Georgia Breast and Cervical Cancer Program annual evaluation report, 2018-2019

Georgia Breast and Cervical Cancer Program Annual Evaluation Report
Reporting Period: July 1, 2018 June 30, 2019 Submitted: November 27, 2019
Prepared by: Janet Y Shin, Breast and Cervical Cancer Program Evaluator, Office of Health Science, Chronic Disease Prevention Section, Georgia Department of Public Health

Key Findings

Executive Summary

Results suggest that the Georgia Breast and Cervical Cancer Program (GBCCP) is making progress to increase breast and cervical cancer screening in Georgia. The majority of the program strategies, including direct screening and patient navigation, were successfully implemented as planned during this reporting period.
A total of 9,294 women were served (i.e., received at least 1 screening or diagnostic services); and 9,054 women were screened (i.e., received at least 1 clinical breast exam (CBE), mammogram, or Pap test) by using Centers for Disease Control and Prevention (CDC) funds. A total of 8,115 CBEs, 8,122 mammograms, 2,085 Pap tests, and 1,116 HPV tests were offered. Ninety-two percent of clients with abnormal breast cancer screenings completed follow-up services; and 97% of women with diagnosis of breast cancers initiated treatment. Eighty-two percent of women with abnormal Pap tests completed follow-up services; and 77% of women with diagnosis of CIN 2, CIN 3, or invasive cervical carcinoma started treatment.
Patient navigators (PNs) educated 7,690 individuals about breast, cervical and colorectal cancer screening by providing group education and one-on-one education sessions. Out of 2,243 GBCCP clients, 1,436 (64%) women were recruited to the program through community outreach. PNs referred 1,456 women without a regular medical home to the nearest federally qualified health center or community clinic.
Among clients that received patient navigation services, 2,093 women completed mammograms; 623 women completed Pap tests; and 422 women received HPV tests. PNs addressed barriers, such as cost (2,276 women), language barriers (1,052 women), lack of information or knowledge (991 women), insurance copayment (575 women), and transportation barriers (237 women). A total of 5,679 phone calls, 1,122 text messages, 909 letters, 483 in person meetings, and 13 home visits were conducted by PNs to deliver client reminders and other navigation services (e.g., scheduling assistance, information, etc).
Evidence-based interventions (EBIs), such as client reminders, provider assessment and feedback, and reduction of structural barriers, were implemented at the East Albany Medical Center. Their clinic-level breast cancer screening rate increased from 42% in 2017 to 70% in 2018. Clinic-level cervical cancer screening rates were 48% in 2017 and 2018.
Six educational sessions were offered at five worksites, and 306 participants attended these events. Composite knowledge scores regarding breast, cervical and colorectal cancer increased from 2.7 to 3.9 / 6 (p<0.0001). Participants' accurate knowledge of cancer increased from 45% to 65%.

Use of Evaluation Results
The GBCCP state office staff met monthly to review data; monitor progress towards cancer screening goals; monitor status of screening and diagnosis, timeliness, and quality of cancer care; discuss barriers and facilitators to program implementation; and make appropriate action plans and changes.
The GBCCP staff is making changes to the environmental approaches by leveraging existing resources and partnerships, coordinating efforts by collaborating with other chronic disease prevention programs within the DPH, and assessing grantees' existing partnerships with worksites and grantees' capacity to develop or enhance wellness policies at worksites. The program staff is planning to use the worksite partnership and capacity assessment results to refine planning and implementation of the environmental approaches and promote wellness policies at worksites. The GBCCP is also making changes to the community-clinical linkages and patient navigation activities, as the Patient Navigation Program has been recently brought into the organizational structure of the DPH.

Lessons Learned Although there was an increase in participants' knowledge scores, results suggest that the worksite
education project has had a minimal impact on increasing cancer screening services. Findings indicate that the program staff may need to revise strategies on reaching the African American
community. Some grantees are experiencing challenges with compliance rates and getting the `buy-in' from African American women to complete cancer screening and follow-up services.

