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Understanding the multilevel factors associated with controlled blood pressure is important to determine modifiable factors for future interventions, especially among populations living in poverty. This study identified clinically important factors associated with blood pressure control among patients receiving care in community health centers.This study includes 31,089 patients with diagnosed hypertension by 2015 receiving care from 103 community health centers; aged 19-64 years; and with ≥1 yearly visit with ≥1 recorded blood pressure in 2015, 2016, and 2017. Blood pressure control was operationalized as an average of all blood pressure measurements during all the 3 years and categorized as controlled (blood pressure140/90), partially controlled (mixture of controlled and uncontrolled blood pressure), or never controlled. Multinomial mixed-effects logistic regression models, conducted in 2022, were used to calculate unadjusted ORs and AORs of being in the never- or partially controlled blood pressure groups versus in the always-controlled group.A total of 50.5% had always controlled, 39.7% had partially controlled, and 9.9% never had controlled blood pressure during the study period. The odds of being partially or never in blood pressure control were higher for patients without continuous insurance (AOR=1.09; 95% CI=1.03, 1.16; AOR=1.18; 95% CI=1.07, 1.30, respectively), with low provider continuity (AOR=1.24; 95% CI=1.15, 1.34; AOR=1.28; 95% CI=1.13, 1.45, respectively), with a recent diagnosis of hypertension (AOR=1.34; 95% CI=1.20, 1.49; AOR=1.19; 95% CI=1.00, 1.42), with inconsistent antihypertensive medications (AOR=1.19; 95% CI=1.11, 1.27; AOR=1.26; 95% CI=1.13, 1.41, respectively), and with fewer blood pressure checks (AOR=2.14; 95% CI=1.97, 2.33; AOR=2.17; 95% CI=1.90, 2.48, respectively) than for their counterparts.Efforts targeting continuous and consistent access to care, antihypertensive medications, and regular blood pressure monitoring may improve blood pressure control among populations living in poverty.

Background Multiple quality metrics have been recommended to ensure consistent, high-quality execution of screening tests for breast, cervical, colorectal, and lung cancers. However, minimal data exist evaluating the evidence base supporting these recommendations and the consistency of definitions and concepts included within and between cancer types. Methods We performed a systematic review for each cancer type using MEDLINE, Embase, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) from 2010 to April 2020 to identify guidelines from screening programs or professional organizations containing quality metrics for tests used in breast, cervical, colorectal, and lung cancer screening. We abstracted metrics’ definitions, target performance levels, and related supporting evidence for test completeness, adequacy (sufficient visualization or collection), accuracy, and safety. Results We identified 11 relevant guidelines with 20 suggested quality metrics for breast cancer, 5 guidelines with 9 metrics for cervical cancer, 13 guidelines with 18 metrics for colorectal cancer (CRC), and 3 guidelines with 7 metrics for lung cancer. These included 54 metrics related to adequacy (n = 6), test completeness (n = 3), accuracy (n = 33), and safety (n = 12). Target performance levels were defined for 30 metrics (56%). Ten (19%) were supported by evidence, all from breast and CRC, with no evidence cited to support metrics from cervical and lung cancer screening. Conclusions Considerably more guideline-recommended test performance metrics exist for breast and CRC screening than cervical or lung cancer. The domains covered are inconsistent among cancers, and few targets are supported by evidence. Clearer evidence-based domains and targets are needed for test performance metrics. Registration PROSPERO 2020 CRD42020179139

Background: A team approach is one of the most effective ways to lower blood pressure (BP) in uncontrolled hypertension, but different models for organizing team-based care have not been compared directly. Methods: A pragmatic, cluster-randomized trial compared 2 interventions in adult patients with moderately severe hypertension (BP≥150/95 mm Hg): (1) clinic-based care using best practices and face-to-face visits with physicians and medical assistants; and (2) telehealth care using best practices and adding home BP telemonitoring with home-based care coordinated by a clinical pharmacist or nurse practitioner. The primary outcome was change in systolic BP over 12 months. Secondary outcomes were change in patient-reported outcomes over 6 months. Results: Participants (N=3071 in 21 primary care clinics) were on average 60 years old, 47% male, and 19% Black. Protocol-specified follow-up within 6 weeks was 32% in clinic-based care and 27% in telehealth care. BP decreased significantly during 12 months of follow-up in both groups, from 157/92 to 139/82 mm Hg in clinic-based care patients (adjusted mean difference −18/−10 mm Hg) and 157/91 to 139/81 mm Hg in telehealth care patients (adjusted mean difference −19/−10 mm Hg), with no significant difference in systolic BP change between groups (−0.8 mm Hg [95% CI, −2.84 to 1.32]). Telehealth care patients were significantly more likely than clinic-based care patients to report frequent home BP measurement, rate their BP care highly, and report that BP care visits were convenient. Conclusions: Telehealth care that includes extended team care is an effective and safe alternative to clinic-based care for improving patient-centered care for hypertension. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02996565.

