Key Points Question Are breast and colorectal cancer screening rates associated with the time of day a patient visits the primary care clinician? Findings In this quality improvement study analysis of 33 primary care practices including 19 254 patients eligible for breast cancer screening and 33 468 patients eligible for colorectal cancer screening, both clinician ordering and patient completion of cancer screening tests decreased as the time of day progressed. Meaning Patients with primary care clinic appointment times later in the day were less likely to be ordered for and receive guideline recommended cancer screening.

SUMMARY Setting Initial cost-effectiveness evaluations of Xpert MTB/RIF (Xpert) for tuberculosis (TB) diagnosis have not fully accounted for realities of implementation in peripheral settings. Objective We evaluated costs and diagnostic outcomes of Xpert testing implemented at various healthcare levels in Uganda. Design We collected empirical cost data from five health centers utilizing Xpert for TB diagnosis, employing an ingredients approach. We reviewed laboratory and patient records to assess outcomes in these sites and ten sites without Xpert. We also estimated incremental cost-effectiveness of Xpert testing; our primary outcome was incremental cost of Xpert testing per newly detected TB case. Results The mean unit cost of an Xpert test was US$21 based on a mean monthly volume of 54 tests per site, though unit cost varied widely (US$16–58) and was primarily determined by testing volume. Total diagnostic costs were 2.4-fold higher in Xpert clinics compared to non-Xpert clinics, though Xpert only increased diagnoses by 12%. Diagnostic costs of Xpert averaged US$119 per newly detected TB case but were as high as US$885 in the lowest-volume center. Conclusion Xpert testing can detect TB cases at reasonable cost but may double diagnostic budgets for relatively small gains, with cost-effectiveness deteriorating with lower testing volumes.

Key PointsQuestionIs an active choice intervention in the electronic health record directed to medical assistants during primary care visits associated with improved rates of breast and colorectal cancer screening?FindingIn this quality improvement study of 25 primary care practices and 69 916 patients, the active choice intervention was associated with a significant increase in clinician ordering of both breast and colorectal cancer screening tests over time when compared with a control group of practices. However, the intervention was not associated with a significant change in patient completion of either type of cancer screening test during a 1-year follow-up.MeaningNudges facilitated by the electronic health record can increase clinician ordering of cancer screening tests but may need to be combined with other interventions to improve patient completion.