Last data update: Sep 23, 2024. (Total: 47723 publications since 2009)
Records 1-30 (of 38 Records) |
Query Trace: Royalty J [original query] |
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Variations in screening quality in a federal colorectal cancer screening program for the uninsured
Nadel MR , Royalty J , Joseph D , Rockwell T , Helsel W , Kammerer W , Gray SC , Shapiro JA . Prev Chronic Dis 2019 16 E67 INTRODUCTION: Screening can decrease colorectal cancer incidence and mortality and is recommended in clinical practice guidelines. Poor quality of colorectal cancer screening can negate the benefit of screening. The objective of this study was to assess the quality of screening services provided by the Centers for Disease Control and Prevention's Colorectal Cancer Control Program from July 2009 through June 2015. METHODS: We collected data from the program's 29 grantees, funded to provide colorectal cancer screening and diagnostic services to asymptomatic, low-income, and underinsured or uninsured adults aged 50 to 64. We collected data on the dates and results of all screening and diagnostic tests and, for colonoscopies, on whether the cecum was reached, whether bowel preparation was adequate, and endoscopists' recommendations for the next test. RESULTS: Overall, 82.9% (range among grantees, 50.0%-97.2%) of positive FOBTs/FITs were followed up by colonoscopy; 95.2% of colonoscopies occurred within 180 days of the positive stool test. Cecal intubation rates ranged among grantees from 94.2% to 100%. Adenoma detection rates met recommended threshold levels for almost all grantees. Recommendations for rescreening and surveillance intervals deviated from guidelines in both directions. Of clients with normal colonoscopies, 85.3% (range, 37.7%-99.7%) were told to return in 10 years, as recommended in national guidelines. Of clients with advanced adenomas, 55.2% (range, 20.0%-84.6%) were told to return in 3 years as recommended, 25.4% (range, 3.8%-56.6%) in 5 or more years, and 18.6% (range, 0%-47.2%) in less than 3 years. CONCLUSION: Although overall screening quality was good, it varied considerably. Ongoing monitoring to identify performance problems is essential for all colorectal cancer screening activities, so that efforts designed to improve performance can be targeted to individual clinicians. |
The impact of performance-based grants management on performance: The Centers for Disease Control and Preventions National Breast and Cervical Cancer Early Detection Program
Poister TH , Pasha O , DeGroff A , Royalty J . Am Rev Public Adm 2018 48 (5) 444-457 Performance-based grants management is a strategy used by public agencies to improve performance and strengthen accountability by connecting annual award amounts to performance information. This study evaluates the impacts of a performance-based grants management process implemented by the U.S. Centers for Disease Control and Prevention to strengthen the effectiveness of its National Breast and Cervical Cancer Early Detection Program. The study uses panel data and interrupted time-series analysis over 10 years for 51 grantees. Results show partial and conditional effectiveness of the performance-based grants management process in strengthening performance. In particular, the implementation of the performance-based grants management system consistently improved the performance of those grantees for whom the targets were challenging. While prior research has found, in some cases, evidence of a positive impact of performance management practices in improving programs delivered directly by public organizations at the local level, this study examines the performance managementperformance relationship in a more challenging context of a federal grants program delivered through a highly decentralized system. |
Cervical cancer screening in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) in four US-affiliated Pacific Islands between 2007 and 2015
Senkomago V , Royalty J , Miller JW , Buenconsejo-Lum LE , Benard VB , Saraiya M . Cancer Epidemiol 2017 50 260-267 BACKGROUND: Cervical cancer incidence in the US-Affiliated Pacific Islands (USAPIs) is double that of the US mainland. American Samoa, Commonwealth of Northern Mariana Islands (CNMI), Guam and the Republic of Palau receive funding from the Centers for Disease Control (CDC) National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to implement cervical cancer screening to low-income, uninsured or under insured women. The USAPI grantees report data on screening and follow-up activities to the CDC. MATERIALS AND METHODS: We examined cervical cancer screening and follow-up data from the NBCCEDP programs in the four USAPIs from 2007 to 2015. We summarized screening done by Papanicolaou (Pap) and oncogenic human papillomavirus (HPV) tests, follow-up and diagnostic tests provided, and histology results observed. RESULTS: A total of 22,249 Pap tests were conducted in 14,206 women in the four USAPIs programs from 2007-2015. The overall percentages of abnormal Pap results (low-grade squamous intraepithelial lesions or worse) was 2.4% for first program screens and 1.8% for subsequent program screens. Histology results showed a high proportion of cervical intraepithelial neoplasia grade 2 or worse (57%) among women with precancers and cancers. Roughly one-third (32%) of Pap test results warranting follow-up had no data recorded on diagnostic tests or follow-up done. CONCLUSION: This is the first report of cervical cancer screening and outcomes of women served in the USAPI through the NBCCEDP with similar results for abnormal Pap tests, but higher proportion of precancers and cancers, when compared to national NBCCEDP data. The USAPI face significant challenges in implementing cervical cancer screening, particularly in providing and recording data on diagnostic tests and follow-up. The screening programs in the USAPI should further examine specific barriers to follow-up of women with abnormal Pap results and possible solutions to address them. |
Costs of colorectal cancer screening provision in CDC's colorectal cancer control program: Comparisons of colonoscopy and FOBT/FIT based screening
Subramanian S , Tangka FK , Hoover S , Royalty J , DeGroff A , Joseph D . Eval Program Plann 2017 62 73-80 We assess annual costs of screening provision activities implemented by 23 of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program (CRCCP) grantees and report differences in costs between colonoscopy and FOBT/FIT-based screening programs. We analysed annual cost data for the first three year of the CRCCP (July 2009-June 2011) for each screening provision activity and categorized them into clinical and non-clinical screening provision activities. The largest cost components for both colonoscopy and FOBT/FIT-based programs were screening and diagnostic services, program management, and data collection and tracking. During the first 3 years of the CRCCP, the average annual clinical cost for screening and diagnostic services per person served was $1150 for colonoscopy programs, compared to $304 for FIT/FOBT-based programs. Overall, FOBT/FIT-based programs appear to have slightly higher non-clinical costs per person served (average $1018; median $838) than colonoscopy programs (average $980; median $686). Colonoscopy-based CRCCP programs have higher clinical costs than FOBT/FIT-based programs during the 3-year study timeframe (translating into fewer people screened). Non-clinical costs for both approaches are similar and substantial. Future studies of the cost-effectiveness of colorectal cancer screening initiatives should consider both clinical and non-clinical costs. |