Background: Few empirical data are available to inform older adults’ decisions about whether to screen or continue screening for colorectal cancer based on their prior history of screening, particularly among individuals with a prior negative exam. Methods: Using a retrospective cohort of older adults receiving healthcare at three Kaiser Permanente integrated healthcare systems in Northern California (KPNC), Southern California (KPSC), and Washington (KPWA), we estimated the cumulative risk of colorectal cancer incidence and mortality among older adults who had a negative colonoscopy 10 years earlier, accounting for death from other causes. Results: Screen-eligible adults ages 76 to 85 years who had a negative colonoscopy 10 years earlier were found to be at a low risk of colorectal cancer diagnosis, with a cumulative incidence of 0.39% [95% CI, 0.31%–0.48%) at 2 years that increased to 1.29% (95% CI, 1.02%–1.61%) at 8 years. Cumulative mortality from colorectal cancer was 0.04% (95% CI, 0.02%–0.08%) at 2 years and 0.46% (95% CI, 0.30%–0.70%) at 8 years. Conclusions: These low estimates of cumulative colorectal cancer incidence and mortality occurred in the context of much higher risk of death from other causes. Impact: Knowledge of these results could bear on older adults’ decision to undergo or not undergo further colorectal cancer screening, including choice of modality, should they decide to continue screening. See related commentary by Lieberman, p. 6

Supplemental Tables

Supplementary Figure 3

Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers’ perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017–2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40–49, 50–74, and ≥75 years. For patients 50–74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40–49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e.

Supplementary Figure 1

To estimate the positive predictive value (PPV) of International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes for identifying HF subtypes.We validated ICD-10-CM HF diagnosis codes among Kaiser Permanente Washington enrollees who were ≥18 years of age and had an ICD-10-CM HF diagnosis code during 2017-2018 and a procedure code for an echocardiogram in the 12 months before through 6 months after the HF code. Left ventricular ejection fraction (LVEF) ascertained from medical chart review was used as the gold standard for classifying patients as having reduced ejection fraction (rEF), mid-range ejection fraction (mEF), or preserved ejection fraction (pEF).Among 6194 eligible patients, we randomly sampled 1000 for medical chart review. A total of 974 patients had LVEF information in their chart. The ICD-10-CM HF code group with the highest PPV for rEF was I50.20-I50.23, "Systolic (congestive) heart failure," PPV = 41.4% (95% CI, 34.5-48.7%); and the highest PPV for mEF or rEF was also I50.20-I50.23, PPV = 70.2% (95% CI, 63.1-76.4%). The highest PPV for pEF was the I50.30-I50.33 group, "Diastolic (congestive) heart failure," PPV = 92.0% (95% CI, 88.1-94.7%); and the highest PPV for mEF or pEF was also I50.30-I50.33, PPV = 97.7% (95% CI, 95.1-99.0%).If the accuracy measure of greatest interest is PPV, our results suggest that ICD-10-CM HF codes alone may not be adequate for identifying patients with rEF but may be adequate for identifying patients with pEF. HF coding practices may vary across settings, which may impact generalizability of our findings.

Background: To reduce colorectal cancer mortality, positive fecal blood tests must be followed by colonoscopy.Methods: We identified 62,384 individuals ages 50 to 89 years with a positive fecal blood test between January 1, 2011 and December 31, 2012 in four health care systems within the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium. We estimated the probability of follow-up colonoscopy and 95% confidence intervals (CI) using the Kaplan–Meier method. Overall differences in cumulative incidence of follow-up across health care systems were assessed with the log-rank test. HRs and 95% CIs were estimated from multivariate Cox proportional hazards models.Results: Most patients who received a colonoscopy did so within 6 months of their positive fecal blood test, although follow-up rates varied across health care systems (P Conclusion: Individual characteristics and health care system were associated with colonoscopy after positive fecal blood tests. Patterns were consistent across health care systems, but proportions of patients receiving follow-up varied. These findings suggest that there is room to improve follow-up of positive colorectal cancer screening tests.Impact: Understanding the timing of colonoscopy after positive fecal blood tests and characteristics associated with lack of follow-up may inform future efforts to improve follow-up. Cancer Epidemiol Biomarkers Prev; 25(2); 344–50. ©2016 AACR.

Supplementary Table S1. Characteristics of PROSPR participants with a positive fecal occult blood test with no covariate information missing, 2011-2012 (N=47,827). Supplementary Table S2. Associations between patient characteristics and time to colonoscopy follow-up after positive fecal occult blood test in PROSPR healthcare systems, 2011-2012, over different follow-up periods.

