Friday, May 7, 2010

A National Campaign to Increase Colorectal Cancer Screening in a Post-Health Care Reform United States - Ian Reynolds

Colorectal cancer (CRC) is the second leading cause of cancer deaths among men and women aged at least fifty years old (1). Two-thirds of all cases of CRC are diagnosed in adults aged sixty-give or older (2). The U.S. Preventive Services Task Force and other professional organizations recommend that men and women age 50-75 be screened for signs of CRC (U.S. Preventive Services Task Force (3). Screening is effective in reducing the incidence and impact of CRC. About 90 percent of people in whom CRC is detected at an early stage live at least five years, yet only 40 percent of CRCs are detected by this stage (4). CRC screening differs from screenings for many other cancers, because it can effectively prevent cancer. Some CRC screening methods involve removal of pre-cancerous growths that are likely to develop into cancer (5). It is estimated that about half of the deaths from CRC occurring annually could be prevented with early detection due to screening (6).

Despite the demonstrated benefits of early CRC detection, only about 47 percent of U.S. adults for whom CRC screening is recommended had been tested in 2005 (5). However, screening prevalence has increased from 38 percent in 2000, and awareness campaigns aimed at increasing Americans’ utilization of CRC screening procedures are ongoing. Most notably, the Centers for Disease Control and Prevention’s Screen for Life: National Colorectal Cancer Action Campaign was launched in 1999. The campaign has continued to receive funding to place multimedia messages that target Americans 50 years and older in order to raise awareness of the consequences of CRC and to compel people to get screened for CRC (7). This campaign was launched after an extensive period of formative research and testing of key messages; it is budgeted at $1,875,000 for fiscal year 2010 (8). The channels through which messages are distributed nationally are donated and paid television spots, radio, and print media (7). Survey research indicates that the national campaign has been effective in reaching primary care patients, and that primary care patients age 50 and over have increased awareness of CRC and screening guidelines (9). The increased awareness correlates with higher CRC screening rates in some groups, although it is unclear to what degree awareness is responsible for the boost in screening. A meta-analysis published in 2002 assessed the effectiveness of a range of interventions to increase adult utilization of cancer screening services, however researchers concluded there was insufficient evidence to adequately assess the impact of media campaigns (10).

Formative research conducted to inform Screen for Life campaign development clearly demonstrates increased public awareness of CRC and screening recommendations as a necessary first step to impact screening rates (7). In fact, there are many U.S. campaigns in operation with awareness goals similar to those of Screen for Life. These campaigns are largely funded by federal grants, state governments and non-profit organizations. For example, the Utah Cancer Action Network, a group of state agencies, independent organizations and individuals has produced a number of colon cancer awareness media messages as part of its Utah Colon Cancer Awareness Campaign since 2003 (11,12).

The Utah Colon Cancer Awareness Campaign utilizes both paid and donated television advertisement times to disseminate its CRC screening messages. Although the Utah campaign has been funded in part by a federal grant from the Centers for Disease Control and Prevention over the same time period that Screen for Life was being implemented, it is not clear to what degree the Utah Cancer Action Network incorporated findings from Screen for Life’s extensive formative research process into the development of its state commercials. The impact of the Utah Colon Cancer Awareness Campaign’s media outreach on CRC screening rates in the state has likely been modest due to deficiencies in the framing of CRC screening and ineffective attempts to downplay perceived barriers to CRC screening. Furthermore, the Utah campaign employees an awareness strategy that does not take any steps to make the health care environment more conducive to CRC screening. In order to effectively increase CRC screening rates, a national awareness campaign built on the current efforts of Screen for Life and targeted to various U.S. subpopulations should be combined with a program that fosters a clinical environment that encourages CRC screening.