Costs of promoting cancer screening: Evidence from CDC's Colorectal Cancer Control Program (CRCCP)
Tangka FK , Subramanian S , Hoover S , Royalty J , Joseph K , DeGroff A , Joseph D , Chattopadhyay S . Eval Program Plann 2016 62 67-72 The Colorectal Cancer Control Program (CRCCP) provided funding to 29 grantees to increase colorectal cancer screening. We describe the screening promotion costs of CRCCP grantees to evaluate the extent to which the program model resulted in the use of funding to support interventions recommended by the Guide to Community Preventive Services (Community Guide). We analyzed expenditures for screening promotion for the first three years of the CRCCP to assess cost per promotion strategy, and estimated the cost per person screened at the state level based on various projected increases in screening rates. All grantees engaged in small media activities and more than 90% used either client reminders, provider assessment and feedback, or patient navigation. Based on all expenditures, projected cost per eligible person screened for a 1%, 5%, and 10% increase in state-level screening proportions are $172, $34, and $17, respectively. CRCCP grantees expended the majority of their funding on Community Guide recommended screening promotion strategies but about a third was spent on other interventions. Based on this finding, future CRC programs should be provided with targeted education and information on evidence-based strategies, rather than broad based recommendations, to ensure that program funds are expended mainly on evidence-based interventions. |
Using evidence-based interventions to improve cancer screening in the National Breast and Cervical Cancer Early Detection Program
DeGroff A , Carter A , Kenney K , Myles Z , Melillo S , Royalty J , Rice K , Gressard L , Miller JW . J Public Health Manag Pract 2016 22 (5) 442-9 CONTEXT: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides cancer screening to low-income, un-, and underinsured women through more than 11 000 primary care clinics. The program is well-positioned to work with health systems to implement evidence-based interventions (EBIs) to increase screening among all women. OBJECTIVE: To collect baseline data on EBI use, evaluation of EBIs, and related training needs among NBCCEDP grantees. DESIGN: The Centers for Disease Control and Prevention conducted a Web-based survey in late 2013 among NBCCEDP grantees for the period July 2012 to June 2013. This was the first systematic assessment of EBIs among NBCCEDP grantees. SETTING: The Centers for Disease Control and Prevention's NBCCEDP. PARTICIPANTS: Primarily program directors/coordinators for all 67 NBCCEDP grantees. MAIN OUTCOME MEASURES: Data captured were used to assess implementation of 5 EBIs, their evaluation, and related training needs. Frequencies and proportions were determined. Cluster analysis identified grantees with similar patterns of EBI use for NBCCEDP clients and providers. RESULTS: On average, 4.1 of 5 EBIs were implemented per grantee for NBCCEDP clients and providers. Four clusters were identified including "high overall EBI users," "high provider EBI users," "high EBI users with no provider assessment and feedback," and "high client EBI users." Only 1.8 EBIs were implemented, on average, with non-NBCCEDP clients and providers. Fewer than half (n = 32, 47.8%) of grantees conducted process or outcome evaluation of 1 or more EBIs. Overall, 47.6% of grantees reported high or medium training needs for client-oriented EBIs and 54.3% for provider-oriented EBIs. CONCLUSIONS: The NBCCEDP grantees are implementing EBIs extensively with clients and providers. Increased EBI use among non-NBCCEDP clients/providers is needed to extend the NBCCEDP's reach and impact. Grantee training and technical assistance is necessary across EBIs. In addition, grantees' use of process and outcome evaluation of EBI implementation must be increased to inform effective program implementation. |
Breast cancer screening of underserved women in the USA: results from the National Breast and Cervical Cancer Early Detection Program, 1998-2012
Howard DH , Tangka FK , Royalty J , Dalzell LP , Miller J , O'Hara B , Joseph K , Kenney K , Guy G , Hall IJ . Cancer Causes Control 2015 26 (5) 657-68 OBJECTIVE: To describe the number and proportion of eligible women receiving mammograms funded by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Low-income, uninsured, and underinsured women aged 40-64 are eligible for mammography screening through the NBCCEDP. We used data from the NBCCEDP, the Current Population Survey, and Medical Expenditure Panel Survey to describe the number and proportion of women screened by the NBCCEDP and overall. RESULTS: In 2011 and 2012, the NBCCEDP screened 549,043 women aged 40-64, an estimated 10.6 % (90 % confidence interval [CI] 10.4-10.9 %) of the eligible population. We estimate that 30.6 % (90 % CI 26.4-34.8 %) of eligible women aged 40-64 were screened outside the NBCCEDP, and 58.8 % (90 % CI 54.6-63.0 %) were not screened. The proportion of eligible women screened by the NBCCEDP varied across states, with an estimated range of 3.2 % (90 % CI 2.9-3.5 %) to 52.8 % (90 % CI 36.1-69.6 %) and a median of 13.7 % (90 % CI 11.0-16.4 %). The estimated proportion of eligible women aged 40-64 who received mammograms through the NBCCEDP was relatively constant over time, 11.1 % (90 % CI 10.2-11.9 %) in 1998-1999 and 10.6 % (90 % CI 10.4-11.9 %) in 2011-2012 (p = 0.23), even as the number of women screened increased from 343,692 to 549,043. CONCLUSIONS: Although the NBCCEDP provided screening services to over a half million low-income uninsured women for mammography, it served a small percentage of those eligible. The majority of low-income, uninsured women were not screened. |
Data sources for identifying low-income, uninsured populations: application to public health - National Breast and Cervical Cancer Early Detection Program
