Routinely collected electronic health data about cancer screening and follow-up would be helpful adjuncts for assessing guideline adherence in real-world populations. We compared the use of insurance claims data to other sources to describe (1) abnormal colorectal cancer, breast cancer, and cervical cancer screening results and (2) follow-up after abnormal cancer screening results.
We evaluated over 100 million person-years of curated claims data from one large national and 2 smaller regional insurers participating in the National Institutes of Health (NIH) Health Care Systems Research Collaboratory Distributed Research Network (DRN).1,2,3,4 We assessed rates of new colorectal, breast, and cervical cancer screenings and abnormal cancer screening results from January 1, 2007 to December 31, 2014, and in 2013, we assessed selected follow-up events (cancer diagnosis, imaging, or biopsy) within 90 days following a new abnormal colorectal, breast, or cervical cancer screening result (Fig. 1). We used US Preventative Services Task Force recommendations5 to establish lower boundaries for age at screening. Individuals aged at least 50, 40, and 21 years for colon, breast, or cervical cancer, respectively, were required to have continuous medical and pharmacy coverage for > 9 months (270 days) before their index cancer screening or abnormal cancer screening result, allowing gaps in coverage ≤ 45 days.
A “new” screening was defined as a cancer screening with no previous screenings of that type in the preceding 270 days. A new abnormal cancer screening result was defined similarly. Screenings, abnormal results, and subsequent follow-up events were defined based on ICD-9-CM diagnosis/procedure codes, CPT codes, and HCPCS codes (codes available from authors).
Each data partner used the same data structure (at the FDA Sentinel common data model).4 The DRN coordinating center distributed a cohort identification and analysis program that executed against each organization’s existing transformed, curated dataset, and returned aggregate results. We measured days to follow-up within 90 days following a first abnormal result among those with medical and pharmacy coverage for > 6 months (183 days) (Fig. 1). The numbers of eligible members, unique patients with new screenings, abnormal screening results, and follow-up events to abnormal results were stratified by age group for each cancer.
The Harvard Pilgrim Health Care Human Studies Committee determined that this project did not constitute human subjects research and therefore did not require further review or approval by the Committee.
Detailed results are shown in Tables 1 and 2. Of > 6 million eligible individuals aged 50–64 years, 2.1 million (309.5 new screening patients/1000) had ≥ 1 new colorectal cancer screening from 2007 to 2014. In the same age group, the absolute number of new breast cancer and cervical cancer screening patients were more common. New screening patients/1000 eligible members were most frequent among patients aged 50–64 years for both colorectal and breast cancers, while those aged 30–39 years had the highest proportion of new cervical cancer screening patients (Table 1).
The proportion of abnormal results among new screening patients varied (1.8–7.7 for colorectal cancer, 23.8–26.0 for breast cancer, and 9.5–18.2 for cervical cancer). For those with abnormal screening results, new patients with follow-up events per 1000 eligible members were fewest for colorectal cancer (68.0–71.9). Mean time to follow-up event was shortest for breast cancer (Table 2).
These results, obtained through a distributed data network, are similar to findings reported from a cancer screening-specific consortium.6 Abnormality rates for colorectal cancer are higher in the 65–74 age group vs. the 50–64 age group, and the highest proportion of patients with follow-up within 90 days was for breast cancer follow-up (> 95%), followed by colorectal and cervical cancers (< 75%).
A strength of this analysis is its employment of a reusable analysis program executing against standardized and curated, routinely collected electronic data from various institutions to enable rapid, privacy-protecting, cost-efficient assessment of practice. These results cannot be extrapolated beyond commercially insured populations and may not capture screenings outside of insured care (e.g., free screenings). We did not account for the results of past tests, follow-up type, or individual health status, all of which may affect observed timing or occurrence of events.
Although additional study is needed to examine the influence of variation in screening processes on disease outcomes, these results support the use of routinely available, quality-checked, observational data to assess adherence to recommended screening and follow-up of common cancers.
Robb MA, Racoosin JA, Sherman RE, et al. The US Food and Drug Administration’s Sentinel Initiative: expanding the horizons of medical product safety. Pharmacoepidemiol Drug Saf 2012;21(Suppl 1):9–11.
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Sentinel System. Sentinel Data Quality Assurance Practices. https://www.sentinelinitiative.org/sites/default/files/data/DistributedDatabase/Sentinel_DataQAPractices_Memo.pdf . Accessed 10 Nov 2017.
Sentinel System. Distributed database and common data model. https://www.sentinelinitiative.org/sentinel/data/distributed-database-common-data-model. Accessed 25 May 2018.
U.S. Preventive Services Task Force. Recommendations for primary care practice. https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations. Accessed 25 May 2018.
Tosteson AN, