Georgia Breast and Cervical Cancer Program annual evaluation report, 2019-2020

Georgia Breast and Cervical Cancer Program Annual Evaluation Report
Reporting Period: July 1, 2019 June 30, 2020 Submitted: November 24, 2020
Prepared by: Janet Y Shin, Breast and Cervical Cancer Program Director, Office of Women's Health, 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. Program implementation, including direct service delivery, has been significantly impacted by the COVID-19 pandemic.
A total of 7,615 women were served (i.e., received at least 1 breast or cervical cancer screening or diagnostic services); 7,180 women were served for breast cancer services; and 2,367 women were served for cervical cancer services by using Centers for Disease Control and Prevention (CDC) funds. A total of 6,676 clinical breast exams (CBEs), 6,620 mammograms, 2,239 Pap tests, and 1,534 HPV tests were offered.
Ninety-five percent of clients with abnormal breast cancer screenings completed follow-up services; and 95% of women with diagnosis of breast cancers initiated treatment. Ninety-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 3,797 women about breast, cervical and colorectal cancer screening by providing group education and one-on-one education sessions. Out of 1,514 GBCCP navigated and that completed screening, 723 (48%) women were recruited to the program through community outreach. PNs referred 937 women without a regular medical home to the nearest federally qualified health center (FQHC) or community clinic.
Among clients that received patient navigation services, 1,386 women completed mammograms; 562 women completed Pap tests; and 301 women received HPV tests. PNs addressed barriers, such as financial barriers (1,498 women), language barriers (914 women), lack of information or knowledge (1,158 women), and transportation barriers (144 women).
Health systems changes and 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 68% (1,169 out of 1,721 women) in 2019. Clinic-level cervical cancer screening rate increased from 48% in 2017 to 63% (1,205 out of 1,920 women) in 2019.

Use of Evaluation Results
The GBCCP state office staff reviewed data on a monthly basis; monitored progress towards service goals; monitored status of screening and diagnosis, timeliness, and quality of cancer care; discussed barriers and facilitators to program implementation; and made appropriate action plans and changes.
Lessons Learned
The COVID-19 pandemic has challenged the program staff and providers to adapt and work in innovative ways with limited resources. We will continue to pursue opportunities to enhance program quality and improve data systems.

1. Environmental Approaches Description of the Strategy: Georgia Breast and Cervical Cancer Program (GBCCP) is planning to develop or enhance policies that increase access to cancer screening at worksites in Gainesville, Gwinnett, and Athens. Three health districts are planning to implement at least one of the interventions: implementing sick leave policies, implementing flextime policies, implementing mobile mammography service at the worksite, providing coverage for breast or cervical cancer screening, sending reminders to employees or providers, implementing a breast or cervical cancer screening referral system at the worksite, providing one-on-one education or group education, and using social media to promote breast or cervical cancer screening among employees.
Evaluation Questions: 1) To what extent do worksites implement the cancer policies? (Process) 2) Do breast and cervical cancer screening rates change after developing and implementing worksite cancer policies? (Outcome)
Methods: Three health districts are planning to conduct the employer-level and employee-level worksite assessments during Fiscal Year (FY) 2021.
Evaluation Results: N/A
Challenges: Due to the COVID-19 pandemic, three health districts (i.e., Waycross, Dublin and Macon) that were planning to implement the Worksite Cancer Screening Initiative have not had the capacity to engage in this initiative during this reporting period. Athens, Gainesville, and Gwinnett health districts are planning to implement this initiative in FY 2021.
2. Community-Clinical Linkages Description of the Strategy: Patient Navigators (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 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 Question: 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. A grantee survey was administered to GBCCP grantees without PNs 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.
Evaluation Results: PNs educated 4,022 individuals (3,797 women and 225 men) about breast, cervical and colorectal cancer
screening by providing group education and one-on-one education sessions. Out of 1,514 GBCCP clients that received patient navigation and completed cancer screening, 723 (48%) women were recruited to the program through community outreach. PNs referred 937 women without a regular medical home to the nearest federally qualified health center (FQHC) or community clinic. A total of 4,125 women received genomic screening; and 181 (4%) screened positive. Fifty-two women completed follow-up genetic testing; and 9 clinically significant pathogenic mutations were identified.
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Challenges: Implementation of CCL activities has been challenging due to the COVID-19 pandemic. PNs employed virtual meeting platforms to host webinars and used social media to promote breast and cervical cancer screening and recruit eligible GBCCP clients.