The television commercials placed by the Utah Colon Cancer Awareness Campaign this year appear to have been designed taking into account elements of the Health Belief Model. The Health Belief model asserts that in determining his or her intention to adopt a health behavior, one assesses the perceived susceptibility to, and severity of, a health state associated with engaging in the health behavior. The individual then weighs this against the perceived barriers to taking up the health behavior in question in order determine whether to adopt it (13). The intent of the messages in the Utah campaign is to eliminate perceived barriers to being screened by rebutting common excuses patients cite for not seeking screening for colon cancer. Specifically, the commercials address the barriers of embarrassment, time constraints, and perceived low risk (14). While there are many criticisms of the Health Belief Model, it has been shown to be a relatively accurate model for preventative health behaviors among those who are symptomatic and wish to preserve health (15).

All the actors in the commercials placed as part of the Utah campaign in the past year have the appearance of non-Hispanic whites, age 50 to 65 years old. In one commercial, an actress refers to all the time she spends at the gym with her private trainer and in Pilates classes. In another, the actress appears wearing a business suit and discusses lack of time due to her busy meeting schedule. The homogeneity, in terms of age and race, of those portrayed in these commercials indicates that the campaign developers failed to take into account important facts regarding racial and ethnic disparities in CRC incidence and screening rates. Like many elements of health care utilization, large racial disparities exist with regard to CRC screening. In general, screening is lower among African Americans than whites, and is even lower for Hispanics (16, 5). These racial disparities are not explained by differences in income and socioeconomic status alone, however. Among low-income women, awareness of screening recommendations and CRC screening utilization is lower for African Americans than whites (17). Those 65 years and older are another important subgroup to consider in CRC prevention. Although their colorectal screening rates are above the national average, people age 65 and over experience CRC incidence and mortality at rates higher than those for younger Americans (18). A comprehensive review study of public health mass media campaigns found that targeting to audience subgroups—especially ethnic subgroups—with culturally relevant content is effective and extremely important to the success of media campaigns (19). None of the Utah campaign commercials appear to be targeted to the groups with the lowest screening rates and highest incidence rates. In fact, judging by the selection of actors and situations depicted, the messages appear to be targeted to a middle-aged non-Hispanic, white audience, a group that enjoys some of the highest CRC screening rates. This is unacceptable in light of the fact that Utah’s population is estimated to consist of about 12 percent persons of Hispanic or Latino origin, and bout nine percent of residents are over age 65 (20).

As discussed, the commercials utilized in the Utah campaign each rebut a different reason patients may cite for not choosing to being screened for CRC. The messages presented take into account elements of the Health Belief Model, seeking to eliminate perceived barriers to screening. While the commercials do address some of the perceived barriers to screening that have been widely reported, they ignore what many studies cite as some of the most important barriers to CRC screening in patients: lack of health insurance coverage for CRC screening procedures and high perceived costs. Health insurance coverage and perceived costs are very strong predictors of patients’ utilization of many preventative health services, including CRC screening (21, 23). In addition to colonoscopy—a relatively expensive procedure—fecal occult blood test, and flexible sigmoidoscopy are effective screening procedures for CRC. Medicare and many insurance plans cover the costs of one or more such tests (22). The Utah campaign does not include any message to dispel common perceptions that CRC screening is a procedure that insurance does not cover, nor does it advise that a number of CRC screening tests are available, some of which are less costly than others. This is particularly important, as Utah residents enjoy one of the highest employer-based insurance rates in the country (23). The Utah campaign seeks to refute common barriers to CRC screening, so it should focus on those barriers that are most often cited in studies of CRC screening.

