Cancer Screening: Provider Assessment and Feedback Breast Cancer

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends provider assessment and feedback interventions on the basis of sufficient evidence of effectiveness in increasing screening for breast cancer by mammography.

The CPSTF has related findings for provider assessment and feedback specific to the following:

Intervention

Provider assessment and feedback interventions both evaluate provider performance in delivering or offering screening to clients (assessment) and present providers with information about their performance in providing screening services (feedback). Feedback may describe the performance of a group of providers (e.g., mean performance for a practice) or an individual provider, and may be compared with a goal or standard.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

Promotional Materials

About The Systematic Review

The CPSTF finding is based on evidence from a Community Guide systematic review published in 2008 (Sabatino, et al., search period through September 2004) combined with more recent evidence (search period 2004 – October 2008). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to cancer prevention and control. This finding updates and replaces the 2008 CPSTF finding on Cancer Screening: Provider Assessment and Feedback Breast Cancer.

The effectiveness of provider-directed interventions was determined by considering evidence across all three cancer screening sites combined, as long as there were not differences in effectiveness by screening test. This was done because provider behavior was thought to be less influenced than client behavior by the nature of screening tests.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement

The review included nine studies that assessed intervention effectiveness for breast, cervical, and colorectal cancers.

  • Screening for breast, cervical or colorectal cancer: median increase of 13.0 percentage points (interquartile interval: 5.5 to 21.8 percentage points; 13 study arms).
  • Completed breast cancer screening by mammography: estimated effects ranged from a 3.4 to 20.6 percentage point increase (4 study arms)

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement

The updated search for evidence included studies about breast, cervical, or colorectal cancer screening. Only one study about colorectal cancer screening qualified for the review. Monetary values are presented in 2009 U.S dollars.

  • The estimated cost of increasing screening for colorectal cancer among military veterans was $1,074 per additional screening.

Applicability

The recommendation to increase screening for breast cancers should be applicable across various settings and provider training status may be related to magnitude of effect.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

The following outlines evidence gaps for provider assessment and feedback to increase breast, cervical, or colorectal cancer screening.

  • Can a single assessment and feedback program targeting all three cancer sites increase screening use for each site?
  • Are some approaches more effective than others (e.g., group versus individual feedback)?
  • Does the magnitude of effect differ for (1) physicians in training versus trained physicians and (2) providers other than physicians?
  • What is required to facilitate dissemination and implementation of provider assessment and feedback to healthcare system settings across the United States?
  • How are the costs and cost effectiveness of these interventions related to the structural characteristics of the settings of interventions? In particular, can HMOs address logistical problems (e.g., contacting providers and reducing administrative time) more readily than fee-for-service practices, thereby lowering costs and improving cost effectiveness?
  • What is the impact of interventions on non cancer related healthcare delivery? For example, does the effect of these interventions spill over into improved delivery of other clinical services?
  • What are the incremental effects of adding intervention components to other interventions?
  • What influence do newer methods of communication (e.g., the Internet, e-mail, social media, automated interactive voice response, texting) have on intervention effectiveness?
  • What is the influence of health system factors on intervention effectiveness?
  • Are interventions effective for promoting colorectal cancer screening with methods other than FOBT?
  • Are interventions to promote colorectal cancer screening equally effective when specific to one type of test as they are when addressing colorectal cancer screening more generally?

Study Characteristics

  • Completed screening outcomes were assessed by medical record review.
  • Provider screening performance was assessed via computer search or chart review.
  • Feedback was provided concerning individual provider performance, group performance, or both.
  • Feedback received by providers varied from a single occurrence to regular intervals.
  • Studies of completed screenings were conducted in urban and rural settings in the U.S. and included both trainee and nontrainee physicians.

Analytic Framework

Effectiveness Review

Analytic Framework see Figure 3 on page 101

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Summary Evidence Table

Effectiveness Review

Summary Evidence Table – Effectiveness Review
Contains evidence from reviews of provider assessment and feedback interventions to increase breast, cervical, and colorectal cancer.

