Reducing Structural Barriers Planning Guide

Introduction

The four Evidence-Based Intervention Planning Guides provide tips to help clinic staff, and those who provide technical assistance to them, implement evidence-based interventions to increase screening for breast, cervical, and colorectal cancer.

Reducing structural barriers increases access to cancer screening. Examples include:

• Modifying hours of service to meet client needs.
• Offering services in alternative or nonclinical settings such as mobile mammography vans at worksites or in residential communities.
• Eliminating or simplifying administrative procedures and other obstacles; for example: offering scheduling assistance, patient navigation, transportation, dependent care, or translation services; or decreasing the number of clinic visits.

See the Community Guide recommendation.

Process flow

Implement and integrate structural changes to reduce obstacles to screening

Reduce or eliminate structural barriers. Outputs and measures for implementation and integration will be specific to the intervention design.

Patient seeks screening services

Potential challenges include: a long distance to a screening facility, limited transportation, a burdensome scheduling process, community distrust of the medical field, the facility’s inaccessibility to those with disabilities, and lack of translation services.

Output: Increased screening appointments by patients

Measure: Appointments among eligible patients.

Example: Number of patients scheduled for screening appointments divided by the number of patients due for screening.

Example: Number of patients showing up for screening appointments divided by the number of patients scheduled.

Patient completes cancer screening

Potential challenges include inconvenient clinic hours, limited capacity or resources to follow-up on abnormal screening results, patient fear, cost, and lack of transportation.

Outcome: Increased screening and diagnostic tests completed by patients

Measure: Screening completion.

Example: Number of patients completing screening divided by the number of patients referred for screening.

Example: Number of patients completing diagnostic follow-up divided by the number of patients with positive screening tests.

Increased cancer screening

Outcome: Increased clinic-level rates of cancer screening

Measure: Age-eligible clinic population up to date with recommended cancer screening.

Example: Uniform Data System (UDS), Healthcare Effectiveness Data and Information Set (HEDIS), National Quality Forum (NQF) 12-month measure used to calculate screening rate.

Components of the intervention

Identify patients and community members due for screening

• Has a priority population been identified?
• Can patients who are due for screening be identified using the electronic health record (EHR) or other patient record system? Is there access to patients' date of birth and date of last screening test?

Identify barriers to screening

Is there a needs assessment for the priority population that can identify common structural barriers or obstacles?

Design a barrier-specific resolution

• Have stakeholders (partners and community members) been asked for their input?
• Are there working relationships or formal partnerships with organizations that can address these barriers?
• Is the resolution feasible?

Track individuals through screening completion

• Is there a way to track whether the provider recommended or ordered a screening test?
• Is there a way to track patients through screening and diagnostic test completion?
• Have a method and tools for tracking been identified or created?
• Have appropriate and feasible performance measures for process and outcome evaluation been selected?

Resources to support implementation

Partnerships

• The type of barrier being addressed influences the number and type of partnerships.
• For transportation to a screening site, partnerships include people or organizations that use vans, taxis, or other modes of transportation.
• To bring mobile screening units into community settings, partnerships involve owners of the screening units and screening sites (such as retirement centers, senior meal sites, churches).
• Intra-clinic relationships reduce the scheduling burden; for example, information technology and billing department, medical directors, office managers, and front desk staff.
• Support for scheduling follow-up testing involves partnering with organizations that use navigators or coordinate volunteer navigators.
• Community-based organizations committed to publicizing or providing services for the program.

Staff

• Providers (physicians, nurses, technicians) to order or deliver testing or interpret results.
• Program managers to orient or train staff, explain the program, and assist as needed.
• Individuals to identify those due for screening and send invitations or reminders.
• Navigators or community health workers (paid or volunteer) to provide individualized help to those due for screening.

Tools

• Method to identify eligible individuals for screening: EHRs, patient database, state drivers' license database, resident list at senior centers or meal sites, or church rosters.
• Paper and postage (if needed) for invitations to screen; the letter may refer to a navigator or contain a prescheduled appointment.
• Audience-relevant educational materials about the test and its role in early detection of cancer, including instructions for at-home test kits.
• Mobile mammography units or transportation to the screening site.

Patient surveys

• Determine the distance patients would travel for a screening test.
• Assess stage of decision-making; used to tailor messages to the individual.
• Identify common obstacles to inform the specific intervention.

Lessons learned from the literature¹

• A continuous quality improvement plan can streamline the number of steps between referral and test and can help with sustainability of the process.
• Due to one-time, fixed costs associated with implementation, the first year of operation for mobile mammography programs is generally more expensive.
• The missed appointment rate decreased with barriers eliminated.
• Tailored navigation increased screening for older individuals.
• Latinas and Asian women were more likely to have a mammogram after a health education session if a van was onsite.
• The intensity and complexity of these interventions depend on how many organizations or organizational units are involved.
• The most fundamental partnerships were with providers (primary care and specialists), health care systems, and laboratories.

Ways to strengthen performance or sustainability

• Prompt individuals with reminders and help them make appointments.
• Educate prospective patients about the testing process, location, and any preparation needed for the test.
• Identify an individual's stage of decision-making and tailor messages to match.
• Reduce out-of-pocket costs to the client.
• Make structural changes a matter of policy or standard workflow.

Community Guide recommendation

The Community Preventive Services Task Force recommends interventions that reduce structural barriers to increase screening for breast and colorectal cancers.²

Settings where the intervention was studied¹

• Urban, suburban, and rural areas in the United States, Australia, the United Kingdom, and Israel.
• Community centers, senior centers, retirement centers, churches, academic and nonacademic affiliated primary care practices and hospitals, and health maintenance organizations.

Outcomes from the systematic review of effectiveness¹

• Completed mammography increased by a median of 17.7 percentage points.
• Completed colorectal cancer screening (any test) increased by a median of 36.9 percentage points.
• Cost (in 2009 US dollars):
  • Mobile mammography ranged from $63 to $150 per woman screened, and the number of women screened affected cost.
  • Cost per additional screen by fecal occult blood test was between $63 and $425, and the cost-effectiveness ratio estimated at $3,000 to $4,000 per year of life saved.

References

¹Sabatino SA, Lawrence B, Elder R, et al. Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for The Guide to Community Preventive Services. Am J Prev Med. 2012;43(1):97–118.

²Community Preventive Services Task Force. Updated recommendations for client- and provider-oriented interventions to increase breast, cervical, and colorectal cancer screening. Am J Prev Med. 2012;43(1):92–96.