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Background: Guidelines for managing abnormal cervical cancer screening results are complex and adherence is challenging for clinicians. Previous studies have identified gaps in knowledge as a possible cause; few have explored the confidence clinicians have in their management decisions. Confidence in decision-making may influence management practices, particularly when guidelines are complex and evolving., Objective: Assess whether confidence in decision-making is associated with making guideline-concordant recommendations for abnormal cervical cancer screening results., Design: A clinician survey used vignettes to ask clinicians to make a management recommendation for different abnormal results and rate their level of confidence in their response., Participants: Physicians and advanced practice providers (APPs) at three diverse health systems in Washington, Texas, and Massachusetts., Main Measures: Correct response to each vignette based on either the 2012 or 2019 American Colposcopy and Cervical Pathology (ASCCP) management guidelines., Key Results: In total, 501 clinicians completed the survey between October and December 2020 (response rate 53.7%). Overall, most clinicians made guideline-recommended management decisions for two vignettes (73.2 and 73.7%), but fewer were confident in their selection (48.3% and 46.6%, respectively). Clinicians who reported high levels of confidence were more often correct than those who reported lower levels of confidence (85.8% vs. 62.2% and 87.5% vs. 60.7%, both p<0.001). After adjusting for clinician and practice characteristics, confidence remained significantly associated with selecting the correct answer., Conclusions: Clinician confidence in management decisions for abnormal cervical cancer screening results was significantly associated with knowing guideline-concordant recommendations. Given the complexity of cervical cancer management guidelines, solutions to improve clinician confidence in decision-making are needed., Competing Interests: Declarations:. Conflict of Interest:: Dang reports travel support from Weill Cornell Medical College. Werner has received travel support from and is a steering committee member of the American Cancer Society National Roundtable on Cervical Cancer (ACS NRTCC). Feldman receives royalties from UpToDate., (© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Purpose: We examined characteristics of clinicians caring for transgender men and nonbinary (TMNB) individuals and guideline concordance of clinicians' cervical cancer screening recommendations. Methods: Using a survey of clinicians who performed ≥10 cervical cancer screenings in 2019, we studied characteristics of clinicians who do versus do not report caring for TMNB individuals and guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women. Results: In our sample ( N  = 492), 49.2% reported caring for TMNB individuals, and 25.4% reported performing cervical cancer screening for TMNB individuals with a cervix. Differences in guideline concordance of screening recommendations for TMNB individuals with a cervix versus cisgender women (45.8% vs. 50% concordant) were not statistically significant. Conclusion: Sizable proportions of clinicians cared for and performed cervical cancer screening for TMNB individuals. Research is needed to better understand clinicians' identified knowledge deficits to develop interventions (e.g., clinician trainings) to improve gender-affirming cervical cancer prevention.