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 contracted 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 (MDEs) 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 Microsoft Access; and 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, 2019 to June 30, 2020 based on the data submitted as of October 2020.

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

Measure

N (%)

Goal

Received 1 mammogram, Clinical Breast Exam (CBE), Pap test, HPV test, screening MRI for women at high risk for breast cancer, breast diagnostic service, or cervical diagnostic service

7,615

9,227

Received 1 mammogram, CBE, screening MRI for women at high risk for breast cancer, or breast diagnostic service

7,180

8,670

Received 1 Pap test, HPV test, or cervical diagnostic service

2,367

2,300

Received 1 CBE, mammogram, or Pap test

7,387

N/A

Received CBE

6,676

N/A

Received mammogram

6,620

N/A

Received Pap test

2,239

N/A

Received HPV test

1,534

N/A

2

Breast follow-up service planned

1,743

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

1,657 (95%)

90%

Received final diagnosis within 60 days of screening date

1,480 (89%)

75%

Final diagnosis pending/missing*

22 (1%)

Lost or refused to diagnostic follow-up

64 (4%)

Breast cancers diagnosed

Invasive

69

N/A

Lobular Carcinoma in Situ (LCIS)

0

Ductal Carcinoma in Situ (DCIS)

34

Status of treatment for breast cancers

Treatment started

98 (95%)

90%

Treatment started within 60 days

96 (98%)

80%

Treatment pending*

1 (1%)

Treatment lost, refused, or not needed

4 (4%)

Cervical follow-up service planned

210

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

193 (92%)

90%

Received final diagnosis within 90 days of Pap test

160 (83%)

75%

Final diagnosis pending/missing*

2 (1%)

Lost or refused to diagnostic follow-up

15 (7%)

Cervical cancers diagnosed

Invasive

3

N/A

CIN 2

8

CIN 3

15

Status of treatment for cervical cancers

Treatment started

20 (77%)

90%

Treatment started within 90 days

19 (95%)

80%

Treatment pending*

2 (8%)

Treatment lost or refused

3 (12%)

Treatment not needed

1 (4%)

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

Among clients that received patient navigation services, 1,386 women completed mammograms; 562 women completed Pap tests; and 301 women received HPV tests. PNs addressed barriers, such as financial
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barriers (1,498 women), language barriers (914 women), lack of information or knowledge (1,158 women), and transportation barriers (144 women).
Challenges:
Direct service delivery has been significantly impacted by the COVID-19 pandemic. PNs at three health districts are not able to schedule appointments directly with clients, as these districts
assigned other staff (e.g., front desk staff, nurse) to schedule appointments. The GBCCP PNP Manager is working closely with the district staff to improve the workflows so that PNs can conduct client reminders and assist with scheduling appointments more efficiently. Due to the issues regarding the GBCCP PNP database system, it has been challenging to track and monitor the implementation of client reminders and other PN activities.
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. 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). Their clinic-level breast cancer screening rate increased from 42% in 2017 to 68% (1,169 out of 1,721
women) in 2019. Clinic-level cervical cancer screening rates increased from 48% in 2017 to 63% (1,205 out of 1,920 women) in 2019.
Challenges: A major challenge in implementing this strategy was limited staff capacity at the health system. 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 reviewed data on a monthly basis; monitored progress towards service goals; monitored status of screening and diagnosis, timeliness, and quality of cancer care; discussed barriers and facilitators to program implementation; and made appropriate action plans and changes.
6. Dissemination of Evaluation Results: 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. The GBCCP state office staff reviewed the site-specific results regarding clinical quality indicators with grantees and provided data-driven recommendations via virtual meetings in September-October 2020.
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