Enhancing Implementation Science: Community/Systems Models to - - PowerPoint PPT Presentation

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

• 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 ROADMAP

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

• ffer 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

• 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 OPPORTUNITY: WHY CRC, WHY NOW?

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

Key collaborators Anne Marie Meyer May Kuo Justin Trogdon Stephanie Wheeler Funding HHSA290-2005- 0040 DP09- 0010303SUPP11 1-U48-DP005017- 01 University Cancer Research Fund Key pubs (>40!) Meyer et al, NCMJ 2012 Wheeler et al, Health Place 2014 Lich et al, PCD, 2017 Wheeler et al, Preventive Med Reports, 2016

Unique linkages: Cancer registry, multi-payer claims data (Medicare, Medicaid, NC private), SSI death index, BRFSS, other data Health Care Claims: 5.5m cases since 2003 NC Cancer Registry: 100% since 2003 320,000 cases Cases linked to claims: 80% of NC cancers 255,000 THE PLAYERS: THE UNC INTEGRATED CANCER INFORMATION & SURVEILLANCE SYSTEM

Key collaborators John McConnell Melinda Davis Stephanie Renfro Shared resources 3 Health economists 5 Statisticians 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

Unique linkages: Oregon All Payer All Claims database (Medicare, Medicaid, private insurers), other data Health Care Claims: From 2007 for Medicare and Medicaid; 2010 for private) THE PLAYERS: THE OHSU CENTER FOR HEALTH SYSTEMS EFFECTIVENESS

Warren Halifax Northampton Hertford Gates Pasquotank Camden Currituck Bertie Perquimans Chowan Vance Nash Edgecombe Martin

HOW WE DEFINE TARGET AREAS FOR INTERVENTION

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 Reminder 5%age point increase in p(screen) $10,000 Develop registry & content (one-time) $200 / year Programming time $0.71 / reminder Materials (postage, paper, ink) $3,850 / year Mail reminders Endoscopy Expansion Individually-specific predicted p(screen) based upon claims-based statistical models $500,000 / facility Financial incentive to locate facility in 6 underserved areas Targeted Mass Media Will reach 80% of blacks, 2%age point increase in p(screen) $368,000 / year Content development (one-time) Will reach 40% of non-blacks, 1%age point increase in p(screen) $332,000 / year Advertising for one month Voucher for uninsured 500 uninsured individuals turning 50 will receive colonoscopies $750 / person Voucher for colonoscopy

15

Underlying Population Screening Patterns Disease Progression Cancer Outcomes Intervention Effects

HOW WE UNDERSTAND ESTIMATED IMPACT AND COST OF POTENTIAL INTERVENTIONS

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 IMPLEMENTATION

See ARM poster #949 Wheeler et al., Poster Session C (Monday, 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)?

35.00% 37.00% 39.00% 41.00% 43.00% 45.00% 47.00% 49.00% 51.00% 2013 2014 2015 2016 2017 2018

AA Control AA ACA Only AA High Enrollment, High Compliance White Control White ACA Only

• ACA and Medicaid

Expansion begins to close disparity gap between African American and White males

• Without ACA,

the disparity gap continues to widen Percent of NC males up-to-date with CRC screening by 2018 with and without ACA and Medicaid Expansion See ARM poster #62 Frerichs et al., Disparities Interest Group (Saturday, June 24, 12:30-2:30)

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)

Differences in cumulative CRC screening and treatment cost savings per person between policy scenarios and the control scenario

ACA and Medicaid Expansion result in substantial long-term cost savings, especially for African American males

See ARM poster #62 Frerichs et al., Disparities Interest Group (Saturday, June 24, 12:30-2:30)

IMPACT

• Outcomes/Products

– Increased CRC screening – Evidence to inform value and support better decision making – Publications, policy briefs, white papers, presentations, etc.

• Dissemination/Implementation

– National level: CDC, NCI, Moonshot, National CRC Roundtable – Provider or State level: Medicaid, CCNC, DPH, NC Roundtable

Melinda Davis, OHSU Stephanie Renfro, OHSU Jackie Shannon, OHSU John McConnell, OHSU

Our Team

Stephanie Wheeler, UNC Mike Pignone, UNC Kristen Hassmiller Lich, UNC Justin Trogdon, UNC Paul Shafer, UNC Florence Tangka, CDC Lisa Richardson, CDC Maria Mayorga, NC State Leah Frerichs, UNC Sarah Drier, UNC

• CDC SIP 11-041 “Behavioral economics of colorectal cancer screening in

underserved populations” (Co-PIs: Pignone and Wheeler)

• CDC and NCI SIP 14-011 “Cancer Prevention and Control Research Network

(CPCRN)” (PI: Wheeler)

• AHRQ 1-K-12 HS019468-01 Mentored Clinical Scientists Comparative

Effectiveness Development Award (PI: Weinberger; Scholar: Wheeler)

• NIH K05 CA129166 Established Investigator Award in Cancer Prevention and

Control: Improving Cancer-Related Patient Decision Making (PI: Pignone)

• NC Translational and Clinical Sciences Institute Pilot Grant “Using systems

science methods to improve colorectal cancer screening in North Carolina” (PI: Lich)

• CMMI‐1150732 CAREER: Incorporating Patient Heterogeneity and Choice into

Predictive Models of Health and Economic Outcomes”. National Science Foundation (PI: Mayorga)

• University of North Carolina at Chapel Hill Cancer Research Fund

THANK YOU!