Dalzell LP , Tangka FK , Powers DS , O'Hara BJ , Holmes W , Joseph K , Royalty J . Cancer Causes Control 2015 26 (5) 699-709 OBJECTIVE: To provide information on the sources of data for estimating low-income, uninsured populations. To recommend uses of these data sources. To demonstrate the application of these data sources in the public health field, using the National Breast and Cervical Cancer Early Detection Program as an example. METHODS: We describe U.S. Census Bureau data sources for identifying low-income, uninsured populations using two population surveys: the Annual Social and Economic Supplement to the Current Population Survey (CPS ASEC) and the American Community Survey (ACS), and using one model-based estimation program, the Small Area Health Insurance Estimates (SAHIE). We provide recommendations for use of these data sources, and we use CPS ASEC and SAHIE to estimate the percent of U.S. women eligible for the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). RESULTS: CPS ASEC, ACS, and SAHIE are produced by the U.S. Census Bureau, and they are reliable sources for estimates of the low-income, uninsured populations in the USA. Key characteristics of these three data sources were presented to highlight the strengths of each to meet the needs of various programs at national and local levels. Recommendations are made on the use of the data sources. Based on these three data sources, estimates of NBCCEDP eligibility showed substantial variation over time at the national and state levels, and across states and counties. CONCLUSIONS: Publicly funded programs that are directed toward low-income, uninsured individuals require information on their eligible populations to make decisions about program policy and resource allocation, and to monitor and evaluate the effectiveness of the programs. The U.S. Census Bureau produces three data sources (CPS ASEC, ACS, and SAHIE) for these estimates. The percent of U.S. women eligible for NBCCEDP varies over time and across states and counties. The data sources for these estimates are changing in order to measure key dimensions of the Affordable Care Act (ACA) and can provide helpful information for assessing the legislation's impact. |
Transition from film to digital mammography: impact for breast cancer screening through the National Breast and Cervical Cancer Early Detection Program
van Ravesteyn NT , van Lier L , Schechter CB , Ekwueme DU , Royalty J , Miller JW , Near AM , Cronin KA , Heijnsdijk EA , Mandelblatt JS , de Koning HJ . Am J Prev Med 2015 48 (5) 535-42 INTRODUCTION: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides mammograms and diagnostic services for low-income, uninsured women aged 40-64 years. Mammography facilities within the NBCCEDP gradually shifted from plain-film to digital mammography. The purpose of this study is to assess the impact of replacing film with digital mammography on health effects (deaths averted, life-years gained [LYG]); costs (for screening and diagnostics); and number of women reached. METHODS: NBCCEDP 2010 data and data representative of the program's target population were used in two established microsimulation models. Models simulated observed screening behavior including different screening intervals (annual, biennial, irregular) and starting ages (40, 50 years) for white, black, and Hispanic women. Model runs were performed in 2012. RESULTS: The models predicted 8.0-8.3 LYG per 1,000 film screens for black women, 5.9-7.5 for white women, and 4.0-4.5 for Hispanic women. For all race/ethnicity groups, digital mammography had more LYG than film mammography (2%-4%), but had higher costs (34%-35%). Assuming a fixed budget, 25%-26% fewer women could be served, resulting in 22%-24% fewer LYG if all mammograms were converted to digital. The loss in LYG could be reversed to an 8%-13% increase by only including biennial screening. CONCLUSIONS: Digital could result in slightly more LYG than film mammography. However, with a fixed budget, fewer women may be served with fewer LYG. Changes in the program, such as only including biennial screening, will increase LYG/screen and could offset the potential decrease in LYG when shifting to digital mammography. |
Explaining variation across grantees in breast and cervical cancer screening proportions in the NBCCEDP
Subramanian S , Tangka FK , Ekwueme DU , Trogdon J , Crouse W , Royalty J . Cancer Causes Control 2015 26 (5) 689-95 PURPOSE: There is substantial variation across the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) grantees in terms of the proportion of the eligible population served by the grantees each year (hereafter referred to as the screening proportion). In this paper, we assess program- and state-level factors to better understand the reason for this variation in breast and cervical cancer screening proportions across the NBCCEDP grantees. METHODS: We constructed a longitudinal data set, consisting of data from NBCCEDP grantees for each of the three study years (program-years 2006-2007, 2008-2009, and 2009-2010). We performed multivariate analysis to explain the variation in breast and cervical cancer screening proportions across the grantees. The program-level factors studied were the total federal funds received, average cost of screening women by grantee, and the overall organizational structure. The state-level variables included were urban versus rural mix, access to care, and the size of the eligible population. RESULTS: Of the 48 grantees included in the study, those that serve larger populations, as measured by the size of the population and the percentage of women eligible for services, had lower screening proportions. Higher average cost of service delivery was also associated with lower screening proportions. In addition, grantees whose populations were more concentrated in urban areas had lower screening proportions. CONCLUSIONS: Overall, the average cost of screening, the overall size of the population eligible, and the concentration of population in urban areas all had a negative relationship to the proportion of eligible women screened by NBCCEDP grantees. |
Provider management of equivocal cervical cancer screening results among underserved women, 2009-2011: follow-up of atypical squamous cells of undetermined significance
Watson M , Benard V , Lin L , Rockwell T , Royalty J . Cancer Causes Control 2015 26 (5) 759-64 PURPOSE: Reflex human papillomavirus (HPV) testing is the preferred triage option for most women diagnosed with atypical squamous cells of undetermined significance (ASC-US). This study was conducted to describe follow-up results of women with ASC-US Pap test results in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), focusing on HPV test use. METHODS: We examined the follow-up of 45,049 women in the NBCCEDP with ASC-US Pap tests during 2009-2011. Data on demographic characteristics, diagnostic procedures, and clinical outcomes were analyzed. RESULTS: NBCCEDP providers diagnosed 45,049 women (4.5 % of all Pap tests) with an ASC-US result. Of those, 28,271 (62.8 %) were followed with an HPV test, 3,883 (8.6 %) with a repeat Pap test, 6,592 (14.6 %) with colposcopy, and 6,303 were lost to follow-up (14.0 %). Women aged 40 and older were followed more often with an HPV test. White, black, and Asian/Pacific Islander women were followed more often with an HPV test after an ASC-US Pap compared to Hispanic and American Indian/Alaska Native (AI/AN) women. Among women with a positive HPV test on follow-up, almost 90 % continued with colposcopy as recommended. AI/AN women had the highest rates of HPV positivity (55.2 %) and of no follow-up (25.0 %). CONCLUSION: This is the first analysis describing follow-up of ASC-US Pap test results in the NBCCEDP, providing a window into current management of ASC-US results. Findings raise concerns about persistent disparities among AI/AN women. During 2009-2011, nearly two-thirds of women with an ASC-US Pap test result were followed with an HPV reflex test. |
