- Patient and Provider Experiences with Comprehensive Lung Cancer Screening Program
This article describes the organizational- and patient-level experiences with the VA Lung Cancer Screening Demonstration Project (LCSDP), and estimates the number of VA patients who may be screening candidates. Findings showed that participants in the LCSDP found implementing a comprehensive lung cancer screening program to be challenging and complex, requiring new tools (e.g., electronic tools to capture necessary clinical data in real time) and patient care processes for staff, in addition to dedicated patient coordination. There was wide variation in processes and patient experience among the study sites. For example, across the eight sites, 58% of patients who were offered screening agreed to be screened, ranging from 34% to 66% across the sites. Overall, 60% of the Veterans screened for lung cancer had a positive result, including having nodules that needing tracking, needing a workup for possible lung cancer, and being diagnosed with lung cancer. It is estimated that nearly 900,000 VA patients may be candidates for lung cancer screening. Implementation of lung cancer screening in the VA healthcare system will likely lead to large numbers of screen-eligible patients – and will require substantial clinical effort for both patients and staff.
Date: March 1, 2017
- Lung Cancer Screening Programs May Have Unintended Consequences on Beliefs about Smoking Cessation
This study aimed to learn from patients who were offered screening how the availability of screening influenced their motivations regarding smoking cessation. Findings showed that current smokers attached exaggerated personal benefits to lung cancer screening. Misperceptions about susceptibility to harms from tobacco can be reinforced and potentially exacerbated by screening due to existing cognitive biases about smoking and exaggerated beliefs in the value of early detection provided by lung cancer screening. Five themes emerged around types of misperceptions related to cessation associated with screening: 1) screening was valuable because everyone screened would be protected, 2) screening would show how much damage had been caused by an individual’s smoking, 3) identification and monitoring of a lung nodule was evidence that cancer can be caught early (e.g., detection of a nodule meant that “screening was working”), 4) screening reduces the likelihood of needing cancer treatment (e.g., screening could cure cancer if the cancer was found early enough), and 5) screening verified the belief that smoking doesn’t harm everyone and “won’t harm me personally.”
Date: September 1, 2015
- Efficacy of Routine Screening Pelvic Examination in Asymptomatic Average-Risk Women
This systematic review evaluated the benefits and harms of the routine screening pelvic examination in asymptomatic, non-pregnant, adult women for indications other than sexually transmitted infection screening, provision of hormonal contraception, and cervical cancer screening. No data supported the use of the routine pelvic examination (excluding cervical cytology) for reduction in morbidity or mortality from any condition. The percentage of women endorsing pain or discomfort during the pelvic exam ranged from 11% to 60% and the percentage of women endorsing fear, embarrassment, or anxiety ranged from 10% to 80%. No studies evaluated mortality or morbidity outcomes of the screening pelvic examination for the diagnosis of other malignancies or other benign gynecologic conditions (i.e., pelvic inflammatory disease).
Date: July 1, 2014
- Underuse of Colorectal Cancer Screening among Healthy Veterans and Overuse among Unhealthy Veterans
This study examined whether the upper age cutoff of the colorectal cancer (CRC) screening quality measure is associated with overuse of screening among 70- to 75-year-olds who are in poor health (limited life expectancy, but within the target age range of the measure) – and underuse in those older than age 75 who are in good health (longer life expectancy, but outside the target age range of the measure). Findings showed that screening rates were relatively stable for Veterans between ages 50-75, but dropped precipitously after age 75. On average, 39% of 75 year-old Veterans were screened, while only 21% of 76 year-old Veterans were screened. However, a Veteran who was 75 years of age and unhealthy – in whom life expectancy may be limited and screening is likely to result in net burden or harm – was significantly more likely to undergo screening than a Veteran who was 76 years of age and healthy (35% vs. 21%, respectively). Future patient-centered quality measures should focus on clinical benefit rather than chronological age to ensure that patients who are likely to benefit from screening receive it (regardless of age), and that those who are are likely to incur harm are spared uncessary and costly care.