1. Environmental Approaches Description of the Strategy: Patient Navigators (PNs)1 educated employees about breast, cervical and colorectal cancer and cancer screening guidelines at five worksites in Georgia. PNs also informed participants about how eligible women can receive the Georgia Breast and Cervical Cancer Program (GBCCP) services and other resources related to breast, cervical and colorectal cancer care.
Evaluation Questions: 1) To what extent do navigators implement worksite education activities? (Process) 2) Do knowledge scores change after implementing worksite education? (Outcome)
Methods: Pre- and post-tests were administered to education participants by using a paper and pencil method. Composite scores of cancer knowledge were calculated. Mean values of cancer knowledge between pre-test and post-test were compared by conducting a t-test. Percentages of accurate cancer knowledge between pre-test and post-test were compared. Data analysis was performed in SAS.
Evaluation Results: Six educational sessions were offered, and 306 participants (283 females and 23 males) attended these
events at worksites. A total of 42 participants (14%) completed the pre- and post- test surveys. Composite knowledge scores regarding breast, cervical and colorectal cancer increased significantly from 2.7
to 3.9 / 6 (p<0.0001). Participants' accurate knowledge of cancer increased from 45% to 65%. Although there was an increase in knowledge scores, results suggest that the worksite education project has
had a minimal impact on increasing cancer screening services.
Challenges: There was a time lapse between the data collection period (i.e., when the worksite wellness survey was
administered to employers) and the implementation phase (i.e., when PNs contacted employers). It was difficult to establish new partnerships with some of the employers, who initially expressed interest in cancer education, because they experienced significant staff turnover. Due to time constraints at the worksites, 14% of participants in these educational sessions completed the pre- and post-test surveys. Given the small sample size, findings must be interpreted carefully.
2. Community-Clinical Linkages Description of the Strategy: PNs implemented community-clinical linkages (CCL) activities (e.g., group education, one-on-one education,
and small media) to raise awareness of cancer screening guidelines, garner participation in recommended cancer screenings, and link underserved Georgia women to breast and cervical cancer screening services. In partnership with the Georgia Center for Oncology, Research and Education (GA CORE), the GBCCP used the Breast Cancer Genetics Referral Screening Tool (B-RST) to provide genomics screenings and refer women at high risk for the Hereditary Breast and Ovarian Cancer (HBOC) genes. A genetic service provider offered genetic testing and counseling services to clients with positive screening results.
Evaluation Questions: To what extent do navigators and program staff implement CCL activities? (Process)
Methods: PNs collected measures regarding implementation of CCL activities in Microsoft Access Patient Navigation Program (PNP) database. The grantee survey was administered to the GBCCP grantees (i.e., 18 health districts and 4 contract providers) by using the Qualtrics platform. Genetic screening data was collected by using the cloud-based B-RST data system. Genetic testing data was collected in Microsoft Excel by the genetic service provider. Descriptive data analysis was conducted in Microsoft Excel. Qualitative responses in the grantee survey data were analyzed by performing thematic analysis.
1 `Patient navigators' refer to `client navigators' in this report. The Georgia Breast and Cervical Cancer Program uses the terminology `client navigators' in day-to-day operations.
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Evaluation Results: PNs educated 7,690 individuals (6,999 women and 691 men) about breast, cervical and colorectal cancer
screening by providing group education and one-on-one education sessions. Out of 2,243 GBCCP clients, 1,436 (64%) women were recruited to the program through community outreach. PNs referred 1,456 women without a regular medical home to the nearest federally qualified health center or community clinic. Survey findings suggest that the program staff may need to revise strategies to reach the African American community more effectively. Grantees are experiencing challenges with improving compliance rates and getting the `buy-in' from African American women to complete screening and follow-up services. A total of 5,564 women received genomic screening; and 242 (4.3%) screened positive. Ninety women completed follow-up genetic testing; and 7 clinically significant pathogenic mutations were identified.
Challenges: The contract with the American Cancer Society (ACS) for implementation of the PNP was terminated on April 1, 2019. After many discussions among the DPH leadership, the GBCCP program director, and the ACS, it was decided to bring the PNP into the organizational structure of the DPH. New positions were established within the DPH both at the state and local level. The DPH Information Technology team was involved in transferring and creating the in-house PNP database system. Under the DPH, the navigator positions became part of selected local health departments and became full-time employees supervised by the GBCCP district nurse coordinators. During this transition phase, PNP services could not be delivered between April 2, 2019 and June 30, 2019.

3. Health Systems Interventions - Direct Screening and Patient Navigation Description of the Strategy: The GBCCP provided timely and appropriate breast and cervical cancer screening and diagnostic services to low income, uninsured and underinsured Georgia women through 18 health districts and 4 contract providers. Priority populations include racial/ethnic minority groups, women 50-64 years of age, and never or rarely screened women. PNs assisted and navigated women to receive screening through the GBCCP.
Evaluation Questions: 1) To what extent do providers perform cancer screening and diagnostic services? (Process) 2) To what extent do navigators perform patient navigation to increase cancer screening? (Process) 3) Is the GBCCP meeting target values of clinical quality indicators? (Outcome)

Methods: Minimum Data Elements (MDE) were collected in Microsoft Access database to track breast and cervical cancer screening and diagnostic services. Navigators collected measures regarding navigation activities in the Microsoft Access Patient Navigation Program (PNP) database. MDE data was analyzed in SAS; PNP data was analyzed in Microsoft Excel.

Evaluation Results: Table 1 summarizes clinical services provided by the program with Centers for Disease Control and
Prevention (CDC) funds from July 1, 2018 to June 30, 2019 based on the data submitted as of October 2019.