The reach and health impacts of the National Breast and Cervical Cancer Early Detection Program
Guy GP Jr , Tangka FK , Hall IJ , Miller JW , Royalty J . Cancer Causes Control 2015 26 (5) 649-50 Early Detection Program,” contains 16 articles that provide an in-depth examination of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). Since 1990, the NBCCEDP has provided access to breast and cervical cancer screening and diagnostic services to more than 4.3 million low-income, underinsured, and uninsured women in the USA [1]. It is the largest organized cancer screening program in the country and, by design, reaches women who are underserved and may not have access to these services otherwise. | The first article in this special issue provides an overview of the NBCCEDP—its design, history, service delivery components, program impact, and potential role moving forward [2]. The remaining articles use data from the NBCCEDP to describe its reach and impact. Together, these findings provide a vital resource for understanding the important role of the NBCCEDP in providing high-quality breast and cervical cancer screening and diagnostic services to underserved women in the USA. |
Clinical outcomes of mammography in the National Breast and Cervical Cancer Early Detection Program, 2009-2012
White A , Miller J , Royalty J , Ryerson AB , Benard V , Helsel W , Kammerer W . Cancer Causes Control 2015 26 (5) 723-32 PURPOSE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) enrolls asymptomatic women for cancer screening and symptomatic women for diagnostic services. This study describes the results of mammograms provided by the NBCCEDP, by examination indication (screening or diagnostic), and by age group. METHODS: For the first NBCCEDP-funded mammogram received during 2009-2012, we calculated age-specific percentages of abnormal findings, rates of follow-up testing, and invasive and in situ breast cancer diagnoses per 1,000 mammograms. Logistic regression was used to estimate the odds for each of these outcomes by examination indication. RESULTS: The NBCCEDP provided 941,649 screening, 175,310 diagnostic, and 30,434 unknown indication mammograms to 1,147,393 women. The percentage with abnormal mammograms was higher for diagnostic mammograms (40.1 %) than for screening mammograms (15.5 %). Compared with women aged 40-49 years, fewer women aged 50-64 years had abnormal results for screening (13.7 vs. 19.7 %) and diagnostic mammograms (37.7 vs. 42.7 %). Follow-up rates per 1,000 mammograms were lower among women aged 50-64 compared to those aged 40-49 (screening: 143.9 vs. 207.5; diagnostic: 645.3 vs. 760.9); biopsy rates exhibited a similar pattern (screening: 24.1 vs. 32.9; diagnostic: 167.7 vs. 169.7). For screening mammograms, older women had more cancers detected than younger women (invasive: 3.6 vs. 2.2; in situ: 2.3 vs. 2.0). Similarly, for diagnostic mammograms, cancer detection was higher for older women (invasive: 67.8 vs. 36.6; in situ: 17.4 vs. 11.1). CONCLUSIONS: Abnormal mammograms and diagnostic follow-up procedures were less frequent in women aged 50-64 years compared to women aged 40-49 years, while breast cancer detection was higher, regardless of indication for the mammogram. Some of these differences between age groups were greater for screening mammograms than for diagnostic mammograms. Cancer detection rates were higher for diagnostic mammograms compared with screening mammograms. These findings support the NBCCEDP's priority of serving women aged 50-64 years and providing both screening and diagnostic mammograms. |
Cervical cancer screening of underserved women in the United States: results from the National Breast and Cervical Cancer Early Detection Program, 1997-2012
Tangka FK , Howard DH , Royalty J , Dalzell LP , Miller J , O'Hara BJ , Sabatino SA , Joseph K , Kenney K , Guy GP Jr , Hall IJ . Cancer Causes Control 2015 26 (5) 671-86 OBJECTIVE: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screens to low-income, uninsured, and underinsured women. We describe the number and proportion of women eligible for cervical cancer screening services and the proportion of eligible women screened over the period 1997-2012. METHODS: Low-income, uninsured, and underinsured women aged 18-64 years who have not had a hysterectomy are eligible for cervical cancer screening through the NBCCEDP. We estimated the number of low-income, uninsured women using data from the US Census Bureau. We adjusted our estimates for hysterectomy status using the National Health Interview Survey and the Behavioral Risk Factor Surveillance System. We used data from the NBCCEDP to describe the number of women receiving NBCCEDP-funded screening and calculated the proportion of eligible women who received screening through the NBCCEDP at the national level (by age group, race/ethnicity) and at the state level by age group. We used the Medical Expenditure Panel Survey to estimate the proportion of NBCCEDP-eligible women who were screened outside the NBCCEDP and the proportion that are not screened. RESULTS: We estimate that in 2010-2012, 705,970 women aged 18-64 years, 6.5 % (705,970 of 9.8 million) of the eligible population, received NBCCEDP-funded Pap tests. We estimate that 60.2 % of eligible women aged 18-64 years were screened outside the NBCCEDP and 33.3 % were not screened. The NBCCEDP provided 623,603 screens to women aged 40-64 years, an estimated 16.5 % of the eligible population, and 83,660 screens to women aged 18-39 years, representing an estimated 1.2 % of the eligible population. The estimated proportions of eligible women screened in each state ranged from 1.5 to 32.7 % and 5 % to 73.2 % among the 18-64 and 40-64 years age groups, respectively. Changes in the proportion of eligible women screened over the study period were nonsignificant. CONCLUSIONS: Although the program provided cervical screening to over 700,000 women between 2010 and 2012, it served a small percent of those eligible. The proportion of women screened varied substantially across age groups, racial/ethnic groups, and states. Many low-income, uninsured women are not being screened. |
Breast and cervical cancers diagnosed and stage at diagnosis among women served through the National Breast and Cervical Cancer Early Detection Program
