Kathleen Louden

May 06, 2015

For patients who do not complete screening tests for breast, cervical, and colorectal cancer, rates can be significantly increased when information technology is used to identify and target interventions, according to results from a new study.

Patient navigation has previously been found to improve cancer screening rates in vulnerable populations. However, our study is unique for two reasons, said Sanja Percac-Lima, MD, from Harvard Medical School and the Massachusetts General Hospital in Boston.

First, the patient navigator discussed screening for as many as three cancers with each patient, if needed; and second, the researchers were able to target patient navigation resources to those at highest risk for noncompliance with recommended screening tests, she explained.

"Vulnerable patients who are at high risk for not completing cancer screenings are scattered throughout our diverse health system," she said. "The challenge is to find them."

Dr Percac-Lima presented results from the randomized controlled trial at the Society of General Internal Medicine 2015 Annual Meeting in Toronto.

Nearly 14,000 patients from 18 practices in the Massachusetts General Hospital network were identified as being overdue for a mammogram, Pap test, or colonoscopy, according to screening guidelines similar to those of the US Preventive Services Task Force.

Finding Patients at Risk

To reduce the number of patients to a manageable number, the researchers used the TopCare tool — Technology for Optimizing Population Care in a Resource-Limited Environment — which was codeveloped by SRG Technology and Massachusetts General Hospital.

The tool assigns risk points to patients who miss appointments for primary care, specialist visits, and screening tests, and takes into account whether patients do not speak English, which is a known barrier to access to care.

The refined sample enrolled in the 8-month randomized trial consisted of 1612 patients.

Four patient navigators were assigned to the 792 patients randomized to the intervention group. The navigators telephoned these patients to explain the importance of cancer screening and to persuade them to schedule an appointment. They also offered insurance and funding assistance, as needed, and were available to accompany patients who needed special services, such as translation, to appointments.

The 820 patients randomized to the control group received usual care, which involved automated letters reminding patients they were due for cancer screening.

Age, sex, insurance status, and percent of English speakers were similar in the intervention and control groups. There were, however, significantly fewer white patients in the intervention group than in the control group (61.7% vs 66.1%; P = .02).

People who could not be reached, who left the network, or who died were included in the intention-to-treat analysis of patients who completed cancer screening.

Rates of screening for all cancers improved with the intervention.

Table: Rates of Patients Completing Screening

Type of Cancer Intervention Group, % Control Group, % Difference, % P Value
Breast 23.4 16.6 6.8 .01
Cervical 14.4 8.6 5.8 .01
Colorectal 13.7 7.0 6.7 .001


Overall, 202 patients in the intervention group completed at least one overdue cancer screening.

"We showed that if you don't navigate these patients, they are not as likely to go for screening," Dr Percac-Lima said.

She founded the navigation program for colorectal cancer screening in 2007 at the Chelsea Health Center. That center was not part of this analysis, but she reported that the rate of colorectal cancer screening there is 74% of eligible patients.

In contrast, the national rate of colorectal cancer screening was 58.6% in 2010, according to the National Health Interview Survey.

Important Accomplishment

"The increase in their screening rates, which may not seem much at first blush, is actually an important accomplishment," said session discussant Craig Earle, MD, from the Institute for Clinical Evaluative Sciences in Toronto.

"This study was in a vulnerable population at high risk for noncompliance who were already overdue for screening, and thus hard to get to attend," he pointed out.

It is not clear whether these results can be generalized to other settings or whether the navigation is cost-effective, which is a study limitation, Dr Earle told Medscape Medical News.

Dr Percac-Lima said they did not study cost-effectiveness. However, she reported, the use of culturally appropriate administrative personnel to review patient charts before navigators call the patients would make the program more cost-effective.

This study received funding from the Lazarex Cancer and the Harvard Medical School Center for Primary Care. Dr Percac-Lima is supported by an American Cancer Society Cancer Control Career Development Award for Primary Care Physicians. Dr Earle has disclosed no relevant financial relationships.

Society of General Internal Medicine (SGIM) 2015 Annual Meeting: Abstract 2 in session K1. Presented April 24, 2015.


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