Enhancing Implementation Science: Community/Systems Models to Implement within Cancer Control Programs Stephanie B Wheeler, PhD MPH Associate Professor Health Policy & Management Gillings School of Global Public Health University of North Carolina at Chapel Hill
ROADMAP • The opportunity • The players • The approach – Define target areas/regions for intervention – Select and adapt interventions – Quantify the expected impact of interventions for specific areas/regions – Implement interventions, measure outcomes
THE OPPORTUNITY: EMERGING FUNDING TRENDS Dissemination and implementation science research • “bridges the gap between clinical research, everyday practice, and • public health by building a knowledge base about how health information, interventions, and new clinical practices, guidelines and policies are transmitted and translated for public health and health care service use in specific settings” (NIH PAR-16-237) Systems science and simulation modeling • “applies approaches such as system dynamic modeling, agent-based • modeling, social network analysis, discrete event analysis, and Markov modeling to better understand complex and dynamic behavioral and social sciences processes and problems relevant to health” (NIH PAR-15-04) Behavioral economics • “seeks to identify individual influences on the effectiveness of • population-level strategies that target behaviors, shape the development of new strategies, and communicate strategies most effectively” (NIH PAR-16-257)
THE OPPORTUNITY: METHODS INTERSECTION • Decision sciences tools, including mathematical simulation models, discrete choice experiments, and economic evaluations, have existed for decades • These tools offer a method to quantify the expected uptake and health and economic impact of implementing evidence based interventions (EBIs), as well as uncertainty • Many implementation science textbooks and articles give lip service to the importance of such tools, but offer little guidance for how to use these tools in practice • These tools can aid in: • Selecting and adapting EBIs for implementation • Evaluating implementation strategies • Selecting relevant implementation outcomes • Evaluating implementation and clinical/comparative effectiveness outcomes
THE OPPORTUNITY: WHY CRC, WHY NOW?
THE OPPORTUNITY: WHY CRC, WHY NOW? We know how to reduce CRC morbidity and mortality • Yet, we are terrible at implementing what we know works • CDC Trends in CRC screening, 2010
THE OPPORTUNITY: WHY CRC, WHY NOW? • Colorectal cancer (CRC) screening via colonoscopy or fecal testing (FOBT/FIT) is effective and saves lives. • CRC screening is underused in both the U.S. (66% up to date) and N.C. (70% up to date) • CRC screening is especially low among rural (& low income, uninsured, and minority) populations • Decision makers need to know the most effective and efficient approach to close the gap in specific settings • Impact and efficiency of CRC screening interventions vary depending on local context • How can healthcare systems be optimized to ensure that age-eligible people receive CRC screening at the lowest cost ?
THE PLAYERS: CANCER PREVENTION AND CONTROL RESEARCH NETWORK (CPCRN) • A national effort funded by CDC and NCI to advance the science and practice of dissemination and implementation in cancer prevention and control
THE PLAYERS: CAROLINA CANCER SCREENING INITIATIVE (CCSI) Key collaborators Alison Brenner Leah Frerichs May Kuo Jennifer Leeman Kristen Hassmiller Lich Anne Marie Meyer Dan Reuland Catherine Rohweder Stephanie Wheeler Shared resources ICISS Funding CDC U48 DP005017-SIP ACS RSG University Cancer Research Fund Key publications Lich et al, 2017, PCD Frerichs et al, 2016, AJPH Brenner et al, 2014, JGIM Wheeler et al, 2016, Preventive Medicine Reports
THE PLAYERS: THE UNC INTEGRATED CANCER INFORMATION & SURVEILLANCE SYSTEM Key collaborators Unique linkages: Anne Marie Meyer May Kuo Cancer registry, multi-payer claims data (Medicare, Justin Trogdon Medicaid, NC private), SSI death index, BRFSS, other data Stephanie Wheeler Funding Health Care Claims : HHSA290-2005- 0040 5.5m cases since 2003 DP09- 0010303SUPP11 1-U48-DP005017- NC Cancer Registry : 01 University Cancer 100% since 2003 Research Fund 320,000 cases Key pubs (>40!) Meyer et al, NCMJ 2012 Cases linked to claims : Wheeler et al, 80% of NC cancers Health Place 2014 Lich et al, PCD, 2017 255,000 Wheeler et al, Preventive Med Reports, 2016
