Race/Ethnicity and Adoption of a Population Health Management Approach to Colorectal Cancer Screening in a Community-Based Healthcare System

• Published in: Journal of general internal medicine : JGIM 2016-11, Vol.31 (11), p.1323-1330
• Main Authors: Mehta, Shivan J., Jensen, Christopher D., Quinn, Virginia P., Schottinger, Joanne E., Zauber, Ann G., Meester, Reinier, Laiyemo, Adeyinka O., Fedewa, Stacey, Goodman, Michael, Fletcher, Robert H., Levin, Theodore R., Corley, Douglas A., Doubeni, Chyke A.
• Format: Article
• Language: English
• Subjects: Aged; Cancer; Cancer screening; Cohort Studies; Colonoscopy - methods; Colorectal cancer; Colorectal carcinoma; Colorectal Neoplasms - diagnosis; Colorectal Neoplasms - ethnology; Colorectal Neoplasms - prevention & control; Communities; Community Health Services - methods; Continental Population Groups - ethnology; Disease Management; Early Detection of Cancer - methods; Ethnic factors; Ethnic Groups; Ethnicity; Female; Follow-Up Studies; Health care; Health Services Accessibility; Hispanic Americans; Humans; Internal Medicine; Leadership; Longitudinal Studies; Male; Medical screening; Medicine; Medicine & Public Health; Middle Aged; Minority & ethnic groups; Native Americans; Original Research; Outreach programs; Population Health; Quality assurance; Race; Retrospective Studies; Sigmoidoscopy - methods
• ISSN: 0884-8734; 1525-1497
• DOI: 10.1007/s11606-016-3792-1

Background Screening outreach programs using population health management principles offer services uniformly to all eligible persons, but racial/ethnic colorectal cancer (CRC) screening patterns in such programs are not well known. Objective To examine the association between race/ethnicity and the receipt of CRC screening and timely follow-up of positive results before and after implementation of a screening program. Design Retrospective cohort study of screen-eligible individuals at the Kaiser Permanente Northern California community-based integrated healthcare delivery system (2004–2013). Subjects A total of 868,934 screen-eligible individuals 51–74 years of age at cohort entry, which included 662,872 persons in the period before program implementation (2004–2006), 654,633 during the first 3 years after implementation (2007–2009), and 665,268 in the period from 4 to 7 years (2010–2013) after program implementation. Intervention A comprehensive system-wide long-term effort to increase CRC that included leadership alignment, goal-setting, and quality assurance through a PHM approach, using mailed fecal immunochemical testing (FIT) along with offering screening at office visits. Main Measures Differences over time and by race/ethnicity in up-to-date CRC screening (overall and by test type) and timely follow-up of a positive screen. Race/ethnicity categories included non-Hispanic white, non-Hispanic black, Hispanic/Latino, Asian/Pacific Islander, Native American, and multiple races. Key Results From 2004 to 2013, age/sex-adjusted CRC screening rates increased in all groups, including 35.2 to 81.1 % among whites and 35.6 to 78.0 % among blacks. Screening rates among Hispanics (33.1 to 78.3 %) and Native Americans (29.4 to 74.5 %) remained lower than those for whites both before and after program implementation. Blacks, who had slightly higher rates before program implementation (adjusted rate ratio [RR] = 1.04, 99 % CI: 1.02–1.05), had lower rates after program implementation (RR for period from 4 to 7 years = 0.97, 99 % CI: 0.96–0.97). There were also substantial improvements in timely follow-up of positive screening results. Conclusions In this screening program using core PHM principles, CRC screening increased markedly in all racial/ethnic groups, but disparities persisted for some groups and developed in others, which correlated with levels of adoption of mailed FIT.