Miller JW , Royalty J , Henley J , White A , Richardson LC . Cancer Causes Control 2015 26 (5) 741-7 PURPOSE: To assess cancers diagnosed and the stage of cancer at the time of diagnosis among low-income, under-insured, or uninsured women who received services through the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). METHODS: Using the NBCCEDP database, we examined the number and percent of women diagnosed during 2009-2011 with in situ breast cancer, invasive breast cancer, and invasive cervical cancer by demographic and clinical characteristics, including age, race and ethnicity, test indication (screening or diagnostic), symptoms (for breast cancer), and screening history (for cervical cancer). We examined these characteristics by stage at diagnosis, a new variable included in the database obtained by linking with state-based central cancer registries. RESULTS: There were 11,569 women diagnosed with invasive breast cancer, 1,988 with in situ breast cancer, and 583 with invasive cervical cancer through the NBCCEDP. Women who reported breast symptoms or who had diagnostic mammography were more likely to be diagnosed with breast cancer, and at a later stage, than those who did not have symptoms or who had screening mammography. Women who had been rarely or never screened for cervical cancer were more likely to be diagnosed with cervical cancer, and at a later stage, than women who received regular screenings. CONCLUSIONS: Women served through the NBCCEDP who have not had prior screening or who have symptoms were more often diagnosed with late-stage disease. |
The effectiveness of targeting never or rarely screened women in a national cervical cancer screening program for underserved women
Benard VB , Royalty J , Saraiya M , Rockwell T , Helsel W . Cancer Causes Control 2015 26 (5) 713-9 PURPOSE: To evaluate the effectiveness of a policy supporting early detection and prevention of cervical cancer among low-income and uninsured women by comparing women who reported never or rarely being screened (last screen >5 years) to those who reported screening in the past ≤5 years. METHODS: We analyzed data from 1,485,251 women who received their first Pap test in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) from July 2002 through June 2012. Of these, 461,893 women (31 %) reported being never or rarely screened and 1,023,358 (69 %) reported being screened in the past 5 years. Demographic (age, race/ethnicity, residence, and region) and clinic (cytologic and histologic results) characteristics were examined for the two groups. RESULTS: Women who were aged ≥50 years, Asian and Pacific Islander, American Indian or Alaska Native, multiracial, living in non-metro areas, or living in the South or a territory were more likely to report being never or rarely screened. The percentage of abnormal Pap tests and the rate of precancer and cancer (combined) was higher in the never or rarely screened group compared with the screened group (abnormal percentage: 2.9 vs 2.6 %, p value < 0.01; rate of precancer and cancer: 6.9 vs 3.7 per 1,000 women, p value < 0.01). CONCLUSIONS: The priority of reaching never or rarely screened women should continue since those women who entered the NBCCEDP not adequately screened had a greater prevalence of high-grade histological lesions and invasive cervical cancers at later stages than women screened more recently. |
A comparative analysis of breast cancer stage between women enrolled in the National Breast and Cervical Cancer Early Detection Program and women not participating in the program
Wu M , Austin H , Eheman CR , Myles Z , Miller J , Royalty J , Ryerson AB . Cancer Causes Control 2015 26 (5) 751-8 PURPOSE: To determine the proportional distribution of early- and late-stage breast cancers diagnosed in years 2004-2009 among women enrolled in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and to compare this distribution to that of geographically comparable non-enrolled women diagnosed with breast cancer. METHODS: Using data from the National Program of Cancer Registries, we compared the demographic characteristics and cancer stage distribution of women enrollees and non-enrollees by use of conditional logistic regression using the odds ratio as a measure of association. RESULTS: NBCCEDP enrollees were slightly younger and more likely to identify as African-American, API and AIAN than were non-enrollees. The proportion of late-stage breast cancer (regional and distant) decreased slightly over the study period. NBCCEDP enrollees generally were diagnosed at a later stage of breast cancer than were those not enrolled in the NBCCEDP. CONCLUSIONS: The NBCCEDP has been effective in achieving its goal of enrolling racial and ethnic populations; however, enrollees had a poorer stage distribution of breast cancer than did non-enrollees underscoring the need to expand breast cancer control efforts among low-income, underserved populations. |
Cost of services provided by the National Breast and Cervical Cancer Early Detection Program
Ekwueme DU , Subramanian S , Trogdon JG , Miller JW , Royalty JE , Li C , Guy GP , Crouse W , Thompson H , Gardner JG . Cancer 2014 120 Suppl 16 2604-11 BACKGROUND: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is the largest cancer screening program for low-income women in the United States. This study updates previous estimates of the costs of delivering preventive cancer screening services in the NBCCEDP. METHODS: We developed a standardized web-based cost-assessment tool to collect annual activity-based cost data on screening for breast and cervical cancer in the NBCCEDP. Data were collected from 63 of the 66 programs that received funding from the Centers for Disease Control and Prevention during the 2006/2007 fiscal year. We used these data to calculate costs of delivering preventive public health services in the program. RESULTS: We estimated the total cost of all NBCCEDP services to be $296 (standard deviation [SD], $123) per woman served (including the estimated value of in-kind donations, which constituted approximately 15% of this total estimated cost). The estimated cost of screening and diagnostic services was $145 (SD, $38) per women served, which represented 57.7% of the total cost excluding the value of in-kind donations. Including the value of in-kind donations, the weighted mean cost of screening a woman for breast cancer was $110 with an office visit and $88 without, the weighted mean cost of a diagnostic procedure was $401, and the weighted mean cost per breast cancer detected was $35,480. For cervical cancer, the corresponding cost estimates were $61, $21, $415, and $18,995, respectively. CONCLUSIONS: These NBCCEDP cost estimates may help policy makers in planning and implementing future costs for various potential changes to the program. |
Strengthening breast and cervical cancer control through partnerships: American Indian and Alaska Native Women and the National Breast and Cervical Cancer Early Detection Program
