Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

Abstract

PURPOSE Health Plans are uniquely positioned to deliver outreach to members. We explored whether telephone outreach, delivered by Medicaid managed care organization (MMCO) staff, could increase colorectal cancer (CRC) screening among publicly insured urban women, potentially reducing disparities. METHODSWe conducted an 18-month randomized clinical trial in 3 MMCOs in New York City in 2008-2010, randomizing 2,240 MMCO-insured women, aged 50 to 63 years, who received care at a participating practice and were overdue for CRC screening. MMCO outreach staff provided cancer screening telephone support, educating patients and helping overcome barriers. The primary outcome was the number of women screened for CRC during the 18-month intervention, assessed using claims.RESULTS MMCO staff reached 60% of women in the intervention arm by telephone. Although significantly more women in the intervention (36.7%) than in the usual care (30.6%) arm received CRC screening (odds ratio [OR] = 1.32; 95% CI, 1.08-1.62), increases varied from 1.1% to 13.7% across the participating MMCOs, and the overall increase was driven by increases at 1 MMCO. In an as-treated comparison, 41.8% of women in the intervention arm who were reached by telephone received CRC screening compared with 26.8% of women in the usual care arm who were not contacted during the study (OR = 1.84; 95% CI, 1.38, 2.44); 7 women needed to be reached by telephone for 1 to become screened. CONCLUSIONSThe telephone outreach intervention delivered by MMCO staff increased CRC screening by 6% more than usual care among randomized women, and by 15.1% more than usual care among previously overdue women reached by the intervention. Our research-based intervention was successfully translated to the health plan arena, with variable effects in the participating MMCOs. INTRODUCTIONC olorectal cancer (CRC) remains the second leading cause of cancer death in the United States 1 despite screening tests that can detect and prevent it. The United States Preventive Services Task Force (USPSTF) gives CRC screening its highest recommendation, 2 and mortality from CRC has declined as screening rates have increased.3,4 Screening rates still lag for Hispanics, African Americans, low-income individuals, and immigrants, [5][6][7] however, contributing to disparities in CRC morbidity and mortality. 3 Telephone outreach, provided by practice or research-based staff or patient navigators, has increased CRC screening in many studies. [8][9][10][11][12][13][14][15][16][17][18][19][20][21] Patient navigators, who commonly begin outreach after patients receive T EL EPHONE OU T R E ACH F OR COLON C A NC ER S CR EENINGreferrals, have played an important role in CRC outreach in New York City and elsewhere, 11-19 improving screening rates particularly among patients whose primary language was not English or who were black 18 or Hispanic. 12In a previous randomized controlled trial, research staff provided telephone support to women recruited in Federally qualified Community Health Centers in New...

Implementation successes and challenges in participating in a pragmatic study to improve colon cancer screening: perspectives of health center leaders

“…In addition, consistent with Dietrich et al who showed that leadership stability was key to success in CRC screening at community health centers, we found that several STOP CRC health centers experienced turnover in key staff positions within the first year of implementation [2]. These findings reinforce the need for health centerand clinic-level data when conducting pragmatic trials and suggest that characteristics of leadership, practice experience, population served, and overall stability need to be recorded.…”

“…Murray and colleagues noted specific challenges in partnering with primary care clinics, which may shut down unexpectedly or fail to implement electronic medical records (EMRs) or other tools on a timeline needed to fulfill the research requirements [1]. Dietrich et al showed that leadership instability threatened the success of a colorectal cancer (CRC) screening program at a community health center [2]. These factors and others may distract focus from research initiatives, which can influence the consistency with which a pragmatic intervention is delivered.…”

Building Equity Improvement into Quality Improvement: Reducing Socioeconomic Disparities in Colorectal Cancer Screening as Part of Population Health Management

“…Prior studies have shown that clinical interventions can improve overall CRC screening, 10,13,17,31 and be effective in vulnerable populations. 11,12,14,15,18,20,21,32 A recent study from our research group showed that culturally tailored patient navigation for CRC screening in a community health center eliminated disparities in CRC screening in Latinos and nonEnglish speakers in the health center, but paradoxically created a disparity in vulnerable patients receiving care in other practices within the primary care network. 16 In the current study, by integrating both health IT and a system-wide population management workforce, we demonstrated that it is possible to improve both quality and equity at the same time in a large healthcare delivery system.…”

“…4,5 Previous studies have demonstrated that several approaches for increasing overall CRC screening and reducing disparities in CRC screening are possible, such as mailed interventions, telephone outreach, and patient navigation. [10][11][12][13][14][15][16][17][18][19][20][21] However, it is unclear whether a pragmatic intervention targeting screening in large healthcare delivery systems with diverse practice types can simultaneously achieve these twin aims of quality and equity improvement. Programs targeting population-level screening rates may actually increase disparities if they are more successful in well-off groups, 13 while interventions meant to improve equity may not increase overall screening rates.…”

In This Issue: A Diversified Portfolio

“…They examine both the reach and outcomes of a telephone outreach intervention designed to increase colorectal cancer screening among publicly insured urban women, delivered by Medicaid Managed Care Organization staff. 7 Safety is an important and underevaluated outcome in primary care practices. Hoffmann et al evaluate the impact of multiple factors on perceptions of a safety climate in primary care practices.…”