Background The US Preventive Services Task Force recommends blood pressure (BP) measurements using 24-h ambulatory monitoring (ABPM) or home BP monitoring before making a new hypertension diagnosis. Objective Compare clinic-, home-, and kiosk-based BP measurement to ABPM for diagnosing hypertension. Design, Setting, and Participants Diagnostic study in 12 Washington State primary care centers, with participants aged 18–85 years without diagnosed hypertension or prescribed antihypertensive medications, with elevated BP in clinic. Interventions Randomization into one of three diagnostic regimens: (1) clinic (usual care follow-up BPs); (2) home (duplicate BPs twice daily for 5 days); or (3) kiosk (triplicate BPs on 3 days). All participants completed ABPM at 3 weeks. Main Measures Primary outcome was difference between ABPM daytime and clinic, home, and kiosk mean systolic BP. Differences in diastolic BP, sensitivity, and specificity were secondary outcomes. Key Results Five hundred ten participants (mean age 58.7 years, 80.2% white) with 434 (85.1%) included in primary analyses. Compared to daytime ABPM, adjusted mean differences in systolic BP were clinic (−4.7mmHg [95% confidence interval −7.3, −2.2]; PP=.92); and kiosk (9.5mmHg [7.5, 11.6];PPP=.52); and kiosk (5.0mmHg [3.8, 6.2]; P Limitations Single health care organization and limited race/ethnicity representation. Conclusions Compared to ABPM, mean BP was significantly lower for clinic, significantly higher for kiosk, and without significant differences for home. Clinic BP measurements had low sensitivity for detecting hypertension. Findings support utility of home BP monitoring for making a new diagnosis of hypertension. Trial Registration ClinicalTrials.gov NCT03130257 https://clinicaltrials.gov/ct2/show/NCT03130257

Background Automated office blood pressure (AOBP) using 3–5 measurements taken with an oscillometric device with or without an attendant in the room may decrease “white coat” effect. We evaluated the impact of the presence or absence of the attendant and rest on BP and diagnosis of hypertension. Methods We randomly assigned 133 adults aged 18–85 with high BP at baseline (≥140/90 mm Hg), no hypertensive diagnosis and no antihypertensive medications to either attended AOBP first, unattended second, or unattended AOBP first, attended second. Outcomes included within-person BP difference for attended vs. unattended measurements; 5 vs. 15 minutes of rest; and the diagnostic performance of AOBP compared with daytime automated blood pressure measurement (ABPM). Results We found no significant differences between attended and unattended AOBP (mean difference attended − unattended [95% confidence interval, CI], systolic 0.14 mm Hg [−0.78, 1.06]; diastolic 0.16 mm Hg [−0.45, 0.78]) or by rest time (mean difference 15 − 5 minutes [95% CI], systolic −0.45 mm Hg [−1.36, 0.47]; diastolic 0.61 mm Hg [−1.23, 0.003]). AOBP was lower than mean daytime ABPM, regardless of attendance or rest (after 5 minutes rest systolic −3.6 and diastolic −2.55 mm Hg, P = 0.001 for both comparisons). Using daytime ABPM of ≥135/85 mm Hg as the diagnostic threshold, AOBP sensitivity and specificity after 5 minutes of rest were 71.0% and 54.1%, respectively. Conclusions The presence or absence of a clinic attendant during AOBP measurement and the amount of rest time before AOBP measurements had no effects on BP. AOBP measurements have low sensitivity and specificity for making a new diagnosis of hypertension.

Background Hypertension control has been decreasing recently. We compared the experience and attitudes toward care between patients with uncontrolled hypertension who are more and less satisfied with that care to identify ways to improve their care. Methods Baseline survey of 3072 patients with diagnosed hypertension and repeated blood pressure measurements at or above 150/95 mmHg during clinic appointments at 21 primary care clinics of a large Midwestern multi-specialty medical group. Survey questions were about previous hypertension care satisfaction, the degree to which that care was patient-centered, their feelings of self-confidence and treatment burden in managing hypertension, and medication side effects. Results A total of 1697 patients completed surveys (response rate = 55%). Of the 1697 patients, the 24% who were most dissatisfied (scored 0 to 5 on a 0 to 10 scale of satisfaction) significantly differed from those most satisfied (scored 9 to 10) on all demographic and clinical characteristics as well as on every measure of care experience and health status. After adjusting for those characteristics, reports of patient-centered care, self-confidence, stopping the medication because of side effects, and the burdensomeness of treatment were all significantly worse (P Conclusions Many patients with uncontrolled hypertension are dissatisfied with their care, but that is associated with different problems for different people. Identifying and attending to these problems may provide opportunities to help them achieve better control.

Background Health insurance plans are increasingly offering mailed fecal immunochemical test (FIT) programs for colorectal cancer (CRC) screening, but few studies have compared the outcomes of different program models (eg, invitation strategies). Methods This study compares the outcomes of 2 health plan-based mailed FIT program models. In the first program (2016), FIT kits were mailed to all eligible enrollees; in the second program (2018), FIT kits were mailed only to enrollees who opted in after an outreach phone call. Participants in this observational study included dual-eligible Medicaid/Medicare enrollees who were aged 50 to 75 years and were due for CRC screening (1799 in 2016 and 1906 in 2018). Six-month FIT completion rates, implementation outcomes (eg, mailed FITs sent and reminders attempted), and program-related health plan costs for each program are described. Results All 1799 individuals in 2016 were sent an introductory letter and a FIT kit. In 2018, all 1906 were sent an introductory letter, and 1905 received at least 1 opt-in call attempt, with 410 (21.5%) sent a FIT. The FIT completion rate was 16.2% (292 of 1799 [95% CI, 14.5%-17.9%]) in 2016 and 14.6% (278 of 1906 [95% CI, 13.0%-16.2%]) in 2018 (P = .36). The overall implementation costs were higher in 2016 ($40,156) than 2018 ($34,899), with the cost per completed FIT slightly higher in 2016 ($138) than 2018 ($126). Conclusions An opt-in mailed FIT program achieved FIT completion rates similar to those of a program mailing to all dual-eligible Medicaid/Medicare enrollees. Lay summary Health insurance plans can use different program models to successfully mail fecal test kits for colorectal cancer screening to dual-eligible Medicaid/Medicare enrollees, with nearly 1 in 6 enrollees completing fecal testing.