Importance: Decisions about whether to stop colorectal cancer (CRC) screening tests in older adults can be difficult and may benefit from shared decision-making (SDM)., Objective: To evaluate the effect of physician training in SDM and electronic previsit reminders (intervention) vs reminders only (comparator) on receipt of the patient-preferred approach to CRC screening and on overall CRC screening rates of older adults at 12 months., Design, Setting, and Participants: This was a secondary analysis of the Promoting Informed Decisions About Colorectal Cancer Screening in Older Adults (PRIMED) cluster randomized clinical trial. In the PRIMED trial, primary care physicians (PCPs) from 36 primary care practices in Massachusetts and Maine were enrolled between May 1 and August 30, 2019, and were randomized to the intervention group or the comparator group. Patients aged 76 to 85 years who were overdue for CRC screening and did not have a prior diagnosis of CRC enrolled between October 21, 2019, and April 8, 2021. Data analysis was performed between May 24, 2022, and May 10, 2023., Interventions: Primary care physicians in the intervention group completed an SDM training course and received previsit reminders of patients eligible for CRC testing discussion, whereas PCPs in the comparator group received reminders only., Main Outcomes and Measures: The primary outcome was concordance, or the percentage of patients who received their preferred screening approach. Postvisit surveys were administered to assess patient preference for testing, and electronic health record review was used to assess CRC testing at 12 months. Heterogeneity of treatment effect analyses examined interaction between study groups and different factors on concordance rates., Results: This study included 59 physicians and 466 older adults. Physicians had a mean (SD) age of 52.7 (9.4) years and a mean (SD) of 21.6 (10.2) years in practice; 30 (50.8%) were women and 16 (27.1%) reported prior training in SDM. Patients had a mean (SD) age of 80.3 (2.8) years; 249 (53.4%) were women and 238 (51.1%) reported excellent or very good overall health. Patients preferred stool-based tests (161 [34.5%]), followed by colonoscopy (116 [24.8%]) or no further screening (97 [20.8%]); 75 (16.1%) were not sure. The distribution of patient preferences was similar across groups (P = .36). At 12 months, test uptake was also similar for both the intervention group (29 [12.3%] for colonoscopy, 62 [26.3%] for stool-based tests, and 145 [61.4%] for no testing) and the comparator group (32 [13.9%] for colonoscopy, 35 [15.2%] for stool-based tests, and 163 [70.9%] for no testing; P = .08). Approximately half of patients in the intervention group received their preferred approach vs the comparator group (115 of 226 [50.9%] vs 103 of 223 [46.2%]; P = .47). Heterogeneity of treatment effect analyses found significantly higher rates with the intervention vs the comparator for patients with a strong intention to follow through with the preferred approach (adjusted odds ratio [AOR], 1.79 [95% CI, 1.11-2.89]; P = .02, P = .05 for interaction) and for patients who reported more than 5 minutes (AOR, 3.27 [95% CI, 1.25-8.59]; P = .02, P = .05 for interaction) of discussion with their PCP regarding screening. Higher rates were also observed among patients who reported 2 to 5 minutes of discussion with their PCP, although this finding was not significant (AOR, 1.89 [95% CI, 0.93-3.84]; P = .08, P = .05 for interaction)., Conclusions and Relevance: In this secondary analysis of a cluster randomized clinical trial, approximately half of older patients received their preferred approach to CRC screening. Physician training in SDM did not result in higher concordance rates overall but may have benefitted some subgroups. Future work to refine and evaluate clinical decision support (in the form of an electronic advisory or reminder) as well as focused SDM skills training for PCPs may promote high-quality, preference-concordant decisions about CRC testing for older adults., Trial Registration: ClinicalTrials.gov Identifier: NCT03959696.

Background: Follow-up of abnormal results is essential to cervical cancer screening, but data on adherence to follow-up are limited. We describe patterns of follow-up after screening abnormalities and identify predictors of guideline-concordant follow-up., Methods: We identified the index screening abnormality (positive human papillomavirus test or atypical squamous cells of undetermined significance or more severe cytology) among women of ages 25 to 65 years at three US healthcare systems during 2010 to 2019. We estimated the cumulative incidence of surveillance testing, colposcopy, or treatment after the index abnormality and initial colposcopy. Logistic regressions were fit to identify predictors of guideline-concordant follow-up according to contemporaneous guidelines., Results: Among 43,007 patients with an index abnormality, the cumulative incidence of any follow-up was 49.6% by 4 years for those with atypical squamous cells of undetermined significance/human papillomavirus-negative and higher for abnormalities warranting immediate colposcopy. The 1-year cumulative incidence of any follow-up after colposcopy was 70% for patients with normal results or cervical intraepithelial neoplasia I and 90% for patients with cervical intraepithelial neoplasia II+. Rates of concordant follow-up after screening and colposcopy were 52% and 47%, respectively. Discordant follow-up was associated with factors including age, race/ethnicity, overweight/obese body mass index, and specific types of public payor coverage or being uninsured., Conclusions: Adherence to the recommended follow-up of cytologic and histopathologic abnormalities is inconsistent in clinical practice. Concordance was poor for mild abnormalities and improved, although suboptimal, for more severe abnormalities., Impact: There remain gaps in the cervical cancer screening process in clinical practice. Further study is needed to understand the barriers to the appropriate management of cervical abnormalities., (©2024 American Association for Cancer Research.)

