RESUMEN
Cancer is the second leading cause of death in the United States. Although screening facilitates prevention and early detection and is one of the most effective approaches to reducing cancer mortality, participation is low-particularly among underserved populations. In a large, preregistered field experiment (n = 7711), we tested whether deadlines-both with and without monetary incentives tied to them-increase colorectal cancer (CRC) screening. We found that all screening invitations with an imposed deadline increased completion, ranging from 2.5% to 7.3% relative to control (ps < .004). Most importantly, individuals who received a short deadline with no incentive were as likely to complete screening (9.7%) as those whose invitation included a deadline coupled with either a small (9.1%) or large declining financial incentive (12.0%; ps = .57 and .04, respectively). These results suggest that merely imposing deadlines-especially short ones-can significantly increase CRC screening completion, and may also have implications for other forms of cancer screening.
Asunto(s)
Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer , Heces/química , Femenino , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Factores de TiempoRESUMEN
BACKGROUND & AIMS: Noninvasive tests used in colorectal cancer screening, such as the fecal immunochemical test (FIT), are more acceptable but detect neoplasias with lower levels of sensitivity than colonoscopy. We investigated whether lowering the cut-off concentration of hemoglobin for designation as an abnormal FIT result increased the detection of advanced neoplasia in a mailed outreach program. METHODS: We performed a prospective study of 17,017 uninsured patients, age 50 to 64 years, who were not current with screening and enrolled in a safety-net system in Texas. We reduced the cut-off value for an abnormal FIT result from 20 or more to 10 or more µg hemoglobin/g feces a priori. All patients with abnormal FIT results were offered no-cost diagnostic colonoscopy. We compared proportions of patients with abnormal FIT results and neoplasia yield for standard vs lower cut-off values, as well as absolute hemoglobin concentration distribution among 5838 persons who completed the FIT. Our primary aim was to determine the effects of implementing a lower hemoglobin concentration cut-off value on colonoscopy demand and yield, specifically colorectal cancer (CRC) and advanced neoplasia detection, compared with the standard, higher, hemoglobin concentration cut-off value. RESULTS: The proportions of patients with abnormal FIT results were 12.3% at the 10 or more µg hemoglobin/g feces and 6.6% at the standard 20 or more µg hemoglobin/g feces cut-off value (P = .0013). Detection rates for the lower vs the standard threshold were 10.2% vs 12.7% for advanced neoplasia (P = .12) and 0.9% vs 1.2% for CRC (P = .718). The positive predictive values were 18.9% for the lower threshold vs 24.4% for the standard threshold for advanced neoplasia (P = .053), and 1.7% vs 2.4% for CRC (P = .659). The number needed to screen to detect 1 case with advanced neoplasia was 45 at the lower threshold compared with 58 at the standard threshold; the number needed to scope to detect 1 case with advanced neoplasia increased from 4 to 5. Most patients with CRC (72.7%) or advanced adenoma (67.3%) had hemoglobin concentrations of 20 or more µg/g feces. In the group with 10 to 19 µg hemoglobin/g feces, there were 3 patients with CRC (3 of 11; 27.3%) and 36 with advanced adenoma (36 of 110; 32.7%) who would not have been detected at the standard positive threshold (advanced neoplasia Pcomparison < .001). The proportion of patients found to have no neoplasia after an abnormal FIT result (false positives) was not significantly higher with the lower cut-off value (44.4%) than the standard cut-off value (39.1%) (P = .1103). CONCLUSIONS: In a prospective study of 17,017 uninsured patients, we found that reducing the abnormal FIT result cut-off value (to ≥10 µg hemoglobin/g feces) might increase detection of advanced neoplasia, but doubled the proportion of patients requiring a diagnostic colonoscopy. If colonoscopy capacity permits, health systems that use quantitative FITs should consider lowering the abnormal cut-off value to optimize CRC detection and prevention. (ClinicalTrials.gov no: NCT01946282.).
