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Research ArticleOriginal Research

Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

Allen J. Dietrich, Jonathan N. Tobin, Christina M. Robinson, Andrea Cassells, Mary Ann Greene, Van H. Dunn, Kimberly M. Falkenstern, Rosanna De Leon and Michael L. Beach
The Annals of Family Medicine July 2013, 11 (4) 335-343; DOI: https://doi.org/10.1370/afm.1469
Allen J. Dietrich
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
MD
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  • For correspondence: allen.j.dietrich@dartmouth.edu
Jonathan N. Tobin
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
PhD
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Christina M. Robinson
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
MS
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Andrea Cassells
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
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Mary Ann Greene
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
MS
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Van H. Dunn
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
MD, MPH, FACP
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Kimberly M. Falkenstern
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
MA
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Rosanna De Leon
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
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Michael L. Beach
Community and Family Medicine, Norris Cotton Cancer Center, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire (Dietrich); Department of Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Robinson, Greene); Clinical Directors Network, Inc (CDN), New York, New York (Tobin, Cassells); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY (Tobin); Allen and Frances Adler Laboratory of Blood and Vascular Biology, The Rockefeller University Center for Clinical and Translational Science, New York, NY (Tobin); Metro Plus Health Plan, New York, NY (Dunn); United Healthcare Community Plan, New York, NY (Falkenstern); Medical Management, HealthPlus-Amerigroup, New York, NY (De Leon); Departments of Anesthesiology and Community and Family Medicine, The Geisel School of Medicine at Dartmouth, Lebanon, NH (Beach).
MD, PhD
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  • Figure 1
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    Figure 1

    Flow diagram displaying the eligibility, randomization, and follow-up of study participants.

    CRC=colorectal cancer.

    aCategories not mutually exclusive.

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    Table 1

    Characteristics of Participating Medicaid Managed Care Organizations According to Membership and Study Patients

    CharacteristicMMCO1MMCO2MMCO3Total
    MMCO membership
    Total membership in New York City (2008), No.215,764276,651349,006841,421
    Members in New York City covered by Medicaid or Family Health Plus in 2008, %93909292
    Study patients, No (%)
    Primary language (from administrative data)
     English359 (80.5)442 (58.9)750 (71.8)1,551 (69.2)
     Spanish20 (4.5)276 (36.8)259 (24.8)555 (24.8)
     Russian61 (13.7)2 (0.3)0 (0)63 (2.8)
     Other6 (1.3)30 (4)35 (3.4)71 (3.2)
    Practice type of study patients
     Publicly funded Community/Migrant Health Center51 (11.4)750 (100)217 (20.8)1,018 (45.4)
     Publicly funded diagnostic and treatment center0 (0)0 (0)827 (79.2)827 (36.9)
     Private practice395 (88.6)0 (0)0 (0)395 (17.6)
    Total number of patients in the study446 (19.9)750 (33.5)1,044 (46.6)2,240 (100)
    • CRC = colorectal cancer; MMCO = Medicaid managed care organization.

    • View popup
    Table 2

    Patient Characteristics From Administrative and Claims Data

    CharacteristicIntervention (n=562)Usual Care (n=1,678)
    Age at baseline, mean y55.855.8
    Language, No. (%)
     English394 (70.1)1,157 (69.0)
     Spanish145 (25.8)410 (24.4)
     Russian11 (2.0)52 (3.1)
     Other12 (2.1)59 (3.5)
    Comorbidities at baseline, No. (%)
     Diabetes159 (28.3)491 (29.3)
     Hypertension348 (61.9)1,013 (60.4)
     High cholesterol level213 (37.9)627 (37.4)
    Baseline screening status, No. (%)
     Up-to-date on breast cancer screening356 (63.3)1,072 (63.9)
     Up-to-date on cervical cancer screening381 (67.8)1,093 (65.1)
    Health care utilization during 18 mo before baseline
     Patients with no outpatient visits, No. (%)56 (10.0)156 (9.3)
     Number of outpatient visits, mean No.10.510.3
     Patients with claim for health maintenance examination, No. (%)277 (49.3)794 (47.3)
    • View popup
    Table 3