Importance: Realizing the benefits of cancer screening requires testing of eligible individuals and processes to ensure follow-up of abnormal results., Objective: To test interventions to improve timely follow-up of overdue abnormal breast, cervical, colorectal, and lung cancer screening results., Design, Setting, and Participants: Pragmatic, cluster randomized clinical trial conducted at 44 primary care practices within 3 health networks in the US enrolling patients with at least 1 abnormal cancer screening test result not yet followed up between August 24, 2020, and December 13, 2021., Intervention: Automated algorithms developed using data from electronic health records (EHRs) recommended follow-up actions and times for abnormal screening results. Primary care practices were randomized in a 1:1:1:1 ratio to (1) usual care, (2) EHR reminders, (3) EHR reminders and outreach (a patient letter was sent at week 2 and a phone call at week 4), or (4) EHR reminders, outreach, and navigation (a patient letter was sent at week 2 and a navigator outreach phone call at week 4). Patients, physicians, and practices were unblinded to treatment assignment., Main Outcomes and Measures: The primary outcome was completion of recommended follow-up within 120 days of study enrollment. The secondary outcomes included completion of recommended follow-up within 240 days of enrollment and completion of recommended follow-up within 120 days and 240 days for specific cancer types and levels of risk., Results: Among 11 980 patients (median age, 60 years [IQR, 52-69 years]; 64.8% were women; 83.3% were White; and 15.4% were insured through Medicaid) with an abnormal cancer screening test result for colorectal cancer (8245 patients [69%]), cervical cancer (2596 patients [22%]), breast cancer (1005 patients [8%]), or lung cancer (134 patients [1%]) and abnormal test results categorized as low risk (6082 patients [51%]), medium risk (3712 patients [31%]), or high risk (2186 patients [18%]), the adjusted proportion who completed recommended follow-up within 120 days was 31.4% in the EHR reminders, outreach, and navigation group (n = 3455), 31.0% in the EHR reminders and outreach group (n = 2569), 22.7% in the EHR reminders group (n = 3254), and 22.9% in the usual care group (n = 2702) (adjusted absolute difference for comparison of EHR reminders, outreach, and navigation group vs usual care, 8.5% [95% CI, 4.8%-12.0%], P < .001). The secondary outcomes showed similar results for completion of recommended follow-up within 240 days and by subgroups for cancer type and level of risk for the abnormal screening result., Conclusions and Relevance: A multilevel primary care intervention that included EHR reminders and patient outreach with or without patient navigation improved timely follow-up of overdue abnormal cancer screening test results for breast, cervical, colorectal, and lung cancer., Trial Registration: ClinicalTrials.gov Identifier: NCT03979495.

Introduction: This study sought to characterize racial and ethnic disparities in cervical cancer screening and follow-up of abnormal findings across 3 U.S. healthcare settings., Methods: Data were from 2016 to 2019 and were analyzed in 2022, reflecting sites within the Multi-level Optimization of the Cervical Cancer Screening Process in Diverse Settings & Populations Research Center, part of the Population-based Research to Optimize the Screening Process consortium, including a safety-net system in the southwestern U.S., a northwestern mixed-model system, and a northeastern integrated healthcare system. Screening uptake was evaluated among average-risk patients (i.e., no previous abnormalities) by race and ethnicity as captured in the electronic health record, using chi-square tests. Among patients with abnormal findings requiring follow-up, the proportion receiving colposcopy or biopsy within 6 months was reported. Multivariable regression was conducted to assess how clinical, socioeconomic, and structural characteristics mediate observed differences., Results: Among 188,415 eligible patients, 62.8% received cervical cancer screening during the 3-year study period. Screening use was lower among non-Hispanic Black patients (53.2%) and higher among Hispanic (65.4%,) and Asian/Pacific Islander (66.5%) than among non-Hispanic White patients (63.5%, all p<0.001). Most differences were explained by the distribution of patients across sites and differences in insurance. Hispanic patients remained more likely to screen after controlling for a variety of clinical and sociodemographic factors (risk ratio=1.14, CI=1.12, 1.16). Among those receiving any screening test, Black and Hispanic patients were more likely to receive Pap-only testing (versus receiving co-testing). Follow-up from abnormal results was low for all groups (72.5%) but highest among Hispanic participants (78.8%, p<0.001)., Conclusions: In a large cohort receiving care across 3 diverse healthcare settings, cervical cancer screening and follow-up were below 80% coverage targets. Lower screening for Black patients was attenuated by controlling for insurance and site of care, underscoring the role of systemic inequity. In addition, it is crucial to improve follow-up after abnormalities are identified, which was low for all populations., (Copyright © 2023 American Journal of Preventive Medicine. All rights reserved.)