Espey D , Castro G , Flagg T , Landis K , Henderson JA , Benard VB , Royalty JE . Cancer 2014 120 Suppl 16 2557-65 The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has played a critical role in providing cancer screening services to American Indian and Alaska Native (AI/ANs) women and strengthening tribal screening capacity. Since 1991, the NBCCEDP has funded states, tribal nations, and tribal organizations to develop and implement organized screening programs. The ultimate goal is to deliver breast and cervical cancer screening to women who do not have health insurance and cannot afford to pay for these services. The delivery of clinical services is supported through complementary program efforts such as professional development, public education and outreach, and patient navigation. This article seeks to describe the growth of NBCCEDP's tribal commitment and the unique history and aspects of serving the AI/AN population. The article describes: 1) how this program has demonstrated success in improving screening of AI/AN women; 2) innovative partnerships with the Indian Health Service, state programs, and other organizations that have improved tribal public health infrastructure; and 3) the evolution of Centers for Disease Control and Prevention work with tribal communities. |
Using data to effectively manage a national screening program
Yancy B , Royalty JE , Marroulis S , Mattingly C , Benard VB , DeGroff A . Cancer 2014 120 Suppl 16 2575-83 The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) of the Centers for Disease Control and Prevention (CDC) is implemented through cooperative agreements with state health departments, US territories, and tribal health organizations (grantees). Grantees typically contract with clinicians and other providers to deliver breast and cervical cancer screening and diagnostic services. As required by the CDC, grantees report biannually a subset of patient and clinical level program data known as the Minimum Data Elements. Rigorous processes are in place to ensure the completeness and quality of program data collection. In this article, the authors describe the NBCCEDP data-collection processes and data management system and discusses how data are used for 1) program monitoring and improvement, 2) evaluation and research, and 3) policy development and analysis. They also provide 2 examples of how grantees use data to improve their performance. |
When performance management works: a study of the National Breast and Cervical Cancer Early Detection Program
DeGroff A , Royalty JE , Howe W , Buckman DW , Gardner J , Poister T , Hayes N . Cancer 2014 120 Suppl 16 2566-74 BACKGROUND: Little empirical evidence exists about the effectiveness of performance management systems in government. This study assessed the effectiveness of the performance management system of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and explored why it works. METHODS: Generalized estimating equation models were used to assess change in program performance after the implementation of a performance management system. In addition, qualitative case study data including observations, interviews, and document review were analyzed using inductive methods. RESULTS: Five of the 7 indicators tested had statistically significant increases in performance postimplementation. Case study results suggest that the system is characterized by high-quality data, measures viewed by grantees as meaningful and fair, and institutionalized data use. CONCLUSIONS: Several factors help to explain the system's effectiveness including characteristics of the NBCCEDP program (eg, service delivery program), qualities of the indicators (eg, process level), financial investment in the system, and a culture of data use. |
National Breast and Cervical Cancer Early Detection Program data validation project
Eheman CR , Leadbetter S , Benard VB , Blythe Ryerson A , Royalty JE , Blackman D , Pollack LA , Adams PW , Babcock F . Cancer 2014 120 Suppl 16 2597-603 BACKGROUND: The objectives of this study were to evaluate the quality of national data generated by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP); to assess variables collected through the program that are appropriate to use for program management, evaluation, and data analysis; and to identify potential data-quality issues. METHODS: Information was abstracted randomly from 5603 medical records selected from 6 NBCCEDP-funded state programs, and 76 categorical variables and 11 text-based breast and cervical cancer screening and diagnostic variables were collected. Concordance was estimated between abstracted data and the data collected by the NBCCEDP. Overall and outcome-specific concordance was calculated for each of the key variables. Four screening performance measures also were estimated by comparing the program data with the abstracted data. RESULTS: Basic measures of program outcomes, such as the percentage of women with cancer or with abnormal screening tests, had a high concordance rate. Variables with poor or inconsistent concordance included reported breast symptoms, receipt of fine-needle aspiration, and receipt of colposcopy with biopsy. CONCLUSIONS: The overall conclusion from this comprehensive validation project of the NBCCEDP is that, with few exceptions, the data collected from individual program sites and reported to the CDC are valid and consistent with sociodemographic and clinical data within medical records. |
From cancer screening to treatment: service delivery and referral in the National Breast and Cervical Cancer Early Detection Program
Miller JW , Hanson V , Johnson GD , Royalty JE , Richardson LC . Cancer 2014 120 Suppl 16 2549-56 The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides breast and cervical cancer screening and diagnostic services to low-income and underserved women through a network of providers and health care organizations. Although the program serves women 40-64 years old for breast cancer screening and 21-64 years old for cervical cancer screening, the priority populations are women 50-64 years old for breast cancer and women who have never or rarely been screened for cervical cancer. From 1991 through 2011, the NBCCEDP provided screening and diagnostic services to more than 4.3 million women, diagnosing 54,276 breast cancers, 2554 cervical cancers, and 123,563 precancerous cervical lesions. A critical component of providing screening services is to ensure that all women with abnormal screening results receive appropriate and timely diagnostic evaluations. Case management is provided to assist women with overcoming barriers that would delay or prevent follow-up care. Women diagnosed with cancer receive treatment through the states' Breast and Cervical Cancer Treatment Programs (a special waiver for Medicaid) if they are eligible. The NBCCEDP has performance measures that serve as benchmarks to monitor the completeness and timeliness of care. More than 90% of the women receive complete diagnostic care and initiate treatment less than 30 days from the time of their diagnosis. Provision of effective screening and diagnostic services depends on effective program management, networks of providers throughout the community, and the use of evidence-based knowledge, procedures, and technologies. |
Impact of the National Breast and Cervical Cancer Early Detection Program on cervical cancer mortality among uninsured low-income women in the U.S., 1991-2007