Asunto(s)
Neoplasias Colorrectales , Sangre Oculta , Colonoscopía , Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer , Heces/química , Hemoglobinas/análisis , Humanos , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND: Financial incentives may improve health behaviors. We tested the impact of offering financial incentives for mailed fecal immunochemical test (FIT) completion annually for 3 years. METHODS: Patients, ages 50 to 64 years, not up-to-date with screening were randomized to receive either a mailed FIT outreach (n = 6,565), outreach plus $5 (n = 1,000), or $10 (n = 1,000) incentive for completion. Patients who completed the test were reinvited using the same incentive the following year, for 3 years. In year 4, patients who returned the kit in all preceding 3 years were reinvited without incentives. Primary outcome was FIT completion among patients offered any incentive versus outreach alone each year. Secondary outcomes were FIT completion for groups offered $5 versus outreach alone, $10 versus outreach alone, and $5 versus $10. RESULTS: Year 1 FIT completion was 36.9% with incentives versus 36.2% outreach alone (P = 0.59) and was not statistically different for $10 (34.6%; P = 0.31) or $5 (39.2%; P = 0.070) versus outreach alone. Year 2 completion was 61.6% with incentives versus 60.8% outreach alone (P = 0.75) and not statistically different for $10 or $5 versus outreach alone. Year 3 completion was 79.4% with incentives versus 74.8% outreach alone (P = 0.080), and was higher for $10 (82.4%) versus outreach alone (P = 0.033), but not for $5 versus outreach alone. Completion was similar across conditions in year 4 (no incentives). CONCLUSIONS: Offering small incentives did not increase FIT completion relative to standard outreach. IMPACT: This was the first longitudinal study testing the impact of repeated financial incentives, and their withdrawal, on FIT completion.
Asunto(s)
Neoplasias Colorrectales/diagnóstico , Neoplasias Colorrectales/economía , Detección Precoz del Cáncer/economía , Detección Precoz del Cáncer/métodos , Femenino , Humanos , Estudios Longitudinales , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVES: Offering financial incentives to promote or "nudge" participation in cancer screening programs, particularly among vulnerable populations who traditionally have lower rates of screening, has been suggested as a strategy to enhance screening uptake. However, effectiveness of such practices has not been established. Our aim was to determine whether offering small financial incentives would increase colorectal cancer (CRC) screening completion in a low-income, uninsured population. METHODS: We conducted a randomized, comparative effectiveness trial among primary care patients, aged 50-64 years, not up-to-date with CRC screening served by a large, safety net health system in Fort Worth, Texas. Patients were randomly assigned to mailed fecal immunochemical test (FIT) outreach (n=6,565), outreach plus a $5 incentive (n=1,000), or outreach plus a $10 incentive (n=1,000). Outreach included reminder phone calls and navigation to promote diagnostic colonoscopy completion for patients with abnormal FIT. Primary outcome was FIT completion within 1 year, assessed using an intent-to-screen analysis. RESULTS: FIT completion was 36.9% with vs. 36.2% without any financial incentive (P=0.60) and was also not statistically different for the $10 incentive (34.6%, P=0.32 vs. no incentive) or $5 incentive (39.2%, P=0.07 vs. no incentive) groups. Results did not differ substantially when stratified by age, sex, race/ethnicity, or neighborhood poverty rate. Median time to FIT return also did not differ across groups. CONCLUSIONS: Financial incentives, in the amount of $5 or $10 offered in exchange for responding to mailed invitation to complete FIT, do not impact CRC screening completion.
Asunto(s)
Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer/estadística & datos numéricos , Pacientes no Asegurados , Motivación , Pobreza , Colonoscopía/estadística & datos numéricos , Heces/química , Femenino , Humanos , Inmunoquímica/estadística & datos numéricos , Masculino , Persona de Mediana EdadRESUMEN
To prepare for the healthcare industry's transition to value-based care, Mayo Clinic Health System implemented a new, value-focused physician compensation plan as part of a larger initiative aimed at systemwide clinical integration. The plan uses three value-based metrics, focusing on outcomes, safety, and patient experience, that initially would determine 5 percent of a physician's compensation. Notable improvements achieved in the first year of the plan's implementation were strong indicators of the potential effectiveness of such a plan.