Background: Little information is available as to whether undergoing hypertension diagnostic testing or receiving a new diagnosis of hypertension leads to psychological distress. Design, Setting, and Participants: BP CHECK was a randomized diagnostic study of 510 adults aged 18-85. Participants had elevated BP in clinic at baseline but no previously diagnosed hypertension. The trial was conducted from 2017 to 2019 in primary care centers of an integrated healthcare system. Participants were randomized to one of three diagnostic regimens: (1) Clinic BP, (2) Home BP, or (3) Kiosk BP. All participants completed 24-hour ambulatory blood pressure monitoring (ABPM) at 3 weeks. ABPM results were sent to participants and their primary care providers and uploaded into the electronic health record. This analysis includes a subset of participants (n=255) who completed psychological distress questionnaires at baseline, and at least one follow-up (after completing their diagnostic regimen and 6 months after randomization) Main Outcomes and Measures: The primary outcomes were within-person change in psychological distress (impact of events and state anxiety scales, BP worry Likert 5-point scale) comparing baseline to 3 weeks and 6 months post-enrollment. Results: Participants were half female (127/255), mostly > age 50 (78%), and White race (83%). Baseline mean BP was 150 mmHg systolic and 80 mmHg diastolic; 63.9% had hypertension on ABPM (daytime average > 135/85 mmHg). There was no significant change in impact of events or state anxiety at either follow-up. BP worry was significantly increased at 3 weeks (mean change 0.22 (0.13-0.30), but not at 6 months. Six month outcomes were not influenced by ABPM test results or receiving a hypertension diagnosis. Conclusion and Relevance: The hypertension diagnostic process increased hypertension worry short term, but not longer-term. It had little impact on other measures of psychologic distress. The risk of psychologic distress after hypertension diagnostic testing and receipt of a hypertension diagnosis appears to be low, reinforcing the importance of timely hypertension diagnoses. Additional studies with more diverse patient populations are needed.

Terminal digit preference has been shown to be associated with inaccurate blood pressure (BP) recording.To evaluate whether converting from manual BP measurement with aneroid sphygmomanometers to automated BP measurement was associated with terminal digit preference, mean levels of recorded BP, and the rate at which hypertension was diagnosed.This quality improvement study was conducted from May 9, 2021, to March 24, 2022, using interrupted time series analysis of medical record data from 11 primary care clinics in a single health care system from April 2008 to April 2015. The study population was patients aged 18 to 75 years who had their BP measured and recorded at least once during the study period.Manual BP measurement before April 2012 vs automated BP measurement with the Omron HEM-907XL monitor from May 2012 to April 2015.The main outcome was the distribution of terminal digits and mean systolic BP (SBP) values obtained during 4 years of manual measurement vs 3 years of automated measurement, assessed using a generalized linear mixed regression model with a random intercept for clinic and adjusted for seasonal fluctuations and patient demographic and clinical characteristics.The study included 1 541 227 BP measurements from 225 504 unique patients during the entire study period, with 849 978 BP measurements from 165 137 patients (mean [SD] age, 47.1 [15.2] years; 58.2% female) during the manual measurement period and 691 249 measurements from 149 080 patients (mean [SD] age, 48.4 [15.3] years; 56.3% female) during the automated measurement period. With manual measurement, 32.8% of SBP terminal digits were 0 (20% was the expected value because nursing staff was instructed to record BP to the nearest even digit). This proportion decreased to 12.4% during the automated measurement period (expected value, 10%) when both even and odd digits were to be recorded. After automated measurement was implemented, the mean SBP estimated with statistical modeling increased by 5.09 mm Hg (95% CI, 4.98-5.19 mm Hg). Fewer BP values recorded during the automated than the manual measurement period were below 140/90 mm Hg (69.9% vs 84.3%; difference, -14.5%; 95% CI, -14.6% to -14.3%) and below 130/80 mm Hg (42.1% vs 60.0%; difference, -17.9%; 95% CI, -18.0% to -17.7%). The proportion of patients with a diagnosis of hypertension was 4.3 percentage points higher (23.4% vs 19.1%) during the automated measurement period.In this quality improvement study, automated BP measurement was associated with decreased terminal digit preference and significantly higher mean BP levels. The method of BP measurement was also associated with the rate at which hypertension was diagnosed. These findings may have implications for pay-for-performance programs, which may create an incentive to record BP levels that meet a particular goal and a disincentive to adopt automated measurement of BP.