One barrier to CRC screening that the Utah campaign has, appropriately, attempted to addresses in its commercials is patient embarrassment associated with discussing and participating in CRC screening. Patient embarrassment is a commonly cited barrier to CRC screening (24), however, the campaign commercial that seeks to address this barrier offers a poor response to patient concerns. The commercial portrays a man admitting to the audience that he is embarrassed to ask his physician about CRC screening. He says, “I mean, we’re talking about a rectal exam.” This is followed by a voiceover stating, “Using an excuse like ‘it’s too embarrassing’ is silly. No more excuses. If you’re fifty or over, go get screened.” It is important to address perceived barriers when promoting health behavior change using the Health Belief Model, but the message in this commercial is devoid of any substantial information to help the patient overcome this barrier. In effect, the commercial is telling the patient that a feeling of embarrassment in interactions with his or her physician is not a serious consideration and that he or she is childish if he or she feels embarrassed to discuss CRC screening. This approach appears to be more an attack on the embarrassed patient than a resource to help the patient overcome the embarrassment. Health behavior messages that communicate strongly-worded, absolute instructions to an audience have been shown to be more likely than messages that present health information in an unbiased framework to elicit high levels of reactance (43). Reactance is in turn associated with a lower rate of health behavior adoption. The presentation of this message in Utah’s campaign commercial is problematic because it lacks accompanying information to support CRC screening and because of its dictatorial tone. The commercial may in fact generate high levels of reactance in the audience, thereby reducing the probability that the audience will seek CRC screening, exactly the opposite of the campaign’s intended goal.

The effects of awareness-only campaigns on the rates of CRC screening are not clear. While overall screening rates have increased slightly in recent years, there are many factors that have likely contributed to this change (5). A more effective approach to increasing CRC screening in the United States would recalibrate and target awareness efforts, engage health care providers, and utilize evidence from health plans. A campaign to increase CRC screening should engage primary care physicians by providing them incentives to screen their patients. A federal program that provides a $2,000 reward annually to primary care physicians who ensure that 70 percent of their Medicaid or Medicare patients age 50 and above are in compliance with CRC screening guidelines would increase physicians’ motivation to ensure that all their patients are being screened. A second component of an integrated CRC campaign will amplify the impact of a physician incentive program. The new campaign should extend the Screen for Life media efforts, with important modifications. Unlike the Utah Colon Cancer Awareness Campaign, Screen for Life is national in scope, its media messages were developed after an extensive period of formative research, and it effectively utilizes personal stories to promote the importance of CRC screening. The revised Screen for Life campaign, however, should focus its media messages for specific target groups. A second round of formative research process should be conducted, with a focus on understanding how to devise media messages that are meaningful for specific target groups. The messages to be developed will differ from previous messages, because they will not be created with the goal of gaining mass appeal to many diverse audiences, but rather different messages will be designed to appeal to the each audience. The campaign should create commercials for different populations as defined by racial and ethnic makeup, as well as geography. The newly developed messages should be placed in carefully chosen media markets such that they will effectively reach the target populations for which they were developed. In order to reduce racial and ethnic disparities in CRC screening rates, additional resources should be devoted to reaching the previously discussed racial and ethnic groups that have relatively lower CRC screening rates compared to the non-Hispanic white population. Another significant modification to the Screen for Life campaign commercials should be the inclusion of information about the widespread health insurance plan coverage of CRC screening. This addition is important at this time, because health care reform legislation recently passed by Congress will assure more people have health insurance, and that all insurance plans provide access to CRC screening procedures at no additional cost (32).

Physician recommendation of colon cancer screening is the single most important predictor of a patient being screened for CRC (21). In one study, only 61 percent of men and women over 50 years old presenting for primary care office visits reported that their physician recommend they be screened for CRC (28). Therefore, a campaign to increase screening must incorporate a program to stimulate physician recommendation of CRC screening for at-risk adults. Ninety percent of primary care residents report feeling knowledgeable and comfortable recommending CRC screening to patients (25). This suggests that physicians are failing to recommend screening for reasons other than a lack of understanding of the guidelines and personal discomfort with the procedure. Indeed, compared to previous years, physicians are increasingly constrained in their time with patients and being asked to address more clinical items per primary care patient (26). By providing a financial incentive to primary care physicians who successfully screen 70 percent of their Medicaid or Medicare patients within the treatment guidelines for CRC, we can begin to create an environment in which screening is prioritized. The use of financial incentives to bring physician treatment practices into alignment with guidelines has proven to be an effective approach (27). The United States currently has an estimated 385,508 primary care physicians (28), so the absolute maximum annual bonus payout under the proposed $2,000 annual award program would be about $770,000,000. It is as yet unclear exactly how much money could be saved on cancer care by such a program, but the National CRC Roundtable is currently examining the very question of potential Medicare savings that could be realized from screening for all beneficiaries age 50 and over. Some analyses from data over the last decade found that universal screening for CRC in the general U.S. population per current guidelines—but no more often—is cost effective overall (29).