Economic Review

Summary Evidence Table – Economic Review

Included Studies

The following list of included studies is for reviews of provider assessment and feedback to increase breast, cervical, and colorectal cancer screening. *Studies that included colorectal cancer screening.

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

*Battat AC, Rouse RV, Dempsey L, Safadi BY, Wren SM. Institutional commitment to rectal cancer screening results in earlier-stage cancers on diagnosis. Ann Surg Oncol 2004;11(11):970 6.

Brady WJ, Hissa DC, McConnell M, Wones RG. Should physicians perform their own quality assurance audits? J Gen Intern Med 1988;3(6):560 5.

Fleming DM, Lawrence MS. Impact of audit on preventive measures. Br Med J 1983;287(6408):1852 4.

*Goebel LJ. A peer review feedback method of promoting compliance with preventive care guidelines in a resident ambulatory care clinic. Jt Comm J Qual Improv 1997;23(4):196 202

*Kern DE, Harris WL, Boekeloo BO, Barker LR, Hogeland P. Use of an outpatient medical record audit to achieve educational objectives: changes in residents’ performances over six years. J Gen Intern Med 1990;5(3):218 24.

Kinsinger LS, Harris R, Qaqish B, Strecher V, Kaluzny A. Using an office system intervention to increase breast cancer screening. J Gen Intern Med 1998;13(8):507 14.

*McPhee SJ, Bird JA, Jenkins CN, Fordham D. Promoting cancer screening. A randomized, controlled trial of three interventions. Arch Intern Med 1989;149(8):1866 72.

Nattinger AB, Panzer RJ, Janus J. Improving the utilization of screening mammography in primary care practices. Arch Intern Med 1989;149(9):2087 92.

*Tierney WM, Hui SL, McDonald CJ. Delayed feedback of physician performance versus immediate reminders to perform preventive care. Effects on physician compliance. Med Care 1986;24(8):659 66.

Economic Review

Wolf MS, Fitzner KA, Powell EF, McCaffrey KR, Pickard AS, McKoy JM, Lindenberg J, Schumock GT, Carson KR, Ferreira MR, Dolan NC, Bennett CL. Costs and cost effectiveness of a health care provider directed intervention to promote colorectal cancer screening among veterans. Journal of Clinical Oncology 2005;23(34):8877-83.

Additional Materials

Planning Guide

Evidence-Based Intervention Planning Guide
Developed by CDC’s Division of Cancer Prevention and Control
This planning guide provides tips to help clinic staff implement provider assessment and feedback interventions to increase screening for breast, cervical, and colorectal cancer. The guide includes a process flow diagram of the intervention theory; process evaluation metrics, outputs, and example measures; a list of resources needed to support implementation, such as partnerships, staff, and tools; lessons learned from studies included the Community Guide systematic reviews; and intervention components.

Action Guide

Increasing Colorectal Cancer Screening: An Action Guide for Working with Health Systems
Developed by CDC’s Division of Cancer Prevention and Control

Search Strategies

The following outlines the search strategy used for these reviews of interventions to increase breast, cervical, and colorectal cancer screening: Client Reminders; Client Incentives; Mass Media Targeting Clients; Group Education for Clients; One-on-One Education for Clients; Reducing Structural Barriers for Clients; Reducing Client Out-of-Pocket Costs; Provider Assessment and Feedback; Provider Incentives.

Effectiveness Review

With the assistance of a CDC librarian, the following databases were searched for publications from 2004 up to 2008: Medline (Ovid), CINAHL (Ovid), PsycINFO (Ovid), Cochrane [Cochrane Reviews, Other Reviews, Methods Studies, Technology Assessments, Economic Evaluations], WoS (SSCI only), Chronic Disease Prevention – cancer prevention and control subcategory (no longer exists).

The team considered studies for inclusion if they were human studies conducted in high income economies according to the World Bank, and published in English.