Date: February 26, 2014
- Home-Based Colorectal Cancer Screening Significantly Improves Screening Rates among Overdue Veterans in a Rural State
This study sought to determine whether a simple 1-step mailing of a fecal immunochemical test (FIT) accompanied by educational materials would improve colorectal cancer (CRC) screening rates in Veterans who were overdue compared to Veterans who received educational materials only and to Veterans who received no mailings. Findings showed that mailing FITs and educational materials to Veterans overdue for CRC screening resulted in significantly higher screening rates than usual care or educational materials alone. At six months, 21% of Veterans in the FIT group had received CRC screening by any method compared to 6% in the educational materials-only group and 6% in the usual care group. Among respondents eligible for FIT, 90% completed and returned a FIT. Among Veterans in the FIT group, 8 (12%) received positive results. Of these Veterans, 6 received a colonoscopy, while the other 2 were advised against the procedure by their physicians due to terminal conditions. The overwhelming reason for not having at-home testing was that it was not recommended by their provider (62%).
Date: October 25, 2013
- Veterans Receiving Primary Care in CBOCs Less Likely to Receive Several Types of Colon Cancer Screening Tests
This study evaluated differences in the choice of colorectal cancer (CRC) screening test in Veterans receiving primary care at community-based outpatient clinics (CBOCs) and at VAMCs. Findings showed that Veterans receiving care at a CBOC were less likely to receive colonoscopy, sigmoidoscopy and double-contrast barium enema than Veterans receiving care at VAMCs, even after adjusting for rural location, distance from a parent VAMC, and other patient demographic and clinical characteristics. Lower rates of screening procedures were not offset by higher utilization of fecal occult blood tests, and were consistent in Veterans at average and high risk for CRC. The difference in the use of colonoscopy in CBOCs and VAMCs was larger for Veterans 65 years or older than for patients less than 65 years, suggesting that older Veterans who receive primary care through CBOCs may use more CRC screening services outside VA relative to those under 65. These findings provide indirect evidence of the importance of examining data from non-VA providers when making judgments about adherence to VA performance measures.
Date: July 5, 2013
- Colorectal Cancer Screening May Be Overused for Many Veterans
Of 4,236 fecal occult blood tests (FOBTs) received by Veterans in this study, 21% met overuse criteria: 8% were done sooner than recommended after a previous FOBT, and 13% sooner than recommended after other procedures (colonoscopy, barium enema, or combination). FOBT overuse after prior FOBT declined between 2003 and 2009 (8%-5%), while overuse after other procedures increased (11%-19%). More than 11% of overused FOBTs were followed by colonoscopy within 12 months. FOBT overuse varied across facilities (9%-32%) and regions (12%-23%). Although the odds of FOBT overuse did not vary by patient demographics, they did increase by 16% with each additional outpatient visit.
Date: July 19, 2012
- Long-Term Outcomes Following Positive Colorectal Screening
Despite persistently low rates of follow-up colonoscopy in older adults with positive fecal occult blood test (FOBT) results, the long-term outcomes of screening and follow-up practices have not been described. This study examined outcomes following a positive screening FOBT result for 212 Veterans ages 70 years or older at four VA facilities in 2001. Both Veterans who did receive a follow-up colonoscopy and Veterans who did not were followed through 2008. Findings showed that, over a 7-year period, a little more than half of the older Veterans in this study received a follow-up colonoscopy after a positive FOBT. Among Veterans who received follow-up colonoscopy, more than 25% had significant adenomas or cancer detected, were treated, and survived for more than five years. Approximately 59% of Veterans who received follow-up colonoscopy had no significant findings, and 10% experienced complications from colonoscopy or cancer treatment. Among Veterans who did not receive follow-up colonoscopy, 57% underwent some form of follow-up other than colonoscopy (e.g., repeat FOBT or sigmoidoscopy) and 59% had more than one non-colonoscopy follow-up test. Nearly half of the non-colonoscopy group died of other causes within five years, and 3% ultimately died of colorectal cancer. Veterans with the best predicted life expectancy were less likely to experience net burden from screening than Veterans with the worst predicted life expectancy. These findings support guidelines that recommend using life expectancy to guide colorectal cancer screening decisions in older adults, and argue against one-size-fits-all interventions that simply aim to increase overall screening and follow-up rates.
