening mammography:
evidence from the 1987 and 1990 National Health Interview Sur-
veys. Am J Public Health. 1994;84:62-67.
25. Dietrich A, O’Connor G, Keller A. Cancer: improving early detection
and prevention. Br Med J. 1992;304:687-691.
26. Manfredi C, Czaja R, Freels S, Trubitt M, Warnecke R, Lacey L.
Prescribe for health. Improving cancer screening in physician prac-
tices serving low-income and minority populations. Arch Fam Med.
1998;7:329-337.
27. Roetzheim R, Christman L, Jacobsen P, et al. A randomized con-
trolled trial to increase cancer screening among attendees of commu-
nity health centers. Ann Fam Med. 2004;2:294-300.
28. Ornstein S, Garr D, Jenkins R, Rust P, Arnon A. Computer-generated
physician and patient reminders: tools to improve population adher-
ence to selected preventive services. J Fam Pract. 1991;32:82-90.
29. Dickey L, Petitti D. A patient-held minirecord to promote adult pre-
ventive care. J Fam Pract. 1992;34:457-463.
6. ANNALS OF FAMILY MEDICINE ✦
WWW.ANNFAMMED.ORG ✦
VOL. 3, NO. 2 ✦
MARCH/APRIL 2005
114
TRIAL TO INCREASE CANCER SCREENING
30. Dietrich A, Tobin J, Sox C, et al. Cancer early-detection services in
community health centers for the underserved: a randomized con-
trolled trial. Arch Fam Med. 1998;7:320-327.
31. Dietrich AJ, Sox CH, Tosteson TD, Woodruff CB. Durability of
improved physician early detection of cancer after conclusion of inter-
vention support. Cancer Epidemiol Biomarkers Prev. 1994;3:335-340.
32. Fletcher S, Harris R, Gonzalez J, et al. Increasing mammography uti-
lization: a controlled study. J Natl Cancer Inst. 1993;85:112-120.
33. Charlson M, Pompei P, Ales K, Mackenzie C. A new method of clas-
sifying prognostic comorbidity in longitudinal studies: development
and validation. J Chron Dis. 1987;40:373-383.
34. Charlson M, Szatrowski T, Peterson J, Gold J. Validation of a com-
bined comorbidity index. J Clin Epidemiol. 1994;47:1245-1251.
35. Liang K, Zeger S. Longitudinal data analysis using generalized linear
models. Biometrika. 1986;73:13-22.
36. Liang K, Zeger S. Regression analysis for correlated data. Ann Rev
Public Health. 1993;14:43-68.
37. Margolis PA, Lannon CM, Stuart JM, Fried BJ, Keyes-Elstein L, Moore
DE Jr. Practice based education to improve delivery systems for pre-
vention in primary care: randomised trial. Br Med J. 2004;328:388.
38. Stange KC, Goodwin MA, Zyzanski SJ, Dietrich AJ. Sustainability of a
practice-individualized preventive service delivery intervention. Am J
Prev Med. 2003;25:296-300.
39. Goodson P, Murphy Smith M, Evans A, Meyer B, Gottlieb NH. Main-
taining prevention in practice: survival of PPIP in primary care set-
tings. Put Prevention Into Practice. Am J Prev Med. 2001;20:184-189.
40. Kinsinger LS, Harris R, Qaqish B, Strecher V, Kaluzny A. Using an
office system intervention to increase breast cancer screening. J Gen
Intern Med. 1998;13:507-514.
41. Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase
use of adult immunization and cancer screening services: a meta-
analysis. Ann Intern Med. 2002;136:641-651.
42. Mandelblatt J, Kanelsky P. Effectiveness of interventions to enhance
physician screening for breast cancer. J Fam Pract. 1995;40:162-171.
43. Lauver DR, Settersten L, Kane JH, Henriques JB. Tailored messages,
external barriers, and women’s utilization of professional breast can-
cer screening over time. Cancer. 2003;97:2724-2735.
44. Valanis B, Whitlock EE, Mullooly J, et al. Screening rarely screened
women: time-to-service and 24-month outcomes of tailored interven-
tions. Prev Med. 2003;37:442-450.
45. Zhu K, Hunter S, Bernard LJ, et al. An intervention study on screen-
ing for breast cancer among single African-American women aged
65 and older. Prev Med. 2002;34:536-545.
46. Zapka JG, Costanza ME, Harris DR, et al. Impact of a breast cancer
screening community intervention. Prev Med. 1993;22:34-53.
47. Allen JD, Stoddard AM, Mays J, Sorensen G. Promoting breast and
cervical cancer screening at the workplace: results from the Woman
to Woman Study. Am J Public Health. 2001;91:584-590.
48. Kim CS, Kristopaitis RJ, Stone E, Pelter M, Sandhu M, Weingarten
SR. Physician education and report cards: do they make the grade?
Results from a randomized controlled trial. Am J Med. 1999;107:556-
560.
49. Hillman AL, Ripley K, Goldfarb N, Nuamah I, Weiner J, Lusk E.
Physician financial incentives and feedback: failure to increase
cancer screening in Medicaid managed care. Am J Public Health.
1998;88:1699-1701.
50. Rimer BK, Conaway M, Lyna P, et al. The impact of tailored inter-
ventions on a community health center population. Patient Educ
Couns. 1999;37:125-140.
51. Messina CR, Lane DS, Grimson R. Effectiveness of women’s tele-
phone counseling and physician education to improve mammogra-
phy screening among women who underuse mammography. Ann
Behav Med. 2002;24:279-289.