Lung cancer is a leading cause of cancer death in Latinos. In a telephone survey, we assessed perceptions about lung cancer and awareness of, interest in, and barriers to lung screening among older current and former smokers. We compared Latino and non-Latino responses adjusting for age, sex, education, and smoking status using logistic regression models. Of the 460 patients who completed the survey (51.5% response rate), 58.0% were women, 49.3% former smokers, 15.7% Latino, with mean age 63.6 years. More Latinos believed that lung cancer could be prevented compared to non-Latinos (74.6% vs. 48.2%, OR 3.07, CI 1.89-5.01), and less worried about developing lung cancer (34.8% vs. 50.3%, OR 0.44, CI 0.27-0.72). Most participants were not aware of lung screening (44.1% Latinos vs. 34.3% Non-Latinos, OR 1.24, CI 0.79-1.94), but when informed, more Latinos wanted to be screened (90.7% vs. 67%, OR 4.58, CI 2.31-9.05). Latinos reported fewer barriers to lung screening.

Background: Current national cancer screening recommendations include the potential risk of psychological harm related to screening. However, data on the relation of psychological distress to cancer screening is limited. The authors conducted a systematic review to assess psychological distress associated with cancer screening procedures., Methods: Studies that administered measures of psychological distress between 2 weeks before and 1 month after the screening procedure were included., Results: In total, 22 eligible studies met criteria for review, including 13 observational trials and 9 randomized controlled trials. Eligible studies used a broad range of validated and unvalidated measures. Anxiety was the most commonly assessed construct and was measured using the State Trait Anxiety Inventory. Studies included breast, colorectal, prostate, lung, and cervical screening procedures. Distress was low across procedures, with the exception of colorectal screening. Distress did not vary according to the time at which distress was measured. None of the studies were conducted exclusively with the intention of assessing distress at the time of screening., Conclusions: Evidence of low distress during the time of cancer screening suggests that distress might not be a widespread barrier to screening among adults who undergo screening. However, more studies are needed using validated measures of distress to further understand the extent to which screening may elicit psychological distress and impede adherence to national screening recommendations. Cancer 2017;123:3882-94. © 2017 American Cancer Society., (© 2017 American Cancer Society.)