The racial disparities in CRC screening rates are an important factor in the formation of the proposed campaign. Non-Hispanic whites are much more likely to be screened than blacks and Hispanics (5). Not only is screening lower in minority populations, but these populations also experience higher CRC incidence and mortality rates (35). Nationally-representative data is not available for other races and ethnicities, but the structural inequities in the health care system suggest that they are also less likely to be screened for CRC and disproportionately effected. Targeting messages by race and ethnicity is important, because a particular message may vary in effectiveness across different audiences depending on the framing and delivery of the message. For example, one study on mammography promotion found that loss-framed messages were effective for Anglo and Hispanic women, but much less so for African Americans (36). To be sure, formative research for Screen for Life has included diverse focus groups. While the actors in commercials represent a variety of racial and ethnic backgrounds and messages have been translated to Spanish, the commercials appear to have been developed for broad appeal rather than targeted to subpopulations. Other CRC screening campaigns like Utah’s appear to appeal narrowly to Non-Hispanic whites. As discussed, the proposed campaign will go beyond such efforts. The success of a new campaign with modified and targeted media messages will depend in part on the number of distinct racial/ethnic communities that are effectively reached with targeted messages.

Expected increases in CRC screenings due to physician bonuses, however, would likely not only increase among Medicare and Medicaid patients, but would impact additional groups of patients as well. Medicare and Medicaid policies have been effective in shaping public sector markets in the past. These “spillover” effects have mostly been in the context of promoting more efficient systems, such as the prospective payment for hospitalizations that impacted hospital protocols, reducing unnecessarily long patient stays and consequently saving money for all insurers and payers (30). It likely that a change encouraging the provision of more CRC screening services, for Medicare and Medicaid beneficiaries will have an impact on physician recommendations to other patients as well. Approximately 27 percent of the United States population is insured through Medicaid or Medicare (19), making the Centers for Medicare and Medicaid by far the largest single source of physician payments in the country. The vast majority of primary care physicians serve Medicare or Medicaid beneficiaries, making them eligible for the bonus payment program. Despite physician statements to the contrary, research has shown that doctors are not more or less likely to recommend CRC screening based on a patient’s insurance status (31). With the knowledge that physicians do not differ in their propensity to recommend CRC screening to individual patients based on their type of insurance or insurance status, it is the expectation that a bonus payment from one prominent payer—the Centers for Medicare and Medicaid—will affect CRC screening recommendations to all patients. That is, patients enrolled in private and employer-based health insurance programs will benefit in higher CRC recommendations due to a physician bonus payment system implemented by the Centers for Medicare and Medicaid. Physicians are the key decision-makers in medical practice and involving them in a campaign to increase CRC screening is crucial. A financial incentive for screening recommendations sends a clear message regarding the importance of CRC screening as a public health issue and will help to prioritize its recommendation in clinical practice.