Ekwueme DU , Uzunangelov VJ , Hoerger TJ , Miller JW , Saraiya M , Benard VB , Hall IJ , Royalty J , Li C , Myers ER . Am J Prev Med 2014 47 (3) 300-8 BACKGROUND: The benefits of the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) on cervical cancer screening for participating uninsured low-income women have never been measured. PURPOSE: To estimate the benefits in life-years (LYs) gained; quality-adjusted life-years (QALYs) gained; and deaths averted. METHODS: A cervical cancer simulation model was constructed based on an existing cohort model. The model was applied to NBCCEDP participants aged 18-64 years. Screening habits for uninsured low-income women were estimated using National Health Interview Survey data from 1990 to 2005 and NBCCEDP data from 1991 to 2007. The study was conducted during 2011-2012 and covered all 68 NBCCEDP grantees in 50 states, the District of Columbia, five U.S. territories, and 12 tribal organizations. Separate simulations were performed for the following three scenarios: (1) women who received NBCCEDP (Program) screening; (2) women who received screening without the program (No Program); and (3) women who received no screening (No Screening). RESULTS: Among 1.8 million women screened in 1991-2007, the Program added 10,369 LYs gained compared to No Program, and 101,509 LYs gained compared to No Screening. The Program prevented 325 women from dying of cervical cancer relative to No Program, and 3,829 relative to No Screening. During this time period, the Program accounted for 15,589 QALYs gained when compared with No Program, and 121,529 QALYs gained when compared with No Screening. CONCLUSIONS: These estimates suggest that NBCCEDP cervical cancer screening has reduced mortality among medically underserved low-income women who participated in the program. |
Moving forward: Using the experience of the CDCs' Colorectal Cancer Screening Demonstration Program to guide future colorectal cancer programming efforts
Seeff LC , Degroff A , Joseph DA , Royalty J , Tangka FK , Nadel MR , Plescia M . Cancer 2013 119 Suppl 15 2940-6 BACKGROUND: The Centers for Disease Control and Prevention (CDC) established and supported a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) from 2005 to 2009 for low-income, under- or uninsured men and women aged 50-64 at 5 sites in the United States. METHODS: A multiple methods evaluation was conducted including 1) a longitudinal, comparative case study of program implementation, 2) the collection and analysis of client-level screening and diagnostic services outcome data, and 3) the collection and analysis of program- and patient-level cost data. RESULTS: Several themes emerged from the results reported in the series of articles in this Supplement. These included the benefit of building on an existing infrastructure, strengths and weakness of both the 2 most frequently used screening tests (colonoscopy and fecal occult blood tests), variability in costs of maintaining this screening program, and the importance of measuring the quality of screening tests. Population-level evaluation questions could not be answered because of the small size of the participating population and the limited time frame of the evaluation. The comprehensive evaluation of the program determined overall feasibility of this effort. CONCLUSIONS: Critical lessons learned through the implementation and evaluation of the CDC's CRCSDP led to the development of a larger population-based program, the CDC's Colorectal Cancer Control Program (CRCCP). Cancer 2013;119(15 suppl):2940-6. (c) 2013 American Cancer Society. |
Costs of planning and implementing the CDC's Colorectal Cancer Screening Demonstration Program
Subramanian S , Tangka FK , Hoover S , Beebe MC , Degroff A , Royalty J , Seeff LC . Cancer 2013 119 Suppl 15 2855-62 BACKGROUND: The Centers for Disease Control and Prevention (CDC) initiated the Colorectal Cancer Screening Demonstration Program (CRCSDP) to explore the feasibility of establishing a large-scale colorectal cancer screening program for underserved populations in the United States. The authors of the current report provide a detailed description of the total program costs (clinical and nonclinical) incurred during both the start-up and service delivery (screening) phases of the 4-year program. METHODS: Tailored cost questionnaires were completed by staff at the 5 CRCSDP sites. Cost data were collected for clinical services and nonclinical programmatic activities (program management, data collection, and tracking, etc). In-kind contributions also were measured and were assigned monetary values. RESULTS: Nearly $11.3 million was expended by the 5 sites over 4 years, and 71% was provided by the CDC. The proportion of funding spent on clinical service delivery and service delivery/patient support comprised the largest proportion of cost during the implementation phase (years 2-4). The per-person nonclinical cost comprised a substantial portion of total costs for all sites. The cost per person screened varied across the 5 sites and by screening method. Overall, economies of scale were observed, with lower costs resulting from larger numbers of individuals screened. CONCLUSIONS: Programs incur substantial variable costs related to clinical services and semivariable costs related to nonclinical services. Therefore, programs that serve large populations are likely to achieve a lower cost per person. Cancer 2013;119(15 suppl):2855-62. (c) 2013 American Cancer Society. |
Outpatient colonoscopy complications in the CDC's Colorectal Cancer Screening Demonstration Program: a prospective analysis
Castro G , Azrak MF , Seeff LC , Royalty J . Cancer 2013 119 Suppl 15 2849-54 BACKGROUND: To the authors's knowledge, there are few published prospective cohort studies of colonoscopy complications in patients at average risk for colorectal cancer who received colorectal cancer screening from a community-based program. In this article, the authors report the rate of colonoscopy complications in the Centers for Disease Control and Prevention (CDC)'s Colorectal Cancer Screening Demonstration Program (CRCSDP), which provided colorectal cancer screening to a medically underserved population aged 50 years to 64 years for screening, diagnostic follow-up after positive stool blood tests, and surveillance purposes. METHODS: Clinical data were collected prospectively from 5 community-based colorectal cancer screening programs. Complications were identified by reviewing the standardized clinical data and medical complication reporting forms submitted by the programs to the CDC. Serious complications were defined as conditions or symptoms that resulted in hospital admission within 30 days after the procedure, including perforation, gastrointestinal bleeding requiring or not requiring blood transfusion, cardiopulmonary events, postpolypectomy syndrome, excessive abdominal pain, or death. RESULTS: A total of 3215 individuals underwent 3355 colonoscopies. Of these, 89% of the colonoscopies were conducted for screening, 9% were conducted for diagnostic follow-up, and 2% were conducted for surveillance purposes. The mean age of the individuals was 55.9 years. Eight individuals experienced serious complications, for an incidence of 2.38 per 1000 colonoscopies. Three patients experienced bowel perforations that required surgery, 1 patient was hospitalized for postpolypectomy bleeding, 3 patients experienced cardiopulmonary events, and 1 patient visited the emergency room for excessive abdominal pain and underwent surgery for an identified colorectal mass. No deaths were reported. CONCLUSIONS: In the CDC's CRCSDP, in which a total of 3215 individuals underwent 3355 colonoscopies, the overall incidence of serious complications from colonoscopy was found to be low. |