Importance: Patient navigation (PN) to improve cancer screening in low-income and racial/ethnic minority populations usually focuses on navigating for single cancers in community health center settings., Objective: We evaluated PN for breast, cervical, and colorectal cancer screening using a population-based information technology (IT) system within a primary care network., Design, Setting, and Participants: Randomized clinical trial conducted from April 2014 to December 2014 in 18 practices in an academic primary care network. All patients eligible and overdue for cancer screening were identified and managed using a population-based IT system. Those at high risk for nonadherence with completing screening were identified using an electronic algorithm (language spoken, number of overdue tests, no-show visit history), and randomized to a PN intervention (n = 792) or usual care (n = 820). Navigators used the IT system to track patients, contact them, and provide intense outreach to help them complete cancer screening., Main Outcomes and Measures: Mean cancer screening test completion rate over 8-month trial for each eligible patient, with all overdue cancer screening tests combined using linear regression models. Secondary outcomes included the proportion of patients completing any and each overdue cancer screening test., Results: Among 1612 patients (673 men and 975 women; median age, 57 years), baseline patient characteristics were similar among randomized groups. Of 792 intervention patients, patient navigators were unable to reach 151 (19%), deferred 246 (38%) (eg, patient declined, competing comorbidity), and navigated 202 (32%). The mean proportion of patients who were up to date with screening among all overdue screening examinations was higher in the intervention vs the control group for all cancers combined (10.2% vs 6.8%; 95% CI [for the difference], 1.5%-5.2%; P < .001), and for breast (14.7% vs 11.0%; 95% CI, 0.2%-7.3%; P = .04), cervical (11.1% vs 5.7%; 95% CI, 0.8%-5.2%; P = .002), and colon (7.6% vs 4.6%; 95% CI, 0.8%-5.2%; P = .01) cancer compared with control. The proportion of overdue patients who completed any cancer screening during follow-up was higher in the intervention group (25.5% vs 17.0%; 95% CI, 4.7%-12.7%; P < .001). The intervention group had more patients completing screening for breast (23.4% vs 16.6%; 95% CI, 1.8%-12.0%; P = .009), cervical (14.4% vs 8.6%; 95% CI, 1.6%-10.5%; P = .007), and colorectal (13.7% vs 7.0%; 95% CI, 3.2%-10.4%; P < .001) cancer., Conclusions and Relevance: Patient navigation as part of a population-based IT system significantly increased screening rates for breast, cervical, and colorectal cancer in patients at high risk for nonadherence with testing. Integrating patient navigation into population health management activities for low-income and racial/ethnic minority patients might improve equity of cancer care., Trial Registration: clinicaltrials.gov Identifier: NCT02553538.

Objectives: Novel health information technology (IT)-based strategies harnessing patient registry data seek to improve care at a population level. We analyzed costs from a randomized trial of 2 health IT strategies to improve cancer screening compared with usual care from the perspective of a primary care network., Study Design: Monte Carlo simulations were used to compare costs across management strategies., Methods: We assessed the cost of the software, materials, and personnel for baseline usual care (BUC) compared with augmented usual care (AUC [ie, automated patient outreach]) and augmented usual care with physician input (AUCPI [ie, outreach mediated by physicians' knowledge of their patient panels]) over 1 year., Results: AUC and AUCPI each reduced the time physicians spent on cancer screening by 6.5 minutes per half-day clinical session compared with BUC without changing cancer screening rates. Assuming the value of this time accrues to the network, total costs of cancer screening efforts over the study year were $3.83 million for AUC, $3.88 million for AUCPI, and $4.10 million for BUC. AUC was cost-saving relative to BUC in 87.1% of simulations. AUCPI was cost-saving relative to BUC in 82.5% of simulations. Ongoing per patient costs were lower for both AUC ($35.63) and AUCPI ($35.58) relative to BUC ($39.51)., Conclusions: Over the course of the study year, the value of reduced physician time devoted to preventive cancer screening outweighed the costs of the interventions. Primary care networks considering similar interventions will need to capture adequate physician time savings to offset the costs of expanding IT infrastructure.

Background: Improving colorectal cancer (CRC) screening rates for patients from socioeconomically disadvantaged backgrounds is a recognized public health priority., Objective: Our aim was to determine if implementation of a system-wide screening intervention could reduce disparities in the setting of improved overall screening rates., Design: This was an interrupted time series (ITS) analysis before and after a population management intervention., Participants: Patients eligible for CRC screening (age 52-75 years without prior total colectomy) in an 18-practice research network from 15 June 2009 to 15 June 2012 participated in the study., Intervention: The Technology for Optimizing Population Care (TopCare) intervention electronically identified patients overdue for screening and facilitated contact by letter or telephone scheduler, with or without physician involvement. Patients identified by algorithm as high risk for non-completion entered into intensive patient navigation., Main Measures: Patients were dichotomized as ≤ high school diploma (≤ HS), an indicator of socioeconomic disadvantage, vs. >HS diploma (> HS). The monthly disparity between ≤ HS and > HS with regard to CRC screening completion was examined., Key Results: At baseline, 72% of 47,447 eligible patients had completed screening, compared with 75% of 51,442 eligible patients at the end of follow-up (p < 0.001). CRC screening completion was lower in ≤ HS vs. >HS patients in June 2009 (65.7% vs. 74.5%, p < 0.001) and remained lower in June 2012 (69.4% vs. 76.7%, p < 0.001). In the ITS analysis, which accounts for secular trends, TopCare was associated with a significant decrease in the CRC screening disparity (0.7%, p < 0.001). The effect of TopCare represents approximately 99 additional ≤ HS patients screened above prevailing trends, or 26 life-years gained had these patients remained unscreened., Conclusions: A multifaceted population management intervention sensitive to the needs of vulnerable patients modestly narrowed disparities in CRC screening, while also increasing overall screening rates. Embedding interventions for vulnerable patients within larger population management systems represents an effective approach to increasing overall quality of care while also decreasing disparities.