Whether physician recommended or patient initiated, CRC screening is not free and patient concerns about paying for CRC screening are valid. The Patient Protection and Affordable Care Act recently signed into U.S. law by President Obama makes significant investments in cancer prevention and takes steps to reduce barriers to cancer screening (32). Most importantly, the law requires health insurers to offer periodic cancer screenings as part of a required minimum package of services in basic health plans. In addition, starting in 2011, all public and private insurers must eliminate patient cost sharing for services considered preventative care, including periodic CRC screenings. As discussed, an overall lack of insurance coverage for CRC screening services is a major perceived barrier for patients. Cost sharing has also been cited as a barrier to screening compliance among Medicare beneficiaries, who have been covered for CRC screening since 2001 (33). Today, 83 percent of Americans lack health insurance coverage, but the Congressional Budget Office estimates that under the health care reform law 95 percent of Americans will have health insurance by 2019 (34). The implication for CRC screening is that by 2019 and estimated 95 percent of the U.S. population will have health insurance coverage that includes periodic CRC screening at no additional cost to the patient. Provisions in the health care reform law effectively remove the financial barriers to CRC screening for all insured Americans, a group that will constitute a growing proportion of the population between now and full implementation in 2019. Therefore, modified Screen for Life campaign commercials should include messages clarifying that, starting in 2011, all insured Americans have access to CRC screening at no additional cost. Patients stand to benefit from the reduced cost burden of CRC screening due to the Protection and Affordable Care Act, but the Screen for Life can also expect an additional boost due to the supportive environment for preventative care in general that the law seeks to advance. By providing increased funding for preventative care research and requiring health plans to cover preventative care, the health care reform law creates a more supportive clinical environment for preventative care. It has been shown that a supportive environment can greatly increase the impact of campaigns to promote the adoption of a health behavior (16). The new focus on preventative care in the U.S. makes now an opportune moment to take advantage of the changes and launch a multi-faceted campaign to increase CRC screening.

The racial disparities in CRC screening rates are an important factor in the formation of the proposed campaign. Non-Hispanic whites are much more likely to be screened than blacks and Hispanics (5). Not only is screening lower in minority populations, but these populations also experience higher CRC incidence and mortality rates (35). Nationally-representative data is not available for other races and ethnicities, but the structural inequities in the health care system suggest that they are also less likely to be screened for CRC and disproportionately effected. In order to increase the impact of the Screen for Life campaign, media messages should be targeted to various racial and ethnic communities, including non-white and Hispanic populations. Targeting by race and ethnicity is important, because a particular message may vary in effectiveness across different audiences depending on the framing and delivery of the message. For example, one study on mammography promotion found that loss-framed messages were effective for Anglo and Hispanic women, but much less so for African Americans (36). There is not likely a single message for each racial and ethnic minority community that will be effective for all who self-identify as members of that community. With that in mind, Screen for Life organizers should do additional formative research to understand the life experiences of racial and ethnic communities in various geographic locations. To be sure, formative research for Screen for Life has included diverse focus groups. While actors in commercials represent a variety of racial and ethnic backgrounds and messages have been translated to Spanish, the commercials appear to have been developed for broad appeal rather than targeted to subpopulations. Other CRC screening campaigns like Utah’s appear to appeal narrowly to Non-Hispanic whites. The success of the campaign will depend in part on the number of distinct racial/ethnic communities that are reached with targeted messages.

CRC is one of the most common types of cancer and a leading cause of mortality in older Americans. Screening for CRC is effective at both preventing CRC incidence and decreasing mortality, yet a minority of Americans for whom it is recommended are have been screened in recent years. Due to an aging U.S. population and disproportionate CRC incidence and mortality among older persons, CRC is an increasingly significant threat to Americans’ health. Campaigns to increase CRC screening through patient awareness, like the Utah Colon Cancer Awareness and the Screen for Life campaigns, have been effective in reaching audiences, yet it is unclear what their actual impact on screening rates has been. A new campaign to increase CRC screening rates should build on the foundation of the Screen for Life Campaign, but make modifications to tailor messages for specific audiences and incorporate a program to provide incentives to Medicaid and Medicare physicians who ensure high CRC screening rates among their patients. This campaign would benefit from the synergy provided by a changing health care system that prioritizes prevention and cancer screening, a strategy that involves physicians, and an approach that recognizes and seeks to address racial and ethnic disparities in current CRC screening rates.


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