Asunto(s)
Médicos/economía , Garantía de la Calidad de Atención de Salud , Salarios y Beneficios , Hospitales Generales , Minnesota , Estudios de Casos Organizacionales , Compra Basada en CalidadRESUMEN
In 2012, Mayo Clinic Health System (MCHS) had 13 different physician compensation models among its operating units, with most based on productivity metrics. MCHS aimed to transition all physicians to a single compensation model that would facilitate its integration with Mayo Clinic and promote physician engagement with emerging value-based payment models. The new model, which was implemented this past January, incorporates quality metrics, provides physicians with regular reports of their performance, and already has resulted in greater physician attention to outcomes, safety, and patient experience.
Asunto(s)
Eficiencia Organizacional , Cuerpo Médico de Hospitales/economía , Salarios y Beneficios , Minnesota , Estudios de Casos Organizacionales , Objetivos OrganizacionalesRESUMEN
IMPORTANCE: Colorectal cancer (CRC) screening saves lives, but participation rates are low among underserved populations. Knowledge on effective approaches for screening the underserved, including best test type to offer, is limited. OBJECTIVE: To determine (1) if organized mailed outreach boosts CRC screening compared with usual care and (2) if FIT is superior to colonoscopy outreach for CRC screening participation in an underserved population. DESIGN, SETTING, AND PARTICIPANTS: We identified uninsured patients, not up to date with CRC screening, age 54 to 64 years, served by the John Peter Smith Health Network, Fort Worth and Tarrant County, Texas, a safety net health system. INTERVENTIONS: Patients were assigned randomly to 1 of 3 groups. One group was assigned to fecal immunochemical test (FIT) outreach, consisting of mailed invitation to use and return an enclosed no-cost FIT (n = 1593). A second was assigned to colonoscopy outreach, consisting of mailed invitation to schedule a no-cost colonoscopy (n = 479). The third group was assigned to usual care, consisting of opportunistic primary care visitbased screening (n = 3898). In addition, FIT and colonoscopy outreach groups received telephone follow-up to promote test completion. MAIN OUTCOME MEASURES: Screening participation in any CRC test within 1 year after randomization. RESULTS: Mean patient age was 59 years; 64% of patients were women. The sample was 41% white, 24% black, 29% Hispanic, and 7% other race/ethnicity. Screening participation was significantly higher for both FIT (40.7%) and colonoscopy outreach (24.6%) than for usual care (12.1%) (P < .001 for both comparisons with usual care). Screening was significantly higher for FIT than for colonoscopy outreach (P < .001). In stratified analyses, screening was higher for FIT and colonoscopy outreach than for usual care, and higher for FIT than for colonoscopy outreach among whites, blacks, and Hispanics (P < .005 for all comparisons). Rates of CRC identification and advanced adenoma detection were 0.4% and 0.8% for FIT outreach, 0.4% and 1.3% for colonoscopy outreach, and 0.2% and 0.4% for usual care, respectively (P < .05 for colonoscopy vs usual care advanced adenoma comparison; P > .05 for all other comparisons). Eleven of 60 patients with abnormal FIT results did not complete colonoscopy. CONCLUSIONS AND REVELANCE: Among underserved patients whose CRC screening was not up to date, mailed outreach invitations resulted in markedly higher CRC screening compared with usual care. Outreach was more effective with FIT than with colonoscopy invitation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01191411.
Asunto(s)
Colonoscopía/métodos , Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer/métodos , Tamizaje Masivo/métodos , Área sin Atención Médica , Cooperación del Paciente , Femenino , Estudios de Seguimiento , Humanos , Inmunohistoquímica , Masculino , Persona de Mediana Edad , Sangre Oculta , Reproducibilidad de los Resultados , Estudios RetrospectivosRESUMEN
BACKGROUND: Optimizing colorectal cancer (CRC) screening requires identification of unscreened individuals and tracking screening trends. A recent National Institutes of Health State of the Science Conference, "Enhancing Use and Quality of CRC Screening," cited a need for more population data sources for measurement of CRC screening, particularly for the medically underserved. Medical claims data (claims data) are created and maintained by many health systems to facilitate billing for services rendered and may be an efficient resource for identifying unscreened individuals. The aim of this study, conducted at a safety-net health system, was to determine whether CRC test use measured by claims data matches medical chart documentation. METHODS: The authors randomly selected 400 patients from a universe of 20,000 patients previously included in an analysis of CRC test use based on claims data 2002-2006 in Tarrant Co, TX. Claims data were compared with medical chart documentation by estimation of agreement and examination of test use over/underdocumentation. RESULTS: The authors found that agreement on test use was very good for fecal occult blood testing (κ = 0.83, 95% confidence interval: 0.75-0.90) and colonoscopy (κ = 0.91, 95% confidence interval: 0.85-0.96) and fair for sigmoidoscopy (κ = 0.39, 95% confidence interval: 0.28-0.49). Over- and underdocumentations of the 2 most commonly used CRC tests--colonoscopy and fecal occult blood testing--were rare. CONCLUSIONS: Use of claims data by health systems to measure CRC test use is a promising alternative to measuring CRC test use with medical chart review and may be used to identify unscreened patients for screening interventions and track screening trends over time.