Mailing HPV self-sampling kits to overdue individuals increases cervical cancer screening adherence; offering self-sampling to previously adherent individuals has not been evaluated in the U.S. Given heterogeneity of the U.S. health system and population, data are needed to optimize how HPV self-sampling is offered to individuals who are overdue, due after successful past screening, or have an unknown screening history.STEP is a pragmatic randomized controlled trial set within a U.S. integrated healthcare delivery system, designed to compare different outreach approaches for offering HPV self-sampling in populations defined by prior screening behavior (previously-adherent, overdue, or unknown screening history). Over 14 months, eligible individuals were identified through electronic medical record (EMR) data and randomized to Usual Care (UC), Education (UC + educational materials about cervical cancer screening), Direct-Mail (UC + Education + a mailed self-sampling kit) or Opt-In (UC + Education + option to request a kit), depending on screening history. The primary objective is to compare screening completion by outreach approach and screening history. Secondary objectives include evaluating incremental cost-effectiveness of outreach approaches, and identifying patient preference for, and satisfaction with, HPV self-screening, and barriers to abnormal results follow-up (measured through interviews and focus groups).The trial was designed to generate data that U.S. health systems can use to inform primary HPV screening implementation strategies that incorporate HPV self-sampling options to improve screening access, adherence, and patient satisfaction. The objective of this report is to describe the rationale and design of this pragmatic trial.

Purpose: To explore financial incentives as an intervention to improve colorectal cancer screening (CRCS) adherence among traditionally disadvantaged patients who have never been screened or are overdue for screening. Approach: We used qualitative methods to describe patients’ attitudes toward the offer of incentives, plans for future screening, and additional barriers and facilitators to CRCS. Setting: Kaiser Permanente Washington (KPWA). Participants: KPWA patients who were due or overdue for CRCS. Method: We conducted semi-structured qualitative interviews with 37 patients who were randomized to 1 of 2 incentives (guaranteed $10 or a lottery for $50) to complete CRCS. Interview transcripts were analyzed using a qualitative content approach. Results: Patients generally had positive attitudes toward both types of incentives, however, half did not recall the incentive offer at the time of the interview. Among those who recalled the offer, 95% were screened compared to only 25% among those who did not remember the offer. Most screeners stated that staying healthy was their primary motivator for screening, but many suggested that the incentive helped them prioritize and complete screening. Conclusions: Incentives to complete CRCS may help motivate patients who would like to screen but have previously procrastinated. Future studies should ensure that the incentive offer is noticeable and shorten the deadline for completion of FIT screening.

ImportanceHuman papillomavirus (HPV) self-sampling addresses barriers to cervical cancer screening, and mailed self-sampling kits have been reported to increase screening uptake. International research suggests mailed kits are cost-effective in certain settings. However, the cost-effectiveness of mailing HPV self-sampling kits for increasing screening uptake has not been evaluated in the US.ObjectiveTo conduct an economic evaluation of a mailed HPV self-sampling intervention among underscreened women enrolled in an integrated US health care system.Design, Setting, and ParticipantsThis economic evaluation involved a cost-effectiveness analysis of results from a randomized clinical trial of 19 851 women aged 30 to 64 years enrolled in a health plan from Kaiser Permanente Washington (KPWA), a US-based integrated health care system. Women were identified through electronic medical records, and eligible participants were enrolled in a health plan for at least 3 years and 5 months, had a primary care clinician, had not received a Papanicolaou test for at least 3 years and 5 months, and had not received a hysterectomy. Enrollment occurred from February 25, 2014, to August 29, 2016, with follow-up through February 25, 2018. The current economic evaluation was conducted between August 2, 2021, and July 30, 2022. Intervention delivery costs were calculated from both the KPWA and Medicare perspectives and were based on either wellness visit or Papanicolaou test–only visit costs.InterventionParticipants in the control group received usual care, which comprised patient reminders and ad hoc outreach for screening. Participants in the intervention group received usual care plus a mailed HPV self-sampling kit.Main Outcome and MeasuresThe primary economic outcome was the incremental cost-effectiveness ratio (ICER) for increased screening uptake, defined as the incremental difference in cost (intervention group minus control group) divided by the difference in the number of participants completing screening (intervention group minus control group) within 6 months of randomization.ResultsAmong 19 851 women (mean [SD] age, 50.1 [9.5] years; 76.7% White), 9960 were randomized to the intervention group, and 9891 were randomized to the control group. Baseline ICERs ranged from $85.84 (95% CI, $85.68-$85.99) using KPWA wellness visits as the cost basis to $146.29 (95% CI, $146.20-$146.38) using Medicare Papanicolaou test–only visits as the cost source. Subgroups of participants aged 50 to 64 years and participants most recently overdue for screening achieved cost-effectiveness at lower levels of willingness to pay for an additional completed screening than other subgroups.Conclusions and RelevanceIn this economic evaluation, mailing HPV self-sampling kits to women overdue for cervical cancer screening was cost-effective for increased screening uptake relative to usual care. These results support mailing HPV kits as an efficient outreach strategy for increasing screening rates among eligible women in US health care systems.

