Sunday, 28 May 2017

Management of people with positive test results and fail-safe mechanisms

The potential reduction of mortality through cancer screening can only be achieved if subjects with abnormal findings receive timely and appropriate follow-up for detected abnormalities.

The findings of a recent US survey indicated that less than 15% of health plans monitor receipt of appropriate follow-up care by patents with abnormal results. This lack of organised tracking systems probably explains the low proportion of people with abnormal screening findings who receive adequate follow-up (Yabroff et al. 2003). In particular, among patients receiving FOBT screening in the Veterans health administration, 41% of those with a positive test failed to receive appropriate assessment (Etzioni et al. 2006). The negative implications of follow-up failures are substantial, including at the population level. A previous analysis of the screening history of invasive cervical cancers identified by a population-based cancer registry showed that about 20–25% of women with invasive cancer had been recommended for an early repeat smear, but had not received adequate follow-up (Bucchi & Serafini 1992). 

Effective interventions targeting the screen-positive individuals include (Bastani et al. 2004): reducing financial and other barriers for further investigations or eliminating the costs for the patients, mail or telephone reminders, and providing written information material or telephone counselling addressing fears related to abnormal findings. All these interventions were found to be successful in increasing the proportion of people receiving timely follow-up. Few interventions have been assessed at the practice/provider level. The offer of same-day follow-up on-site colposcopy for abnormal Pap-smears (Holschneider et al. 1999) or an on-site colonoscopy following a positive sigmoidoscopy (Stern et al. 2000), has led to improved patient compliance. In a predominantly minority and indigent population targeted for cervical cancer screening, subjects managed through a specialised clinic, including nurse case manager, tracking system, reminder calls, rescheduling of missed appointments and clinical staffing with on-site colposcopy, achieved a significantly increased follow-up compared to a randomly assigned control group (Engelstad et al. 2001). The implementation of infrastructure (computerised systems for tracking and monitoring of screening abnormalities) and organisational changes (multidisciplinary team work) are required to ensure sustainability over time of effective interventions. 

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