Asunto(s)
Neoplasias Colorrectales/diagnóstico , Detección Precoz del Cáncer/métodos , Planes de Sistemas de Salud , Revisión de Utilización de Seguros , Anciano , Neoplasias Colorrectales/epidemiología , Detección Precoz del Cáncer/normas , Femenino , Planes de Sistemas de Salud/normas , Humanos , Revisión de Utilización de Seguros/normas , Masculino , Persona de Mediana Edad , Sangre Oculta , Estadística como Asunto/métodos , Estadística como Asunto/normasRESUMEN
BACKGROUND: Data on the number of individuals eligible for screening, and rates of screening, are necessary to assess national colorectal cancer screening efforts. Such data are sparse for safety-net health systems. METHODS: A retrospective cohort study of individuals ages 50 to 75 served by a safety-net health system in Tarrant County, TX was conducted to determine (a) the size of the potential screen-eligible population ages 50 to 75, (b) the rate of screening over 5 years among individuals ages 54 to 75, and (c) the potential predictors of screening, including sex, race/ethnicity, insurance status, frequency of outpatient visits, and socioeconomic status. RESULTS: Of 28,708 potential screen-eligible individuals, 20,416 were ages 54 to 75 and analyzed for screening; 22.0% were screened within the preceding 5 years. Female gender, Hispanic ethnicity, ages 65 to 75, insurance status, and two or more outpatient visits were independently associated with screening. Access to care was an important factor: adjusted odds ratio, 2.57 (95% confidence interval, 2.23-2.98) for any insurance; adjusted odds ratio, 3.53 (95% confidence interval, 3.15-3.97) for two or more outpatient visits. CONCLUSIONS: The screen-eligible population served by our safety-net health system was large, and the projected deficit in screen rates was substantial. Access to care was the dominant predictor of screening participation. If our results are replicable in similar health systems, the data suggest that screening guidelines and policy efforts must take into account the feasibility of proposed interventions. Strong advocacy for more resources for colorectal cancer screening interventions (including research into the best manner to provide screening for large populations) is needed.
Asunto(s)
Neoplasias Colorrectales/diagnóstico , Accesibilidad a los Servicios de Salud , Atención Primaria de Salud/métodos , Anciano , Estudios de Cohortes , Neoplasias Colorrectales/epidemiología , Neoplasias Colorrectales/prevención & control , Femenino , Humanos , Cobertura del Seguro , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Estudios Retrospectivos , Clase SocialRESUMEN
BACKGROUND: Retained foreign objects (RFOs) after surgical procedures are an infrequent but potentially devastating medical error. The Mayo Clinic, Rochester (MCR), undertook a quality improvement program to reduce the incidence of surgical RFOs. METHOD: A multidisciplinary, multiphase approach was initiated in 2005. The effort, led by surgical, nursing, and administrative institutional leaders, was divided into three phases. The first phase included a defect analysis and policy review. A detailed analysis of all RFOs (both true and near misses) was undertaken to identify patterns of failures unique to our institution and operating room culture. Simultaneously, a review of all relevant institutional policies was performed, with comprehensive revisions focusing on increased clarity and inter- and intrapolicy consistency. The second phase involved increasing awareness and communication among all operating room personnel, including surgeons, residents, nursing, and allied health staff. The education program included all-staff conferences, team training, simulation videos, and daily education reminders and in-room audits. Finally, a monitoring and control phase involved rapid leadership response teams to any events, enhanced staff communication, and policy reviews. RESULTS: When the program started, MCR was averaging a surgical RFO every 16 days. After the intervention, the average interval between RFO events increased to 69 days, a level of performance that has been sustained for more than two years. DISCUSSION: MCR experienced a significant and sustained reduction in the incidents of RFOs, attributed to the multidisciplinary nature of the initiative, the active engagement of institutional leadership, and use of the principles of enhanced communication between operating room staff members to improve operating room situational awareness.
