1. Evidence of a Program's Effectiveness in Improving Colorectal Cancer Screening Rates in Federally Qualified Health Centers
Robert L. Stephens, PhD, MPH1; Kara S. Riehman, PhD1
1 American Cancer Society, Intramural Research, Statistics and Evaluation Center
Abstract
Methods
Results
This study provides evidence for the effectiveness of an American Cancer Society (ACS) grant program that funded implementation of evidence-based screening promotion interventions.
We compared colorectal cancer (CRC) screening rates in 77 ACS-grant-funded federally qualified health centers (FQHCs) between 2013 and 2015 with rates in 77 non-funded FQHCs selected using a genetic matching technique. The Uniform Data System (UDS) from 2013 to 2015 served as our data source. Funded grantees differed significantly from non-grantees on several indicators at baseline.
Genetic matching resulted in good quality matched samples. While both groups increased screening rates over time, grantees increased their rates significantly more than non-grantees, especially between 2013 and 2014, where funded FQHCs increased by 9% and non-funded FQHCs increased by 3%. Findings suggest grant funding was effective in promoting improvements in CRC screening rates in funded FQHCs, and these improvements exceeded those of non-funded FQHCs.
Funding that results in targeted, intensive efforts supported by technical assistance and accountability for data and reporting, can result in improved system policies and practices that, in turn, can increase screening rates among uninsured and underserved populations.
Study Sample
The sample consisted of 1,141 FQHCs that reported Uniform Data System (UDS) data for 2013–2015, had complete data in the 2013 (baseline year) data set on covariates used for matching, and had aggregate CRC screening outcome data for all 3 years.
Among these, 77 FQHCs were funded by ACS through the CHANGE grant program. The remaining 1,064 non-funded FQHCs provided the pool of potential comparison cases for matching, from which 77 were selected.
Data
Rates of appropriate CRC screening reported by FQHCs in the 2013–2015 UDS served as the primary outcome of interest.
HRSA provides guidance to FQHCs regarding the definition of appropriate CRC screening. Adult patients aged 51 through 74 years, who had at least one medical visit during the reporting period, serve as the denominator. Number of patients aged 51 through 74 years with appropriate screening for CRC serve as the numerator.
Patients who have or who have had CRC or colectomy are excluded. Appropriate screening includes a documented colonoscopy conducted during the measurement year or the previous 9 years, a flexible sigmoidoscopy conducted during the measurement year or the previous 4 years, or a fecal occult blood test or fecal immunochemical test conducted during the measurement year.
Statistical Analysis
In the absence of randomization, it is reasonable to expect that some differences will exist between samples. We addressed this using propensity scores and a genetic matching technique.
Genetic matching has been shown in simulation studies to achieve better covariate balance than propensity score matching alone. In the current application of genetic matching, 31 covariates, along with the propensity score, were included in the model, and matching was implemented without replacement of comparison (non-funded) FQHCs.
Changes in the outcome (rates of appropriate CRC screening) in the matched samples over time were analyzed using a generalized linear model to implement a repeated measures analysis of variance with group membership (funded versus non-funded FQHCs) as a fixed between-site effect and time (2013, 2014, 2015) as a fixed within- site effect.
Covariate
Before
Match
After
Total number of male patients
54.03
4.33
Percentage of male patients 18 years and younger
48.40
-4.03
Percentage of male patients years old
-36.93
9.60
Percentage of male patients years old
-39.09
1.02
Percentage of male patients 65 and older
-36.63
4.83
Total number of female patients
56.90
2.14
Percentage of female18 years and younger
40.45
-5.39
Percentage of female patients years old
-14.43
-5.83
Percentage of female patients years old
-30.37
7.76
Percentage of female patients 65 years and older
-30.08
3.46
Percentage of Black
14.01
4.45
Percentage of White
-40.46
-1.98
Percentage of Hispanic
30.88
-6.66
Total number with income less than or equal to 100% of the Federal poverty level
47.80
-3.49
Total number of patients 17 years and younger uninsured
52.66
4.58
Total number of patients 18 years and older uninsured
62.90
-1.24
Total number of patients 17 years and younger Medicaid
50.63
-3.39
Total number of patients 18 years and older Medicaid
33.71
4.03
Total number of patients 18 years and older Medicare
34.63
9.02
Total number of visits for asthma
43.45
4.17
Total number of patients with asthma
47.49
-2.13
Total number of visits for chronic bronchitis/emphysema
45.57
5.30
Total number of patients with chronic bronchitis/emphysema
49.00
6.11
Total number of visits for diabetes
48.08
3.52
Total number of patients with diabetes
55.41
-5.17
Total number of visits for hypertension
4.67
Total number of patients with hypertension
58.34
-1.77
Percentage of female patients Pap tested
19.93
-6.35
Percentage of asthmatic patients given therapy
50.37
18.46
Percentage of patients with coronary artery disease given therapy
25.61
1.33
Total revenue (in millions of dollars)
43.15
6.35
Percentage of patients aged with appropriate CRC screening
-25.42
-13.16
Background
CRC ranks as the third leading cause of cancer death in the U.S.
Appropriate screening can effectively detect CRC and reduce related mortality.
ACS recommends screening for CRC in average risk adults beginning at age 50 years and continuing until age 75 years. Yet, in 2013, only about 60% of eligible U.S. adults were up-to-date for CRC screening.
Among the nation’s uninsured, underinsured, and medically underserved populations, screening rates are even lower.
FQHCs provide healthcare services, including cancer screening, to more than 23 million low-income individuals. Despite the availability of low-cost or free services, the CRC screening rate among those served in FQHCs was only 38% in 2015.
ACS initiated the Community Health Advocates implementing Nationwide Grants for Empowerment and Equity (CHANGE) grant program to address this disparity. Potential grantees were required to select at least two intervention strategies having sufficient evidence for increasing cancer screening rates.
Objectives
Results
Conclusions
Report on CRC screening rates in FQHCs funded by the CHANGE grant program between 2013 and 2015.
Compare them with those of a non-funded sample of FQHCs selected using a genetic matching technique.
Funded FQHCs served larger patient populations who were disproportionally members of racial/ethnic minority groups, more likely to live in poverty, and more likely to have Medicaid, Medicare, or no health insurance. Funded FQHCs lagged behind non-funded FQHCs on CRC screening at baseline (26.4% vs 30.4%).
The genetic matching analysis resulted in good quality matched samples. Results indicate adequate balancing. All covariates and the propensity score showed substantial reductions in standardized mean differences. The 4.0% difference at baseline between groups prior to matching dropped to 2.1% after matching.
The generalized linear model analysis indicated the matched samples both increased CRC screening rates significantly over time, F(2, 304)=40.57, p< On average, CRC screening rates for both groups increased nearly 11% from 27.4% in 2013 to % in While the Group main effect was not significant, the Group X Time was, F(2, 304)=3.10, p= An orthogonal polynomial decomposition of the interaction indicated the linear component was not significant, but the quadratic component was, F(1, 152)=0.38, p=0.022, suggesting that the rate of acceleration in CRC screening rates over time was greater for funded FQHCs than non-funded FQHCs.
Funded FQHCs increased screening rates faster than non-funded FQHCs, particularly between 2013 and 2014, during the initial years of the CHANGE grant program.
Targeted, intensive efforts supported by TA and accountability for data and reporting, can result in improved system policies and practices that in turn can increase CRC screening rates.
Future work will determine the extent to which these types of programs are sustainable.