Cancer Screening: Provider Incentives — Colorectal Cancer

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 Incentives Colorectal 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.

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

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

• Screening completion for breast, cervical or colorectal cancer: median increase of 1.7 percentage points (interquartile interval: 0.1 to 3.6 percentage points; 7 study arms)
• Completed colorectal cancer screening: estimated effects ranged from a 0.1 percentage point decrease to a 2.8 percentage point increase (3 study arms)

An economic review of this intervention was not conducted because the CPSTF did not have enough information to determine if the intervention works.

Applicability of this intervention across different settings and populations was not assessed because the CPSTF did not have enough information to determine if the intervention works.

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 reviews of provider incentives to increase breast, cervical, and colorectal cancer screening.

The effectiveness of provider incentives in increasing colorectal, breast, and cervical cancer screening has not been established. Despite great interest in and use of provider incentives in many organized health systems (e.g., pay-for-performance models), relatively little published scientific information is available to assess the effectiveness of incentives in increasing screening for breast, cervical, and colorectal cancers. Several research questions remain.

• Are provider incentives effective in increasing screening for colorectal, breast, and cervical cancers?
• Do provider incentives incrementally increase the effectiveness of provider assessment and feedback interventions?
• What are the most cost-effective approaches to reward cancer screening performance and/or referral by practitioners?
• Do these interventions result in other positive or negative changes in health behavior or use of healthcare 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?

• Physician settings included individual practice associations or physician practices, and patient populations included commercially insured health plan members.
• Included studies reported completed screenings or recommended or offered screenings.
• Studies that reported completed screenings used claims data from health plans to measure outcomes.
• Incentives varied across studies.

Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for The Guide to Community Preventive Services. American Journal of Preventive Medicine. 2012;43(1):765-86.

Community Preventive Services Task Force. Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening. American Journal of Preventive Medicine. 2012;43(1):92–6.

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.

Effectiveness Review

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

The following list of included studies is for reviews of provider incentives to increase breast, cervical, and colorectal cancer screening. *Notes 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

*Armour BS, Friedman C, Pitts MM, Wike J, Alley L, Etchason J. The influence of year-end bonuses on colorectal cancer screening. Am J Manag Care 2004;10(9):617 24.

Grady KE, Lemkau JP, Lee NR, Caddell C. Enhancing mammography referral in primary care. Prev Med 1997;26(6):791 800.

*Hillman AL, Ripley K, Goldfarb N, Nuamah I, Weiner J, Lusk E. Physician f nancial incentives and feedback: failure to increase cancer screening in Medicaid managed care. Am J Public Health 1998;88(11):1699 701.

Reid GS, Robertson AJ, Bissett C, Smith J, Waugh N, Halkerston R. Cervical screening in Perth and Kinross since introduction of the new contract. BMJ 1991;303(6800):447 50.

Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA 2005;294(14):1788 93.

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*)

Sabatino SA, Habarta N, Baron RC. Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers: systematic reviews of provider assessment and feedback and provider incentives. Am J Prev Med 2008;35(1S):67-74.

The CPSTF did not have enough evidence to determine whether the intervention is or is not effective. This does not mean that the intervention does not work, but rather that additional research is needed to determine whether or not the intervention is effective.