Keywords

Note: discrepancies in number of results are due to limits being applied here (-) and new refs added to database (+)

PUBMED

1 AND (2 OR 3) NOT 4

1. INTERVENTIONS
(uptake*or outreach or intervention*).tw or exp intervention studies/or exp patient compliance/ or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*).tw adj4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*).tw) or (access* adj5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation

2. TYPES OF CANCER
exp uterine cervical neoplasms/pc or exp cervical intraepithelial neoplasia/pc or exp uterine cervical dysplasia/pc or exp breast neoplasms/pc or exp colorectal neoplasms/pc or exp colonic neoplasms/pc or exp neoplasms/pc

3. TYPES OF SCREENING (A OR B OR C)
A. Specific
exp mammography/ or exp vaginal smears/ or exp colonoscopy / or exp occult blood/ or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear*

B. Not specific
repeat screening* or diagnostic imag*

C. Other mass screening
exp mass screening/ut or exp preventive health services/ut

4. NOT
exp *skin neoplasms/ or exp *prostatic neoplasms/ or exp *bone neoplasms/ or exp *biliary tract neoplasms/ or exp *esophageal neoplasms/ or exp *cecal neoplasms/ or exp *duodenal neoplasms/ or exp *ileal neoplasms/ or exp *jejunal neoplasms/ or exp *stomach neoplasms/ or exp *liver neoplasms/ or exp *pancreatic neoplasms/ or exp *peritoneal neoplasms/ or exp *eye neoplasms/ or exp *”head and neck neoplasms”/ or exp *hematologic neoplasms/ or exp *nervous system neoplasms/ or exp *skin neoplasms/ or exp *splenic neoplasms/ or exp *thoracic neoplasms/

*** Bold terms replace “exp *gastrointestinal neoplasms/”

CINAHL

1 AND (2 OR 3) NOT 4

1. INTERVENTIONS
(uptake*or outreach or intervention*).tw or exp EARLY INTERVENTION/ or exp INTERVENTION TRIALS/ or exp PATIENT COMPLIANCE/ or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*).tw adj4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*).tw) or (access* adj5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation

2. TYPES OF CANCER
exp CERVIX NEOPLASMS/pc or exp UTERINE NEOPLASMS/pc or exp VAGINAL NEOPLASMS/pc or exp GENITAL NEOPLASMS, FEMALE/pc or exp BREAST NEOPLASMS/pc or exp BREAST NEOPLASMS, MALE/pc or exp DIGESTIVE SYSTEM NEOPLASMS/pc or exp INTESTINAL NEOPLASMS/pc or exp CECAL NEOPLASMS/pc or exp COLORECTAL NEOPLASMS/pc or exp COLONIC NEOPLASMS/pc or exp SIGMOID NEOPLASMS/pc or exp RECTAL NEOPLASMS/pc or exp ANUS NEOPLASMS/pc or exp NEOPLASMS/pc

3. TYPES OF SCREENING (A OR B OR C)
A. Specific
exp mammography/ or exp Cervical Smears/ or exp COLONOSCOPY/ or exp occult blood/ or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear*

B. Not specific
repeat screening* or diagnostic imag*

C. Other mass screening
exp Cancer Screening/ut or exp Preventive Health Care/ut

4. NOT
exp *prostatic neoplasms/ or exp *biliary tract neoplasms/ or exp *esophageal neoplasms/ or exp *cecal neoplasms/ or exp *duodenal neoplasms/ or exp *ileal neoplasms/ or exp *jejunal neoplasms/ or exp *stomach neoplasms/ or exp *liver tneoplasms/ or exp *pancreatic neoplasms/ or exp *peritoneal neoplasms/ or exp *hematologic neoplasms/ or exp *thoracic neoplasms/ or exp *bone neoplasms/ or exp *endocrine gland neoplasms/ or exp *eye neoplasms/ or exp *”head and neck neoplasms”/ or exp *hematologic neoplasms/ or exp *nervous system neoplasms/ or exp *skin neoplasms/ or exp *soft tissue neoplasms/ or exp *splenic neoplasms/ or exp *urogenital neoplasms/