    Colon Cancer Screening Status During the 18-Month Intervention Period, Intervention vs Usual Care

    Study ParticipantsUp-to-Date on Colorectal Cancer ScreeningOdds Ratio (95% CI)
    Intervention ArmUsual Care Arm% Difference
    No.No. (%)No.No. (%)UnadjustedAdjusteda
    All randomized patients (N = 2,240)562206 (36.7)1,678514 (30.6)6.0b1.31a (1.07–1.61)1.32b (1.08–1.62)
     Members of MMCO111228 (25.0)33468 (20.4)4.61.30 (0.76–2.21)1.32 (0.79–2.22)
     Members of MMCO218879 (42.0)562159 (28.3)13.7c1.84c (1.28–2.62)1.98c (1.39–2.82)
     Members of MMCO326299 (37.8)782287 (36.7)1.11.05 (0.78–1.41)1.02 (0.76–1.38)
    As-treated subset (n=1,061)d306128 (41.8)755202 (26.8)15.1c1.97c (1.47–2.62)1.84c (1.38–2.44)
     Subset members of MMCO18021 (26.3)14421 (14.6)11.72.08e (1.06–4.08)1.86 (0.93, 3.72)
     Subset members of MMCO29650 (52.1)24966 (26.5)25.6c3.01c (1.79–5.06)3.11c (1.87–5.17)
     Subset members of MMCO313057 (43.8)362115 (31.8)12.1e1.68e (1.09–2.58)1.54e (1.01–2.35)
    • MMCO = Medicaid managed care organization.

    • ↵a Adjusted for age, comorbidities (diabetes, hypertension, and high cholesterol), visits within 18 months, insurance (Medicaid or Family Health Plus), and primary language, all at baseline.

    • ↵b P <.01. Bivariate outcomes analyzed using an unadjusted χ2 test.

    • ↵c P <.001. Bivariate outcomes analyzed using an unadjusted χ2 test.

    • ↵d This analysis excludes women who were up-to-date at baseline or otherwise ineligible according to final electronic administrative and claims data, and compares intervention arm women reached by telephone with usual care women with whom no study contact was attempted.

    • ↵e P <.05. Bivariate outcomes analyzed using an unadjusted χ2 test.

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  • The Article in Brief

    Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial

    Allen J. Dietrich , and colleagues

    Background Health plans are uniquely positioned to deliver outreach to their members. This study explores whether telephone outreach delivered by Medicaid managed care organization staff can increase colorectal cancer screening (CRC) among publicly insured urban women.

    What This Study Found A previously proven telephone outreach intervention delivered by research-based staff to increase CRC screening can be successfully translated to the health plan arena. In this study, staff of a Medicaid managed care organization increases CRC screening rates by one-third to nearly double among publicly insured urban women. The study, involving 2,240 women overdue for screening and insured by 1 of 3 New York City Medicaid managed care organizations, finds intervention women are significantly more likely than usual care women to become up-to-date on CRC screening. Increases vary from 1 percent to 14 percent across participating organizations, with the overall increase driven by increases at one particular Medicaid managed care organization.

    Implications

    • Medicaid managed care organizations, key players in the delivery of health care to publicly insured and underserved populations, can successfully implement interventions to increase CRC screening, reducing health care disparities among a difficult to reach population.
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The Annals of Family Medicine: 11 (4)
The Annals of Family Medicine: 11 (4)
Vol. 11, Issue 4
July/August 2013
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Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial
Allen J. Dietrich, Jonathan N. Tobin, Christina M. Robinson, Andrea Cassells, Mary Ann Greene, Van H. Dunn, Kimberly M. Falkenstern, Rosanna De Leon, Michael L. Beach
The Annals of Family Medicine Jul 2013, 11 (4) 335-343; DOI: 10.1370/afm.1469

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Telephone Outreach to Increase Colon Cancer Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial
Allen J. Dietrich, Jonathan N. Tobin, Christina M. Robinson, Andrea Cassells, Mary Ann Greene, Van H. Dunn, Kimberly M. Falkenstern, Rosanna De Leon, Michael L. Beach
The Annals of Family Medicine Jul 2013, 11 (4) 335-343; DOI: 10.1370/afm.1469
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