THE PLAYERS: THE OHSU CENTER FOR HEALTH SYSTEMS EFFECTIVENESS Key collaborators Unique linkages: John McConnell Melinda Davis Oregon All Payer All Claims database (Medicare, Medicaid, Stephanie Renfro private insurers), other data Shared resources 3 Health economists Health Care Claims : 5 Statisticians From 2007 for Medicare and Medicaid; 2010 for private) 3 Research assistants 1 program coordinator Funding 1-U48-DP005017- 01 Key pubs (>52) McConnell et al, Health Affairs, 2017 Davis et al, J of Rural Health, 2016 Charlesworth et al, JAMA IM, 2016
HOW WE DEFINE TARGET AREAS FOR INTERVENTION Currituck Camden Northampton Gates Warren Pasquotank Hertford Vance Halifax Perquimans Chowan Bertie Nash Edgecombe Martin
HOW WE SELECT AND ADAPT SPECIFIC INTERVENTIONS FOR LOCAL IMPLEMENTATION Level Approaches Policy Payment model reforms (e.g., Medicaid and private insurance expansion) Access to care for uninsured (e.g., CDC-funded CRC control program) System Care coordination (e.g., through medical homes, ACOs) Improving health IT infrastructure • Population identification • Visit-based reminders • Tracking systems/registries Provider Provider outreach, education Quality reporting and incentives to meet screening goals Patient/Person Decision aids delivered at visit Patient navigation support Community outreach, education, media campaigns Client reminders Mailed FIT kits
INTERVENTIONS SELECTED FOR NC MODELS Intervention Effect Size Base ($) Cost Components Medicaid Mailed 5%age point increase in p(screen) $10,000 Develop registry & Reminder content (one-time) $200 / year Programming time $0.71 / Materials (postage, reminder paper, ink) $3,850 / year Mail reminders Endoscopy Individually-specific predicted $500,000 / Financial incentive to Expansion p(screen) based upon claims-based facility locate facility in 6 statistical models underserved areas Targeted Mass Will reach 80% of blacks, 2%age $368,000 / Content development Media point increase in p(screen) year (one-time) Will reach 40% of non-blacks, $332,000 / Advertising for one year 1%age point increase in p(screen) month Voucher for 500 uninsured individuals turning $750 / Voucher for uninsured 50 will receive colonoscopies person colonoscopy
HOW WE UNDERSTAND ESTIMATED IMPACT AND COST OF POTENTIAL INTERVENTIONS Underlying Population Screening Patterns Disease Progression Cancer Outcomes Intervention Effects 15
WHAT HAVE WE LEARNED FROM NC DATA? Endoscopy proximity does not predict CRC screening in publicly insured populations. But sending reminders to Medicaid enrollees has the potential to greatly increase screening, at low cost. Additional persons screened for CRC
TARGETED See ARM poster #949 Wheeler et al., Poster Session C (Monday, IMPLEMENTATION June 26, 6:30-8:00PM)
But wait… there’s more!
Current Research Questions Using This Approach • Claims data only analyses: 1) What is the regional variation in CRC screening within publically and commercially insured populations in Oregon ? 2) What is the regional variation in CRC screening modalities used across CCOs in Oregon ? • Simulation analyses: 3) What is the projected impact of Medicaid expansion on CRC screening and outcomes among African American males in NC ? 4) What is the impact of the ACA private insurance expansion on CRC screening and outcomes in NC ? 5) What is the impact of the ACA private insurance expansion and Medicaid expansion on CRC screening and outcomes in Oregon ? 6) What interventions are recommended to increase CRC screening in publically insured populations in Oregon ? 7) What combination of interventions would be required to get to 80% by 2018 (the National Colorectal Cancer Roundtable target)?
See ARM poster #62 Frerichs et al., Disparities Interest Group (Saturday, June 24, 12:30-2:30) 51.00% Percent of NC males up-to-date with CRC screening by 2018 with and without ACA and Medicaid Expansion • ACA and Medicaid 49.00% Expansion begins to close disparity 47.00% gap between 45.00% African American and White males 43.00% • Without ACA, 41.00% AA Control the disparity AA ACA Only gap continues to 39.00% AA High Enrollment, High Compliance widen White Control 37.00% White ACA Only 35.00% 2013 2014 2015 2016 2017 2018
Change in disparity gap between White and African American males in the percent up-to-date with colorectal cancer screening from baseline to 2023 by NC geographic regions See ARM poster #62 Frerichs et al., Disparities Interest Group (Saturday, June 24, 12:30-2:30)
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