Background: Patient navigation (PN) can improve breast cancer care among disadvantaged women. We evaluated the impact of a PN program on follow-up after an abnormal mammogram., Methods: Between 2007 and 2010, disadvantaged women with an abnormal mammogram (Breast Imaging-Reporting and Data System [BI-RADS] codes 0, 3, 4, 5) cared for in a community health center (CHC) with PN were compared to those receiving care in 11 network practices without PN. Multivariable logistic regression and Cox proportional hazards modeling were used to compare the percentages receiving appropriate follow-up and time to follow-up between the groups., Results: Abnormal mammography findings were reported for 132 women in the CHC with PN and 168 from practices without PN. The percentage of women with appropriate follow-up care was higher in the practice with PN than in non-PN practices (90.4% vs. 75.3%, adjusted p=0.006). RESULTS varied by BI-RADS score for women in PN and non-PN practices (BI-RADS 0, 93.7% vs. 90.2%, p=0.24; BI-RADS 3, 85.7% vs. 49.2%, p=0.003; BI-RADS 4/5, 95.1% vs. 82.8%, p=0.26). Time to follow-up was similar for BI-RADS 0 and occurred sooner for women in the PN practice than in non-PN practices for BI-RADS 3 and 4/5 (BI-RADS 3, adjusted hazard ratio [aHR], 95% confidence interval [CI]: 2.41 [1.36-4.27], BI-RADS 4/5, aHR [95% CI]: 1.41 [0.88-2.24])., Conclusions: Disadvantaged women from a CHC with PN were more likely to receive appropriate follow-up after an abnormal mammogram than were those from practices without PN. Expanding PN to include all disadvantaged women within primary care networks could improve equity in cancer care.

Background: The long-term effects of interventions to improve colorectal (CRC) screening in vulnerable populations are uncertain. The authors evaluated the impact of patient navigation (PN) on the equity of CRC prevention over a 5-year period., Methods: A culturally tailored CRC screening PN program was implemented in 1 community health center (CHC) in 2007. In a primary care network, CRC screening rates from 2006 to 2010 among eligible patients from the CHC with PN were compared with the rates from other practices without PN. Multivariable logistic regression models for repeated measures were used to assess differences over time., Results: Differences in CRC screening rates diminished among patients at the CHC with PN and at other practices between 2006 (49.2% vs 62.5%, respectively; P < .001) and 2010 (69.2% vs 73.6%, respectively; P < .001). The adjusted rate of increase over time was higher at the CHC versus other practices (5% vs 3.4% per year; P < .001). Among Latino patients at the CHC compared with other practices, lower CRC screening rates in 2006 (47.5% vs 52.1%, respectively; P = .02) were higher by 2010 (73.5% vs 67.3%, respectively; P < .001). Similar CRC screening rates among non-English speakers at the CHC and at other practices in 2006 (44.3% vs 44.7%, respectively; P = .79) were higher at the CHC by 2010 (70.6% vs 58.6%, respectively; P < .001). Adjusted screening rates increased more over time for Latino and non-English speakers at the CHC compared with other practices (both P < .001)., Conclusions: A PN program increased CRC screening rates in a CHC and improved equity in vulnerable patients. Long-term funding of PN programs has the potential to reduce cancer screening disparities., (© 2014 American Cancer Society.)