Date: May 9, 2011
- Despite Improved Quality of VA Healthcare, Racial Disparity Persists for Important Clinical Outcome
This article reports on trends in the quality of care and racial disparities in relation to 10 VA clinical performance measures that assessed cancer screening, cardiovascular care, and diabetes care from 2000 to 2009. Findings show that in the decade following VA’s organizational transformation, quality of care improved and racial disparities were minimal for most process measures, such as glucose and LDL screening. However, these were not accompanied by meaningful reductions in racial disparity for important clinical outcomes, such as blood pressure, glucose, and cholesterol control. A gap in clinical outcomes of as much as nine percentage points was observed between African-American and white Veterans. Almost all of the disparity in outcomes was explained by within-facility disparity, which suggests that VA medical centers will need to measure and address racial gaps in care for their patient populations. Of the five performance measures with an absolute racial disparity of 5 percentage points or more in the initial year of the study, there were statistically significant reductions in racial disparity for three: glucose control, BP control, and CRC screening. However, the reductions in disparity were modest, and none were reduced by more than 2 percentage points.
Date: April 1, 2011
- VA Healthcare Outperforms Private-Sector, Medicare-Managed Care among Older Patients
This study compared clinical performance between VA and Medicare-managed care plans, known as Medicare Advantage (MA). Findings show that VA outperformed MA health plans on 10 out of 11 widely used clinical performance indicators assessing diabetes, cardiovascular, and cancer screening care among patients ages 65 and older in the initial study year – and on all 12 measures by the final year. Moreover, for 10 of the 12 measures studied, even the best-performing MA plans lagged behind the lowest-performing VAMCs. The performance advantage for VA was substantial. For example, in 2006 and 2007, adjusted differences between VA and MA ranged from 4.3 percentage points for cholesterol testing in coronary heart disease to 30.8 percentage points for colorectal cancer screening. VA delivered care that was less variable by site, geographic region, and socioeconomic status. For 9 of the 12 measures, socioeconomic disparities were lower in VA than in MA.
Date: March 18, 2011
- Electronic Record Intervention Improves Follow-Up of Veterans with Positive Colorectal Cancer Screening
This randomized trial of eight VAMCs evaluated an electronic record intervention for follow-up of Veterans with a positive fecal occult blood test (FOBT). Findings show that a simple electronic intervention involving an automatic GI consult for Veterans with a positive FOBT result improved follow-up and reduced the time between a positive FOBT and GI evaluation, as well as complete diagnostic evaluation (CDE). The 30, 90, and 180 day GI consult rates improved 21% to 33% among intervention sites, but did not change in the usual care sites. Thirty, 90, and 180 day CDE rates improved 9% to 31% in intervention sites, but did not significantly change in usual care sites. Time to GI consult and CDE decreased significantly over time in the intervention sites, but remained unchanged in the usual care sites.
Date: February 15, 2011
- Education Intervention Decreases Inappropriate Prostate Cancer Screening among Veterans
This study tested an e-mail-based intervention called “spaced education” (SE) that was developed to reduce clinicians’ inappropriate screening for prostate cancer. Findings show that during the intervention period (36 weeks), clinicians who received the spaced education intervention ordered significantly fewer inappropriate PSA screening tests than clinicians in the control group. Over the 72-week follow-up period, SE clinicians continued to order fewer inappropriate tests compared to controls, representing a 40% relative reduction in inappropriate screening. The impact of the intervention was unaffected by clincians’ age, gender, or provider type.
Date: November 1, 2010
- Prostate Screening Does Not Reduce Prostate Cancer or All-Cause Mortality
In a 2006 review of the evidence, authors identified insufficient evidence to either support or refute the use of routine screening for prostate cancer. This article presents findings from their updated study, in which investigators sought to determine whether population-based screening reduces prostate cancer-specific mortality and/or all-cause mortality. They also examined its impact on quality of life, including adverse events (e.g., harms of screening from false-positive or false-negative results). Findings show that prostate cancer screening did not result in a statistically significant reduction in prostate cancer-specific or all-cause mortality. One of the studies in this review showed a marginally significant benefit for prostate cancer screening among a subgroup of men aged 55 to 69. Among this group, it was reported that 1,410 men would need to be screened, with 48 men needing prostate cancer treatment, to prevent one additional death from prostate cancer during a 9-year period. Any benefits from prosate cancer screening may take up to 10 years to accrue; therefore, the authors suggest that men with a life expectancy of less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. None of the studies reviewed provided detailed assessment of the effect of screening on quality of life or costs associated with screening.