Asunto(s)
Cuerpos Extraños/prevención & control , Errores Médicos/prevención & control , Grupo de Atención al Paciente/normas , Procedimientos Quirúrgicos Operativos/efectos adversos , Cuerpos Extraños/epidemiología , Cuerpos Extraños/etiología , Humanos , Capacitación en Servicio/métodos , Relaciones Interprofesionales , Errores Médicos/estadística & datos numéricos , Quirófanos/organización & administración , Estudios de Casos Organizacionales , Grupo de Atención al Paciente/organización & administración , Evaluación de Programas y Proyectos de Salud , Garantía de la Calidad de Atención de Salud/métodos , Recursos HumanosRESUMEN
Chronic renal failure (CRF) is a serious clinical problem and currently there are no adequate therapeutic strategies for treatment. Many possible treatment strategies have been tested in rats with CRF induced by subtotal nephrectomy. However, reports in the literature concerning the consequences of this procedure on rat kidney function are contradictory. For instance, such an intervention in male Sprague-Dawley rats apparently initiates the development of interstitial renal fibrosis, while in our similar studies on female Wistar rats (HW) there was minimal renal fibrosis. Therefore, we carried out experiments in adult rats to investigate the long-term consequences of 5/6 nephrectomy (5/6NX) in relation to (1) sex, (2) strain, and (3) two methods of surgical ablation. Ten weeks after 5/6NX, body weight gain, systolic blood pressure, creatinine clearance, and urinary protein were measured, along with renal hydroxyproline concentration determinations to assess the deposition of extracellular matrix. Also, light microscopic investigations were done to characterize renal damage. The functional parameters clearly indicated the development of CRF, while morphologic investigations showed only moderate fibrotic areas containing atrophic tubules and lymphocytic infiltrates. However, 45-60% of glomeruli were sclerotic. In summary, 5/6NX, using either method of partial nephrectomy, induces signs of moderate glomerulonephritis preferentially in female HW rats. Thus 5/6NX in female HW rats can be recommended as a suitable model in the induction of renal fibrosis.
Asunto(s)
Modelos Animales de Enfermedad , Glomerulonefritis/fisiopatología , Glomerulonefritis/veterinaria , Nefrectomía/veterinaria , Animales , Peso Corporal , Femenino , Fibrosis/fisiopatología , Fibrosis/veterinaria , Riñón/fisiología , Masculino , Ratas , Ratas Sprague-Dawley , Ratas Wistar , Factores SexualesRESUMEN
PURPOSE: Hospital practices in academic medical centers have fewer medical residents available to provide hospital care, necessitating alternative models for patient care. This article reports a new model for care of inpatients with cardiovascular diseases. METHOD: In 1998, a new nonresident cardiovascular patient care (Cardiology IV) service was implemented that used a team approach of staff attending cardiologists, cardiovascular fellows, midlevel practitioners (nurse practitioners and physician's assistants), and nurses to evaluate and treat patients. Standard dismissal information was collected for all patients dismissed in 1998 to compare diagnosis-related group, length of stay, in-hospital mortality, and 30-day readmission rates for Cardiology IV. These characteristics were compared with those for the remaining resident teaching services. Patients' satisfaction surveys from 1997 and 1998 were compared. Attending physicians' and internal medicine residents' satisfaction before and after the implementation of the new service was also compared. RESULTS: Staff and resident physicians were more satisfied with their hospital rotations after this intervention was introduced. Optimal patient care was maintained, and efficiency enhanced. Patients on Cardiology IV had a shorter length of stay compared with patients on the resident teaching service. CONCLUSIONS: This new hospital model has provided an alternative to patient care without the need for residents and protects education on the conventional teaching services. This model maintains optimal patient care and has resulted in enhanced satisfaction of attending staff and residents.