Assessing screening quality in the CDC's Colorectal Cancer Screening Demonstration Program
Nadel MR , Royalty J , Shapiro JA , Joseph D , Seeff LC , Lane DS , Dwyer DM . Cancer 2013 119 Suppl 15 2834-41 BACKGROUND: Gaps in screening quality in community practice have been well documented. The authors examined recommended indicators of screening quality in the Centers for Disease Control and Prevention's Colorectal Cancer Screening Demonstration Program (CRCSDP), which provided colorectal cancer screening and diagnostic services between 2005 and 2009 for asymptomatic, low-income, underinsured, or uninsured individuals at 5 sites around the United States. METHODS: For each client screened in the CRCSDP, a standardized set of colorectal cancer clinical data elements was collected. Data regarding client age, screening history, risk level, screening test indication, results, and recommendation for the next test were analyzed. For colonoscopies, data were analyzed regarding whether the cecum was reached, bowel preparation was adequate, and identified lesions were completely removed. RESULTS: Overall, 53% of the fecal occult blood tests (FOBTs) (2295 tests) distributed were completed and returned. At the 2 sites with adequate numbers of FOBTs, 77% and 97%, respectively, of clients with positive results received follow-up colonoscopies. Site-specific cecal intubation rates ranged from 90% to 98%. Adenoma detection rates were 32% for men and 21% for women. For approximately one-third of colonoscopies, the recommended interval to the next test was shorter than recommended by national guidelines. At some sites, endoscopists failed to report on the adequacy of bowel preparation and completeness of polyp removal. CONCLUSIONS: Cecal intubation rates and adenoma detection rates met recommended levels. The authors identified the need for improvements in the follow-up of positive FOBTs, documentation of important elements in colonoscopy reports, and recommendations for rescreening or surveillance intervals after colonoscopy. Monitoring quality indicators is important to improve screening quality. |
Clinical costs of colorectal cancer screening in 5 federally funded demonstration programs
Tangka FK , Subramanian S , Beebe MC , Hoover S , Royalty J , Seeff LC . Cancer 2013 119 Suppl 15 2863-9 BACKGROUND: The Centers for Disease Control and Prevention initiated the Colorectal Cancer Screening Demonstration Program (CRCSDP) to explore the feasibility of establishing a large-scale colorectal cancer (CRC) screening program for underserved populations in the United States. The authors of this report assessed the clinical costs incurred at each of the 5 participating sites during the demonstration period. METHODS: By using data on payments to providers by each of the 5 CRCSDP sites, the authors estimated costs for specific clinical services and overall clinical costs for each of the 2 CRC screening methods used by the sites: colonoscopy and fecal occult blood test (FOBT). RESULTS: Among CRCSDP clients who were at average risk for CRC and for whom complete cost data were available, 2131 were screened by FOBT, and 1888 were screened by colonoscopy. The total average clinical cost per individual screened by FOBT (including costs for screening, diagnosis, initial surveillance, office visits, and associated clinical services averaged across all individuals who received screening FOBT) ranged from $48 in Nebraska to $149 in Greater Seattle. This compared with an average clinical cost per individual for all services related to the colonoscopy screening ranging from $654 in St. Louis to $1600 in Baltimore City. CONCLUSIONS: Variations in how sites contracted with providers and in the services provided through CRCSDP affected the cost of clinical services and the complexity of collecting cost data. Health officials may find these data useful in program planning and budgeting. |
Clinical outcomes from the CDC's Colorectal Cancer Screening Demonstration Program
Seeff LC , Royalty J , Helsel WE , Kammerer WG , Boehm JE , Dwyer DM , Howe WR Jr , Joseph D , Lane DS , Laughlin M , Leypoldt M , Marroulis SC , Mattingly CA , Nadel MR , Phillips-Angeles E , Rockwell TJ , Ryerson AB , Tangka FK . Cancer 2013 119 Suppl 15 2820-33 BACKGROUND: Colorectal cancer remains the second leading cause of cancer-related deaths among US men and women. Screening rates have been slow to increase, and disparities in screening remain. METHODS: To address the disparity in screening for this high burden but largely preventable disease, the Centers for Disease Control and Prevention (CDC) designed and established a 4-year Colorectal Cancer Screening Demonstration Program (CRCSDP) in 2005 for low-income, under-insured or uninsured men and women aged 50 to 64 years in 5 participating US program sites. In this report, the authors describe the design of the CRCSDP and the overall clinical findings and screening test performance characteristics, including the positive fecal occult blood testing (FOBT) rate; the rates of polyp, adenoma, and cancer detection with FOBTs and colonoscopies; and the positive predicative value for polyps, adenomas, and cancers. RESULTS: In total, 5233 individuals at average risk and increased risk were screened for colorectal cancer across all 5 sites, including 44% who underwent screening FOBT and 56% who underwent screening colonoscopy. Overall, 77% of all individuals screened were women. The FOBT positivity rate was 10%. Results from all screening or diagnostic colonoscopies indicated that 75% had negative results and required a repeat screening colonoscopy in 10 years, 16% had low-risk adenomas and required surveillance colonoscopy in 5 to 10 years, 8% had high-risk adenomas and required surveillance colonoscopy in 3 years, and 0.6% had invasive cancers. CONCLUSIONS: This report documents the successes and challenges in implementing the CDC's CRCSDP and describes the clinical outcomes of this 4-year initiative, the patterns in program uptake and test choice, and the comparative test performance characteristics of FOBT versus colonoscopy. Patterns in final outcomes from the follow-up of positive screening tests were consistent with national registry data. |
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