Objective: To optimize a new visit-independent, population-based cancer screening system (TopCare) by using operations research techniques to simulate changes in patient outreach staffing levels (delegates, navigators), modifications to user workflow within the information technology (IT) system, and changes in cancer screening recommendations., Materials and Methods: TopCare was modeled as a multiserver, multiphase queueing system. Simulation experiments implemented the queueing network model following a next-event time-advance mechanism, in which systematic adjustments were made to staffing levels, IT workflow settings, and cancer screening frequency in order to assess their impact on overdue screenings per patient., Results: TopCare reduced the average number of overdue screenings per patient from 1.17 at inception to 0.86 during simulation to 0.23 at steady state. Increases in the workforce improved the effectiveness of TopCare. In particular, increasing the delegate or navigator staff level by one person improved screening completion rates by 1.3% or 12.2%, respectively. In contrast, changes in the amount of time a patient entry stays on delegate and navigator lists had little impact on overdue screenings. Finally, lengthening the screening interval increased efficiency within TopCare by decreasing overdue screenings at the patient level, resulting in a smaller number of overdue patients needing delegates for screening and a higher fraction of screenings completed by delegates., Conclusions: Simulating the impact of changes in staffing, system parameters, and clinical inputs on the effectiveness and efficiency of care can inform the allocation of limited resources in population management.

Background: Patient navigator (PN) programs can improve breast cancer screening in low income, ethnic/racial minorities. Refugee women have low breast cancer screening rates, but it has not been shown that PN is similarly effective., Objective: Evaluate whether a PN program for refugee women decreases disparities in breast cancer screening., Design: Retrospective program evaluation of an implemented intervention., Participants: Women who self-identified as speaking Somali, Arabic, or Serbo-Croatian (Bosnian) and were eligible for breast cancer screening at an urban community health center (HC). Comparison groups were English-speaking and Spanish-speaking women eligible for breast cancer screening in the same HC., Intervention: Patient navigators educated women about breast cancer screening, explored barriers to screening, and tailored interventions individually to help complete screening., Main Measures: Adjusted 2-year mammography rates from logistic regression models for each calendar year accounting for clustering by primary care physician. Rates in refugee women were compared to English-speaking and Spanish-speaking women in the year before implementation of the PN program and over its first 3 years., Results: There were 188 refugee (36 Somali, 48 Arabic, 104 Serbo-Croatian speaking), 2,072 English-speaking, and 2,014 Spanish-speaking women eligible for breast cancer screening over the 4-year study period. In the year prior to implementation of the program, adjusted mammography rates were lower among refugee women (64.1 %, 95 % CI: 49-77 %) compared to English-speaking (76.5 %, 95 % CI: 69 %-83 %) and Spanish-speaking (85.2 %, 95 % CI: 79 %-90 %) women. By the end of 2011, screening rates increased in refugee women (81.2 %, 95 % CI: 72 %-88 %), and were similar to the rates in English-speaking (80.0 %, 95 % CI: 73 %-86 %) and Spanish-speaking (87.6 %, 95 % CI: 82 %-91 %) women. PN increased screening rates in both younger and older refugee women., Conclusion: Linguistically and culturally tailored PN decreased disparities over time in breast cancer screening among female refugees from Somalia, the Middle East and Bosnia.

Objectives: To assess the ability of a health information technology system to facilitate population- based breast cancer screening., Study Design: Cohort study with 2-year follow-up after a 1-year cluster randomized trial., Methods: Study population was women 42 to 69 years old receiving care within a 12-practice primary care network. The management informatics system (1) identified women overdue for mammograms, (2) connected them to primary care providers using a web-based tool, (3) created automatically generated outreach letters for patients specified by providers, (4) monitored for subsequent mammography scheduling and completion, and (5) provided practice delegates with a list of women remaining unscreened for reminder phone calls. Eligible women overdue for a mammogram during a 1-year study period included those overdue at study start (prevalent cohort) and those who became overdue during follow-up (incident cohort). The main outcome measure was mammography completion rates over 3 years., Results: Among 32,688 eligible women, 9795 (30%) were overdue for screening (4487 intervention, 5308 control). Intervention patients were somewhat younger, more likely to be non-Hispanic white, and more likely to have health insurance compared with control patients. Adjusted completion rates in the prevalent cohort (n = 6697) were significantly higher among intervention patients after 3 years (51.7% vs 45.8%; P = .002). For patients in the incident cohort (n = 3098), adjusted completion rates after 2 years were 53.8% versus 48.7%, respectively (P = .052)., Conclusions: Population-based informatics systems can enable sustained increases in mammography screening rates beyond rates seen with office-based visit reminders.