Background: Over 14,000 cervical cancers are diagnosed annually in the U.S. In 2019, ~30% of individuals with a cervix were under-screened based on current guidelines. Previous studies established feasibility of mailed self-sampling high-risk HPV test kits to improve screening adherence. Qualitative findings from our HOME trial found unmet information needs and anxiety among patients with a positive kit result. We designed the STEP trial to test optimized implementation strategies for educating patients about screening when offering the kit to patients due/overdue for screening, and when reporting results. Purpose: To evaluate acceptability of the implementation strategies, we interviewed individuals after receiving a positive kit result about the result communication processes and their information needs. Methods: The STEP trial added a centralized licensed practical nurse to communicate about and arrange scheduling for all patients with positive kit results, and provided an educational pamphlet to explain the purpose of HPV testing (especially difference to Pap testing) and how latent infections can reactivate. Telephone interviews were conducted from December 2021 to March 2022 with 29 patients (56% of invited) who had a positive kit result. Interview guide asked about reaction to the kit, results communication, patient-provider interactions, and follow-up visit experiences; and included a survey regarding attitudes toward the kit. Five coders analyzed interview transcripts using iterative content analysis; 12 transcripts were double-coded. Codes were organized into node reports to identify overarching themes. Results: Of 29 participants, most (65.5%) were non-Hispanic White and the average age was 47.5 years (SD=11.2). Participants appreciated the convenience of the kit, though a few worried about the accuracy of self-sampling test results, especially compared to screening performed by a provider. While surprised by the positive kit result, all reported feeling reassured after talking with the nurse and understood next steps in the diagnosis and management process, although some reported still wanting to check with their primary care provider about the test findings. Though an educational pamphlet was provided with the home HPV kit, most participants did not recall receiving it or using it to understand their kit results. After reflecting on home kit versus in-clinic screening, most (69%) preferred using the kit on their own to provider-collected screening. All (100%) agreed that the kit instructions were easy to understand, however 90% were sure that they had sampled the right place, and 86% believed that the home test results were correct. Discussion: Unlike the prior HOME trial, there was less negative affect expressed by patients after receiving results. This suggests patients received the information needed to continue with the screening process and supports the value of a centralized nurse. Providing educational materials at multiple timepoints may further improve results communication in the future. Citation Format: Meera Muthukrishnan, Jasmin A. Tiro, Kris Hansen, John Lin, Caitlin Dorsey, Hongyuan Gao, Catherine Troja, Melissa Anderson, Richard Meenan, Beverly B. Green, Diana S.M. Buist, Rachel Winer. Improving communication and management following a positive home HPV self-sampling kit result [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A108.

Primary care provider's (PCP) perceptions of colorectal cancer screening test effectiveness and their recommendations for testing intervals influence patient screening uptake. Few large studies have examined providers’ perceptions and recommendations, including their alignment with evidence suggesting comparable test effectiveness and guideline recommendations for screening frequency. Providers (n = 1,281) within four healthcare systems completed a survey in 2017–2018 regarding their perceptions of test effectiveness and recommended intervals for colonoscopy and fecal immunochemical testing (FIT) for patients ages 40–49, 50–74, and ≥75 years. For patients 50–74 (screening eligible), 82.9% of providers rated colonoscopy as very effective versus 59.6% for FIT, and 26.3% rated colonoscopy as more effective than FIT. Also, for this age group, 77.9% recommended colonoscopy every 10 years and 92.4% recommended FIT annually. For patients ages 40–49 and ≥75, more than one-third of providers believed the tests were somewhat or very effective, although >80% did not routinely recommend screening by either test for these age groups. Provider screening test interval recommendations generally aligned with colorectal cancer guidelines; however, 25% of providers believed colonoscopy was more effective than FIT for mortality reduction, which differs from some modeling studies that suggest comparable effectiveness. The latter finding may have implications for health systems where FIT is the dominant screening strategy. Only one-third of providers reported believing these screening tests were effective in younger and older patients (i.e.

During the COVID-19 pandemic, telemedicine has emerged worldwide as an indispensable resource to improve the surveillance of patients, curb the spread of disease, facilitate timely identification and management of ill people, but, most importantly, guarantee the continuity of care of frail patients with multiple chronic diseases. Although during COVID-19 telemedicine has thrived, and its adoption has moved forward in many countries, important gaps still remain. Major issues to be addressed to enable large scale implementation of telemedicine include: (1) establishing adequate policies to legislate telemedicine, license healthcare operators, protect patients’ privacy, and implement reimbursement plans; (2) creating and disseminating practical guidelines for the routine clinical use of telemedicine in different contexts; (3) increasing in the level of integration of telemedicine with traditional healthcare services; (4) improving healthcare professionals’ and patients’ awareness of and willingness to use telemedicine; and (5) overcoming inequalities among countries and population subgroups due to technological, infrastructural, and economic barriers. If all these requirements are met in the near future, remote management of patients will become an indispensable resource for the healthcare systems worldwide and will ultimately improve the management of patients and the quality of care.

