title: Race/Ethnicity and Adoption of a Population Health Management Approach to Colorectal Cancer Screening in a Community-Based Healthcare System.
abstract: Screening outreach programs using population health management principles offer services uniformly to all eligible persons, but racial/ethnic colorectal cancer (CRC) screening patterns in such programs are not well known.
  
  
  
  To examine the association between race/ethnicity and the receipt of CRC screening and timely follow-up of positive results before and after implementation of a screening program.
  
  
  
  Retrospective cohort study of screen-eligible individuals at the Kaiser Permanente Northern California community-based integrated healthcare delivery system (2004-2013).
  
  
  
  A total of 868,934 screen-eligible individuals 51-74 years of age at cohort entry, which included 662,872 persons in the period before program implementation (2004-2006), 654,633 during the first 3 years after implementation (2007-2009), and 665,268 in the period from 4 to 7 years (2010-2013) after program implementation.
  
  
  
  A comprehensive system-wide long-term effort to increase CRC that included leadership alignment, goal-setting, and quality assurance through a PHM approach, using mailed fecal immunochemical testing (FIT) along with offering screening at office visits.
  
  
  
  Differences over time and by race/ethnicity in up-to-date CRC screening (overall and by test type) and timely follow-up of a positive screen. Race/ethnicity categories included non-Hispanic white, non-Hispanic black, Hispanic/Latino, Asian/Pacific Islander, Native American, and multiple races.
  
  
  
  From 2004 to 2013, age/sex-adjusted CRC screening rates increased in all groups, including 35.2 to 81.1 % among whites and 35.6 to 78.0 % among blacks. Screening rates among Hispanics (33.1 to 78.3 %) and Native Americans (29.4 to 74.5 %) remained lower than those for whites both before and after program implementation. Blacks, who had slightly higher rates before program implementation (adjusted rate ratio [RR] = 1.04, 99 % CI: 1.02-1.05), had lower rates after program implementation (RR for period from 4 to 7 years = 0.97, 99 % CI: 0.96-0.97). There were also substantial improvements in timely follow-up of positive screening results.
  
  
  
  In this screening program using core PHM principles, CRC screening increased markedly in all racial/ethnic groups, but disparities persisted for some groups and developed in others, which correlated with levels of adoption of mailed FIT.
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
authors.forename: Shivan J
authors.initials: SJ
authors.lastname: Mehta
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, CA, USA.
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Jensen
authors.affiliation: Research & Evaluation, Kaiser Permanente, Pasadena, CA, USA.
authors.forename: Virginia P
authors.initials: VP
authors.lastname: Quinn
authors.affiliation: Research & Evaluation, Kaiser Permanente, Pasadena, CA, USA.
authors.forename: Joanne E
authors.initials: JE
authors.lastname: Schottinger
authors.affiliation: Memorial Sloan Kettering Cancer Center, New York, NY, USA.
authors.forename: Ann G
authors.initials: AG
authors.lastname: Zauber
authors.affiliation: Erasmus University Medical Center (Erasmus MC), Rotterdam, Netherlands.
authors.forename: Reinier
authors.initials: R
authors.lastname: Meester
authors.affiliation: Division of Gastroenterology, Howard University College of Medicine, Washington, DC, USA.
authors.forename: Adeyinka O
authors.initials: AO
authors.lastname: Laiyemo
authors.affiliation: Surveillance and Health Services Research, American Cancer Society, Atlanta, GA, USA.|Emory University, Atlanta, GA, USA.
authors.forename: Stacey
authors.initials: S
authors.lastname: Fedewa
authors.affiliation: Emory University, Atlanta, GA, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Goodman
authors.affiliation: Harvard Medical School, Boston, MA, USA.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Fletcher
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, CA, USA.
authors.forename: Theodore R
authors.initials: TR
authors.lastname: Levin
authors.affiliation: Division of Research, Kaiser Permanente, Oakland, CA, USA.
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Corley
authors.affiliation: Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Gates 2 Pavilion, Philadelphia, PA, 19104, USA. chyke.doubeni@uphs.upenn.edu.
authors.forename: Chyke A
authors.initials: CA
authors.lastname: Doubeni
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003113:Colonoscopy / Q000379:methods; D015179:Colorectal Neoplasms / Q000175:diagnosis* / Q000208:ethnology* / Q000517:prevention & control; D003153:Community Health Services / Q000379:methods*; D019468:Disease Management; D055088:Early Detection of Cancer / Q000379:methods*; D005006:Ethnicity; D005260:Female; D005500:Follow-Up Studies; D006297:Health Services Accessibility; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D000075485:Population Health; D044469:Racial Groups / Q000208:ethnology; D012189:Retrospective Studies; D012812:Sigmoidoscopy / Q000379:methods
keywords: cancer screening; colorectal cancer; health care delivery; population health; race & ethnicity