Follow-up to Abnormal Cancer Screening Tests: Considering the Multilevel Context of Care

Abstract

The call for multilevel interventions to improve the quality of follow-up to abnormal cancer screening has been out for a decade but published work emphasizes individual approaches, and conceptualizations differ regarding the definition of levels. To investigate the scope and methods being undertaken in this focused area of follow-up to abnormal tests (breast, colon, cervical), we reviewed recent literature and grants (2007-2012) funded by the National Cancer Institute. A structured search yielded 16 grants with varying definitions of “follow-up” (e.g. completion of recommended tests, time to diagnosis); most included minority racial/ethnic group participants. Ten grants concentrated on measurement/intervention development, and 13 piloted or tested interventions (categories not mutually exclusive). All studies considered patient level factors and effects. While some directed interventions at provider levels, few measured group characteristics and effects of interventions on the providers or levels other than the patient. Multilevel interventions are being proposed, but clarity regarding endpoints, definition of levels, and measures is needed. The differences in the conceptualization of levels and factors that affect practice need empirical exploration and we need to measure their salient characteristics to advance our understanding of how context affects cancer care delivery in a changing practice and policy environment.

Interventions to Improve Follow-up of Positive Results on Fecal Blood Tests

“…Timely diagnostic colonoscopy after a positive fecal test result is a critical step on the CRC screening continuum (16). Although research has primarily focused on screening completion (54, 55), fecal testing will not be effective if positive results are not followed up.…”

“…Colonoscopy follow-up is complex because it involves the interaction of several levels of care and evaluating the appropriateness of an invasive diagnostic test (16, 17). Several patient-, provider-, and system-level factors have been evaluated to improve follow-up of test-positive patients (13, 18–21), but lack of comparative data impedes implementation of potentially effective interventions.…”

Variation in Screening Abnormality Rates and Follow-Up of Breast, Cervical and Colorectal Cancer Screening within the PROSPR Consortium

“…Gaining insight into best screening processes of care within PROSPR will require multi-level investigation of patient, provider, clinic, and health system factors, and entails assembling health system information not readily available through electronic health records alone. 38,39 Clinical care pathways regarding communication of test results is one such area where the consortium is actively working to document current practices. These data will enable evaluation of the role of communication at care interfaces in the timely follow-up of screening abnormalities.…”

Organizational Predictors of Colonoscopy Follow-up for Positive Fecal Occult Blood Test Results: An Observational Study

“…Most prior studies examining contributors to FOBT+ follow-up have focused on non-modifiable individual-level factors,(20;21) identifying significant associations with patient age,(22–25) gender,(14;24;26) race,(25) comorbidity,(23) personal history of bowel disease,(27) family history of colorectal cancer,(28) and recent colonoscopy. (25) A few have identified modifiable individual-level contributors, including patient fears and worries about colorectal cancer(27;28) and provider awareness of guidelines(29;30) and intentions to order diagnostic testing for FOBT+ results.…”

“…(25) A few have identified modifiable individual-level contributors, including patient fears and worries about colorectal cancer(27;28) and provider awareness of guidelines(29;30) and intentions to order diagnostic testing for FOBT+ results. (26) However, very few prior studies have examined the contribution of modifiable organizational-level factors to FOBT+ follow-up patterns,(21) despite growing recognition that understanding the role that the care environment plays in assuring quality is essential to designing effective interventions and making further improvements in cancer care. (31;32)…”