Background: Proportion of time covered (PTC, or “covered time”) is a longitudinal measure of adherence to preventive health services, the use of which has increased in recent years. This measure is helpful for evaluating the success of delivering screening interventions over time. However, there are challenges and nuances in computing and interpreting PTC. Methods: In this manuscript, we describe some desired properties of PTC measures, challenges in achieving those, and potential solutions using hypothetical examples. Results: We propose a modified PTC measure (mPTC) to complement the standard, existing PTC measure. The mPTC measure focuses on screening completion rather than initiation when a screening modality requires more than one step; is affected less by loss to follow-up, death, or cancer during covered time than the standard PTC measure; and is not sensitive to screening episode results. We propose weighting strategies to ensure that the average PTC and mPTC are more heavily influenced by individuals who were observed for longer and are thus more informative. We further describe how PTC and mPTC measures can incorporate test indication to focus specifically on screening. Conclusions: We recommend that studies of covered time present ample descriptive information, calculate both PTC and mPTC, describe how symptoms and indication are handled, and present multiple complementary measures, such as the proportion never screened and the proportion in need of screening. Impact: Common approaches, terminology, and reporting practices for covered time measures have the potential to improve the study of longitudinal cancer screening adherence.

Objectives: In this study, we conducted telephone interviews with patients in community clinics who had abnormal fecal immunochemical test (FIT) results to identify follow-up colonoscopy challenges. The FIT is an effective colorectal cancer screening method, but its value is contingent on follow-up diagnostic colonoscopy. Methods: We explored barriers at 3 timepoints: (1) abnormal FIT-result communication, (2) scheduling/completion of colonoscopy, and (3) receipt of results. We sought to understand variation in experience by both Spanish and English language patients. Results: We interviewed 32 patients (16 English; 16 Spanish), 66% of whom were women. There were 13 early completers (≤ 2 months after FIT result), 14 later completers (> 2 months after FIT result), and 5 non-completers of the colonoscopy. The greatest challenge was fear of the procedure, expressed more often by Spanish language (SL) participants and later completers. SL participants also cited cost and lack of clear communication about the need for a colonoscopy. English language (EL) participants experienced lack of reliable transportation. Conclusions: Barriers to timely colonoscopy completion following an abnormal FIT can occur at different transitions in care and vary by patient characteristics. Our findings may inform the design of programs to improve colonoscopy completion in safety net clinics.

BeneFIT was a demonstration project that worked with a Medicaid/Medicare health plan to implement a mailed fecal immunochemical test (FIT) program. The goal was to reach age-eligible enrollees who were due for colorectal cancer (CRC) screening and prompt them to complete a FIT. One health insurance plan collaborated with six federally qualified health centers (FQHCs) in Oregon. Reach was defined as the percent of eligible individuals overdue for CRC screening who were mailed a FIT in 2016. We examined patient-level factors associated with reach, using multivariable log binomial regression and FIT completion rates at 6 months. The health plan identified 3386 age-eligible members overdue for CRC screening. Of these, 2615 (77.2%) were reached (mailed FIT kits) and 771 (22.8%) were not; 478 (14.1%) because they were not considered to be clinic patients and 290 (8.6%) because of mailing issues. Patient-level factors associated with not being reached were: being male, being Medicaid-insured (vs. Medicare), and having no primary care visits (vs. 4+ visits) in the last year. Among all enrollees identified as overdue for CRC screening, FIT completion rates at 6 months were 14.8% overall and 18.5% in the subgroup reached. In a mailed FIT program, a health insurance plan attempted to reach as many enrollees overdue for CRC screening as possible, however 22.8% were not mailed a FIT. Additional efforts are needed to ensure that the hardest to reach enrollees can participate in CRC screening.

Background Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. To the authors' knowledge, little is known regarding the effectiveness of direct‐to‐member outreach by Medicaid health insurance plans to raise colorectal cancer screening use, nor how best to deliver such outreach. Methods BeneFIT is a hybrid implementation‐effectiveness study of 2 program models that health plans developed for a mailed fecal immunochemical test (FIT) intervention. The programs differed with regard to whether they used a centralized approach (Health Plan Washington) or collaborated with health centers (Health Plan Oregon). The primary implementation outcome of the current study was the percentage of eligible enrollees to whom the plans delivered each intervention component. The primary effectiveness outcome was the rate of FIT completion within 6 months of mailing of the introductory letter. Results The health plans identified 12,000 eligible enrollees (8551 in Health Plan Washington and 3449 in Health Plan Oregon). Health Plan Washington mailed an introductory letter and FIT kit to 8551 enrollees (100%) and delivered a reminder call to 839 (10.3% of the 8132 attempted). Health Plan Oregon mailed an introductory letter, and a letter and FIT kit plus a reminder postcard to 2812 enrollees (81.5%) and 2650 enrollees (76.8%), respectively. FIT completion rates were 18.2% (1557 of 8551 enrollees) in Health Plan Washington. In Health Plan Oregon, completion rates were 17.4% (488 of 2812 enrollees) among enrollees who were mailed an introductory letter and 18.3% (484 of 2650 enrollees) among enrollees who also were mailed a FIT kit plus reminder postcard. Conclusions The implementation of mailed FIT outreach by health plans may be effective and could reach many individuals at risk of developing colorectal cancer., Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. The implementation of mailed fecal immunochemical test outreach among health plans may be effective and could reach many individuals at risk of developing colorectal cancer.