Table 1. Breast and Cervical Cancer Screening and Diagnostic Services Provided Using the CDC Funds

Measure

N (%)

Received 1 clinical breast exam (CBE), mammogram, Pap test, HPV test, or diagnostic service

9,294

Received 1 CBE, mammogram, or Pap test

9,054

Received CBE

8,115

Received mammogram

8,122

Received Pap test

2,085

2

Received HPV test

1,116

Breast follow-up service planned

1,885

Completed breast follow-up (i.e., received final diagnosis)

1,735 (92%)

Received final diagnosis within 60 days of screening date

1,545 (89%)

Final diagnosis pending/missing*

80 (4%)

Lost or refused to diagnostic follow-up

70 (4%)

Breast cancers diagnosed

Invasive

69

Lobular Carcinoma in Situ (LCIS)

3

Ductal Carcinoma in Situ (DCIS)

35

Status of treatment for breast cancers

Treatment started

104 (97%)

Treatment started within 60 days

94 (90%)

Treatment pending*

3 (3%)

Treatment lost, refused, or not needed

0 (0%)

Cervical follow-up service planned

153

Completed cervical follow-up (i.e., received final diagnosis)

125 (82%)

Received final diagnosis within 90 days of Pap test

119 (95%)

Final diagnosis pending/missing*

8 (5%)

Lost or refused to diagnostic follow-up

20 (13%)

Cervical cancers diagnosed

Invasive

1

CIN 2

5

CIN 3

7

Status of treatment for cervical cancers

Treatment started

10 (77%)

Treatment started within 90 days

9 (90%)

Treatment pending*

1 (8%)

Treatment lost or refused

1 (8%)

Treatment not needed

1 (8%)

*The percentage of pending parameters should decrease as the program receives more complete follow-up data.

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Among clients that received navigation, 2,093 women completed mammograms; 623 women completed Pap tests; and 422 women received HPV tests. PNs assessed and reduced barriers, such as cost (2,276 women), language barriers (1,052 women), lack of information and knowledge (991 women), insurance copayment (575 women), and transportation barriers (237 women). PNs made 1,469 phone calls to provide appointment reminders and 240 phone calls to conduct annual reminders. A total of 5,679 phone calls, 1,122 text messages, 909 letters, 483 in person meetings, and 13 home visits were conducted by PNs to deliver client reminders and other navigation services (e.g., scheduling appointments, providing information, etc).
4. Health Systems Interventions Implementing EBIs for Systems Change Description of the Strategy: The GBCCP contracted with the Albany Area Primary Health Care (AAPHC) to implement evidence-based interventions (EBIs) for health systems change. The East Albany Medical Center (EAMC) conducted client reminders; performed provider assessments and feedback; and reduced structural barriers.
Evaluation Questions: 1) To what extent do navigators and program staff perform EBIs to increase cancer screening? (Process) 2) Do clinic-level screening rates change after implementing EBIs? (Outcome)
Methods: Baseline and annual clinic data, including clinic-level breast and cervical cancer screening rates and EBI implementation, was collected and used.
Evaluation Results: PNs and partner coalition staff performed client reminders on an on-going basis. Non-compliance lists for
cancer screening were ran and addressed monthly. Reminders were sent by making phone calls, sending letters, and sending patient portal messages for web-enabled patients. The AAPHC staff assessed provider performance and provided feedback to 9 providers at monthly meetings. Feedback reports were also shared with providers via email on an as-needed basis. The EAMC addressed structural barriers by providing services on Saturdays, offering bus tokens and gas cards, providing translation services, and delivering navigation services (e.g., scheduling assistance). The clinic-level breast cancer screening rate increased from 42% in 2017 to 70% in 2018. Clinic-level cervical cancer screening rates were 48% in 2017 and 2018 and did not change over time.
Challenges: A major challenge in implementing this strategy was limited staff capacity at the state office and the health system; and staff turnover at the clinic. Another challenge in implementing client reminders was that patients do not always provide reliable contact information. In some cases, patients lost their phone service.
5. Use of Evaluation Results: The GBCCP state office staff met monthly to review data; monitor progress towards cancer screening goals; monitor status of screening and diagnosis, timeliness, and completeness of cancer care; discuss barriers and facilitators to program implementation; and make appropriate action plans and changes. The GBCCP staff is making changes to the environmental approaches by leveraging existing resources and partnerships, coordinating efforts by collaborating with other chronic disease prevention programs within the DPH, and assessing grantees' existing partnerships with worksites and grantees' capacity to develop or enhance wellness policies at worksites. The program staff is planning to use the worksite partnership and capacity assessment survey results to refine planning and implementation of the environmental approaches and promote wellness policies at worksites. The GBCCP is also making changes to the CCL strategy and PNP activities, as the PNP has been recently brought into the organizational structure of the DPH.
6. Dissemination of Evaluation Results: Evaluation results were shared with program staff and grantees via PowerPoint presentation at the GBCCP Annual Meeting on November 6, 2019. The annual evaluation report was disseminated to program staff, grantees and stakeholders via email and the DPH website. The feedback report about MDE data findings was disseminated to grantees on a monthly basis.
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Attachments 1) PowerPoint Presentation (Presented at GBCCP Annual Meeting on 11/6/2019) 2) DPH Website url: https://dph.georgia.gov/BCCP and https://dph.georgia.gov/evaluation 3) Years 3-5 GBCCP Evaluation Plan (Revised in October 2019)
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