Background: Information technology offers the promise, as yet unfulfilled, of delivering efficient, evidence-based health care., Objective: To evaluate whether a primary care network-based informatics intervention can improve breast cancer screening rates., Design: Cluster-randomized controlled trial of 12 primary care practices conducted from March 20, 2007 to March 19, 2008., Patients: Women 42-69 years old with no record of a mammogram in the prior 2 years., Interventions: In intervention practices, a population-based informatics system was implemented that: connected overdue patients to appropriate care providers, presented providers with a Web-based list of their overdue patients in a non-visit-based setting, and enabled "one-click" mammography ordering or documented deferral reasons. Patients selected for mammography received automatically generated letters and follow-up phone calls. All practices had electronic health record reminders about breast cancer screening available during clinical encounters., Main Measures: The primary outcome was the proportion of overdue women undergoing mammography at 1-year follow-up., Key Results: Baseline mammography rates in intervention and control practices did not differ (79.5% vs 79.3%, p = 0.73). Among 3,054 women in intervention practices and 3,676 women in control practices overdue for mammograms, intervention patients were somewhat younger, more likely to be non-Hispanic white, and have health insurance. Most intervention providers used the system (65 of 70 providers, 92.9%). Action was taken for 2,652 (86.8%) intervention patients [2,274 (74.5%) contacted and 378 (12.4%) deferred]. After 1 year, mammography rates were significantly higher in the intervention arm (31.4% vs 23.3% in control arm, p < 0.001 after adjustment for baseline differences; 8.1% absolute difference, 95% CI 5.1-11.2%). All demographic subgroups benefited from the intervention. Intervention patients completed screening sooner than control patients (p < 0.001)., Conclusions: A novel population-based informatics system functioning as part of a non-visit-based care model increased mammography screening rates in intervention practices., Trial Registration: ClinicalTrials.gov; NCT00462891.

Background: Minority racial/ethnic groups have low colorectal cancer (CRC) screening rates., Objective: To evaluate a culturally tailored intervention to increase CRC screening, primarily using colonoscopy, among low income and non-English speaking patients., Design: Randomized controlled trial conducted from January to October of 2007., Setting: Single, urban community health center serving a low-income, ethnically diverse population., Patients: A total of 1,223 patients 52-79 years of age overdue for CRC screening, randomized to intervention (n = 409) vs. usual care control (n = 814) groups., Intervention: Intervention patients received an introductory letter with educational material followed by phone or in-person contact by a language-concordant "navigator." Navigators (n = 5) were community health workers trained to identify and address patient-reported barriers to CRC screening. Individually tailored interventions included patient education, procedure scheduling, translation and explanation of bowel preparation, and help with transportation and insurance coverage. Rates of colorectal cancer screening were assessed for intervention and usual care control patients., Results: Over a 9-month period, intervention patients were more likely to undergo CRC screening than control patients (27% vs. 12% for any CRC screening, p < 0.001; 21% vs. 10% for colonoscopy completion, p < 0.001). The higher screening rate resulted in the identification of 10.5 polyps per 100 patients in the intervention group vs. 6.8 in the control group (p = 0.04)., Limitations: Patients were from one health center. Some patients may have obtained CRC screening outside our system., Conclusions: A culturally tailored, language-concordant navigator program designed to identify and overcome barriers to colorectal cancer screening can significantly improve colonoscopy rates for low income, ethnically and linguistically diverse patients. ClinicalTrials.gov registration number: NCT00476970.