BackgroundImaging tests are one of the most frequently used diagnostic modalities in healthcare, but the benefits of their direct impacts on clinical decision-making have been countered by concerns that they can be overused. Assessing the relative value of imaging tests has largely focused on measures of test accuracy, which overlooks more comprehensive benefits and risks of imaging tests, particularly their impact on patient-centred outcomes (PCOs). We present the findings of the Patient Reported Outcomes of Diagnostics (PROD) research study in response to a methodological gap in the area of diagnostic test comparative effectiveness research.MethodsOver a 3-year period, the PROD Study engaged with multiple stakeholders to identify existing conceptual models related to PCOs for imaging testing, conducted primary research and evidence synthesis, and developed consensus recommendations to describe and categorise PCOs related to imaging testing.ResultsThe PROD framework categorises PCOs from imaging studies within four main domains: information or knowledge yielded, physical impact, emotional outcomes and test burden. PCOs interact with each other and influence effects across domains, and can be modified by factors related to the patient, clinical situation, healthcare team and the testing environment.ConclusionsUsing PCOs to inform healthcare decision-making will require ways of collating and presenting information on PCOs in ways that can inform patient–provider decision-making, and developing methods to determine the relative importance of outcomes (including test accuracy) to one another.

Hypertension control is falling in the US yet efficacious interventions exist. Poor patient reach has limited the ability of pragmatic trials to demonstrate effectiveness. This paper uses quantitative and qualitative data to understand factors influencing reach in Hyperlink 3, a pragmatic hypertension trial testing an efficacious pharmacist-led Telehealth Care intervention in comparison to a physician-led Clinic-based Care intervention. Referrals to both interventions were ordered by physicians.A sequential-explanatory mixed methods approach was used to understand barriers and facilitators to reach. Reach was assessed quantitatively using EHR data, defined as the proportion of eligible patients attending intended follow-up hypertension care and qualitatively, via semi-structured interviews with patients who were and were not reached. Quantitative data were analyzed using descriptive and inferential statistics. Qualitative data were analyzed via combined deductive and inductive content analysis.Of those eligible, 27% of Clinic-based (n = 532/1945) and 21% of Telehealth patients (n = 385/1849) were reached. In both arms, the largest drop was between physician-signed orders and patients attending initial intended follow-up care. Qualitative analyses uncovered patient barriers related to motivation, capability, and opportunity to attend follow-up care.Although the proportion of eligible patients with signed orders was high in both arms, the proportion ultimately reached was lower. Patients described barriers related to the influence of one's own personal beliefs or priorities, decision making processes, logistics, and patient perceptions on physician involvement on reach. Addressing these barriers in the design of pragmatic interventions is critical for future effectiveness.NCT02996565.

Introduction: Despite recommendations to use out of office blood pressure (BP) to confirm diagnosis of hypertension, there is little robust evidence on the acceptability of different methods for confirming hypertension. Most evaluations have involved small observational studies and have not compared measurement methods. The Blood Pressure Checks for Diagnosing Hypertension trial (BP-CHECK) trial compared the acceptability and adherence of clinic, home, kiosk and 24-hour ambulatory monitoring (ABPM) among adults with elevated BP who had not been diagnosed with hypertension. Methods: Adults presenting to Kaiser Permanente Washington primary care clinics with elevated BP but who did not have a hypertension diagnosis, were randomized to one of three arms: office, home and kiosk. ABPM was also conducted on all participants. Acceptability of each method to patients was measured using a validated questionnaire to calculate an overall score. Differences in mean acceptability by randomization arms and ABPM were calculated using linear regression models and Generalized Estimating Equations. Adherence was calculated as the proportion of participants completing their BP testing protocols and compared using chi-square tests. Results: A total of 510 individuals were randomized, with mean age 59 years, 80% white, 51% male, with mean BP of 150/88. The overall acceptability score was highest (i.e. most acceptable) for home (mean 6.2, SD 0.7) and lowest (i.e. least acceptable) for ABPM (mean 5.0, SD 1.0). Scores were intermediate for clinic (5.5, SD 1.1) and kiosk (5.4, SD 1.0) groups. Acceptability was significantly higher for all three intervention arms compared to ABPM. Adherence to the minimum number of BP readings pre-specified in the study protocol was higher for home (90.6%) and clinic (87.2%) groups than for the kiosk group (67.9%). Conclusions: Home BP measurement was the most acceptable method for diagnosing hypertension followed by measurement in the clinic or at kiosks, with ABPM the least acceptable, due to its discomfort, disturbance to sleep and to everyday activities. Although ABPM is considered the gold standard for confirming elevated BP, patients find home BP more acceptable.