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BACKGROUND Despite the growing recognition of the importance of colorectal cancer (CRC) screening in reducing cancer mortality, national screening rates are low, indicating a critical need to understand the barriers and remedies for underutilization of CRC screening tests. METHODS Using results from independent cross-sectional telephone surveys with patients aged ≥50 years performed before (2000; n = 498) and after (2003; n = 482) a quality improvement intervention for CRC screening within a large managed care health plan, the trends and predictors of CRC screening with fecal occult blood test (FOBT) and/or endoscopy (flexible sigmoidoscopy/colonoscopy) were examined from a patient perspective. RESULTS In 2000, patient reported screening rates within guidelines were 38% for any test, 23% for endoscopy, and 22% for FOBT. In 2003, screening rates increased to 50% for any test, 39% for endoscopy, and 24% for FOBT. Having discussed CRC with a doctor significantly increased the odds of being screened (FOBT: odds ratio [OR], 2.09 [95% confidence interval (95% CI), 1.47–2.96]; endoscopy: OR, 2.33 [95% CI, 1.67–3.26]; and any test: OR, 2.86 [95% CI, 2.06–3.96]), and reporting barriers to CRC in general decreased the odds of being screened (FOBT: OR, 0.76 [95% CI, 0.60–0.95]; endoscopy: OR, 0.74 [95% CI, 0.60–0.92]; and any test: OR, 0.66 [95% CI, 0.54–0.80]). CONCLUSIONS Although screening rates increased over the 3-year period, evidence was found of ongoing underutilization of CRC screening. The 2 strongest determinants of obtaining CRC screening were provider influence and patient barriers related to CRC screening in general, pointing to the need for multilevel interventions that target both the provider and patient. Cancer 2008. © 2008 American Cancer Society.

Although consumers purchasing health plans in the new Health Insurance Marketplace will be provided information on the cost and quality of participating health plans, it is unclear whether the state-wide plan quality averages that will be reported will accurately represent quality at the pricing region level where care will be received.To evaluate whether currently reported state-wide health plan quality scores accurately represent quality within pricing regions established for the Health Insurance Marketplace.Observational, historical cohort study using health plan administrative and pharmacy data.A total of 5.2 million members enrolled in the preferred provider organization health plans of 1 large commercial California insurer in 2012.State-wide and pricing region performance on each of the 17 Healthcare Effectiveness Data and Information Set (HEDIS) measures.Across the 17 measures assessed in each of the 19 pricing regions, scores were statistically different (P0.05) than the overall plan rate for 176 (54%). Variations in scores across regions were observed for each measure ranging from 6.4-percentage points for engagement in treatment for people with dependence of alcohol or other drugs to 47.2-percentage points for appropriate testing for pharyngitis among children.Quality scores in California vary greatly across geographic regions. Statewide averages may misrepresent the quality of care that consumers are likely to receive within a geographic area making difficult assessments about the value of the health care.

BACKGROUND Colorectal cancer (CRC) is the third most common cause of cancer deaths; however, rates of regular screening for this cancer are low. A quality improvement (QI) program to increase CRC screening was developed for use in a managed care health plan. METHODS Thirty-six provider organizations (POs) contracting with the health plan were recruited for a randomized controlled effectiveness trial testing the QI program. The intervention was delivered over a 2-year period, and its effectiveness was assessed by chart review of a random sample of patients from each PO. RESULTS Thirty-two of the 36 POs were evaluable for outcome assessment. During the 2-year intervention period, only 26% of the eligible patients received any CRC screening test. Twenty-nine percent of patients had any CRC screening test within guidelines, with no differences between the intervention or control POs. Significant predictors of having received CRC screening within guidelines were older age (P = 0.0004), receiving care in an integrated medical group (P < 0.0001) and having had a physical examination within the past 2 years (P < 0.0001). CONCLUSIONS A facilitated QI intervention program for CRC screening that focused on the PO did not increase rates of CRC screening. Overall CRC screening rates are low and are in need of improvement. Cancer 2005. © 2005 American Cancer Society.

BACKGROUND Colorectal cancer (CRC) screening tests (e.g., fecal occult blood testing [FOBT], flexible sigmoidoscopy [FS], etc.) are underused. Primary care providers (PCPs) play a critical role in screening, but barriers to and facilitators of screening as perceived by PCPs in managed care settings are poorly understood. The objectives of the current study were to describe current CRC screening practices and to explore determinants of test use by PCPs in a managed care setting. METHODS In 2000, a self-administered survey was mailed to a stratified, random sample of 1340 PCPs in a large, network model health maintenance organization in California. RESULTS The survey response rate was 67%. PCPs indicated that 79% of their standard-risk patients were screened for CRC. PCP-reported median rates of recommendation for the use of specific screening tests were 90% for FOBT and 70% for FS. In logistic regression models, perceived barriers to the use of FOBT and FS included patient characteristics (e.g., education) and PCP-related barriers (e.g., failure to recall that patients were due for testing). Perceived facilitators of the use of FOBT and FS included interventions targeting certain aspects of the health care system (e.g., reimbursement) and interventions targeting certain aspects of the tests themselves (e.g., provision of evidence of a test's effectiveness). Assignment of high priority to screening, integrated medical group (as opposed to independent practice association) affiliation, and the proportion of patients receiving routine health maintenance examinations were positively associated with reported test use. CONCLUSIONS CRC screening tests appear to be underused in the managed care setting examined in the current study. The perceived barriers and facilitators that were identified can be used to guide interventions aimed at increasing recommendations for, as well as actual performance of, CRC screening. Cancer 2004. © 2004 American Cancer Society.

Evidence-based guidelines recommend regular colorectal cancer (CRC) screening for adults 50 years and older, yet screening rates remain very low. In this paper we describe the challenges associated with recruitment and retention of provider organizations (POs) for a group randomized, controlled effectiveness trial to increase CRC screening, among patients in a managed care health insurance plan. Using the health plan as the sampling frame, we recruited POs to test a facilitated quality improvement program to increase CRC screening. Defined eligibility and recruitment procedures were used as part of this process. We successfully recruited 36 POs over the course of 9 months; however, there were many challenges associated with the recruitment and retention process, including difficulties in (a) identifying the PO medical director and the individual authorized to agree to study participation, (b) making contact with the medical director, and (c) obtaining the materials necessary to initiate the study. All of these factors delayed the research substantially. Retention activities were also a major challenge in that one-third of the medical directors changed during the course of the intervention. This study benefited from a strong partnership between the health plan and the research group. Although many challenges exist, there are tremendous opportunities that result from the design and conduct of effectiveness research in existing POs. Successful implementation of programs that are feasible and take advantage of existing quality improvement mechanisms within the PO has potential to improve CRC screening rates and can have a major public health impact.