Date: September 1, 2010
- Fixing an Electronic Communication Problem that Reduced Follow-Up of Positive Cancer Screens at One VAMC
This study sought to determine if technical and/or workflow-related aspects of automated communication in VA’s electronic health record could lead to the lack of response to a positive fecal occult blood test (FOBT). A problem with software configuration at one VA medical center intended to alert VA primary care physicians about positive FOBT results led to breakdowns in transmission of a subset of test results. About one-third of the 490 positive FOBTs examined for this study were not directly reported to PCPs as CPRS alerts. Upon correction of the technical problem, lack of timely follow-up of test results decreased from 29.9% to 5.4% -- and was sustained for four months following the intervention. The authors recommend that electronic communication of positive FOBT results should be monitored to avoid limiting the benefits of colorectal cancer screening. They are currently investigating whether this problem exists in other VA facilities, or if this was an isolated event.
Date: December 9, 2009
- Strategies to Improve Follow-Up for Positive Colorectal Cancer Screening
In 2006, VA launched a national effort to increase the proportion of patients receiving a colonoscopy within 60 days of a positive fecal occult blood test (FOBT). This study sought to determine the proportion of VA patients with a positive FOBT between March and June of 2007 that received a colonoscopy within 60 days. Investigators also examined data from a 2007 web-based survey that was completed by 132 VAMCs on their FOBT follow-up quality improvement strategies. Results show that only 1 in 4 Veterans received follow-up colonoscopies within 60 days of a positive FOBT for colorectal cancer screening. Findings also show that developing QI infrastructure appears to be an effective strategy for improving FOBT follow-up, when this work is followed by process improvements (e.g., strategies to decrease cancellations, revise colonoscopy prep education protocols). On average, facilities indicated that they had fully implemented 6.84 of 16 improvement strategies. The number of strategies fully implemented was positively associated with 60-day follow-up. The most commonly cited barriers to improvement involved capacity constraints, e.g., sites listing insufficient gastroenterology staff as a barrier had a lower percentage of Veterans receiving timely follow-up. However, none of the improvement strategies designed to address gastroenterology capacity constraints were associated with timely follow-up, suggesting that this barrier may be more difficult or take more time to address than process inefficiencies.
Date: August 1, 2009
- Multi-faceted Quality Improvement Intervention Improves Follow-up Colonoscopy for Veterans with Positive Colorectal Cancer Screening Test
Inadequate follow-up of abnormal fecal occult blood test (FOBT) screening for colorectal cancer (CRC) may be related to patient, provider, or system-level factors. Thus, in calendar years 2004 and 2005 the Houston VAMC implemented multi-faceted quality improvement (QI) activities to improve follow-up of positive FOBT results. This study examined the effects of these activities on timeliness and appropriateness of positive-FOBT follow-up for 800 Veterans, and also identified factors that affect colonoscopy performance. Findings show that in cases where a colonoscopy was indicated, the proportion of Veterans who received timely referral and performance was significantly higher after the implementation of the QI activities. In addition, there was a significant decrease in median times to colonoscopy referral and performance. However, colonoscopy was not indicated in more than one-third of Veterans with positive FOBTs, raising concerns about current screening practices and the appropriate performance measures related to CRC screening.
Date: April 1, 2009
- Ethnic Differences in Self-Reported Cancer Screening
Several studies suggest that non-whites may be more likely than whites to over-report screening behavior, which may have considerable implications for research on racial and ethnic disparities in cancer screening. Findings from this study show that racial and ethnic minorities may be less likely to provide accurate reports of their cancer screening behavior and that over-reporting may be particularly problematic. Research suggests that this might be rectified by changing how screening questions are worded and developing different methods for data collection. A conceptual framework offered by study investigators has the potential to guide exploration of where and why possible bias may be occurring and suggests ways in which these biases might be reduced.
Date: February 1, 2009