PSYCINFO

1 AND (2 OR 3) NOT 4

1. INTERVENTIONS
(uptake*or outreach or intervention*).tw or exp intervention/or exp treatment compliance/ or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*).tw adj4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*).tw) or (access* adj5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation

2. TYPES OF CANCER
exp *neoplasms/ or exp breast neoplasms/

3. TYPES OF SCREENING (A OR B OR C)
A. Specific
exp mammography/ or exp cancer screening/ or exp breast cancer screening/ or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear*

B. Not specific
repeat screening* or diagnostic imag*

C. Other mass screening
mass screening or preventive health service*

4. NOT
exp *endocrine neoplasms/ or exp *leukemias/ or exp *nervous system neoplasms/ or ((skin or prostate* or bone or biliary tract or esophageal or cecal or duodenal or ileal or jejunal or stomach or liver or pancreas* or peritone* or eye or “head and neck” or splenic or spleen or thoracic) adj1 (cancer* or neoplasm*)).ti

COCHRANE

MeSH terms all done separately and exploded. Cannot copy/paste strategies this way.

1 AND (2 OR 3) NOT 4 (TOTAL )

1. INTERVENTIONS
(uptake*or outreach or intervention*):ti or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law or laws or assessment* or feedback or checklist* or ((cancer* or neoplasm* or tumor*) next/4 (control* or early detection or health promotion* or reminder* or recall* or incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*)):ti or (access* next/5 health) or expand* hour* or longer hour* or weekend clinic* or saturday clinic* or schedul* or transporting or transportation
MeSH done seperately: exp intervention studies or exp patient compliance

2. TYPES OF CANCER
exp uterine cervical neoplasms/pc or exp cervical intraepithelial neoplasia/pc or exp uterine cervical dysplasia/pc or exp breast neoplasms/pc or exp colorectal neoplasms/pc or exp colonic neoplasms/pc or exp neoplasms/pc

3. TYPES OF SCREENING
exp mammography/ or exp vaginal smears/ or exp colonoscopy / or exp occult blood/ or exp mass screening/ut or exp preventive health services/ut or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or occult blood or vaginal smear* or repeat screening* or diagnostic imag*

4. NOT (cannot restrict to major topic)
exp skin neoplasms/ or exp bone neoplasms/ or exp nervous system neoplasms/ or exp biliary tract neoplasms/

WEB OF SCIENCE

1 AND 2

1. INTERVENTIONS
TI=(uptake*or outreach or intervention* or “patient acceptance of health care” or provider* or doctor* or nurse* or resident* or physician* or “allied health” or incentive* or law* or assessment* or feedback or checklist* or control* or early detection or health promotion* or reminder* or recall*)
or
TI=(incentive* or mass media or small media or pamphlet* or brochure* or education or translation service* or reduced co-pay* or reduced cost* or women* health service* or mobile or promotor* or health advisor* or patient navigator or communit*)
or
TS=((access* same health) or hour* or weekend clinic* or saturday clinic* or schedul* or transport* or intervention studies or patient compliance)

2. TYPES OF CANCER or TYPES OF SCREENING [18 terms]
TI=(((cervical or breast or colorectal or colon*) same (neoplasm* or cancer*)) or mammogra* or vaginal smear* or colonoscopy or occult blood or clinical breast exam* or barium enema* or colonoscop* or endoscop* or pap* smear* or screening* or diagnostic imag* or preventive health service*)

Economic Review

No content is available for this section.

Considerations for Implementation

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.
  • While assessment and feedback interventions showed positive effects in both trainee and nontrainee physician populations, there is some evidence to suggest trainees are more responsive.
  • Reported barriers to implementation included the following:
    • Potential burdens on practices or clinic staff to complete audits and prepare and provide feedback
    • Possible sensitivity of some providers to the source of evaluation. Trained physicians may be sensitive to evaluation and criticism from other physicians or insurance companies.

Crosswalks

Healthy People 2030

Healthy People 2030 icon Healthy People 2030 includes the following objective related to this CPSTF recommendation.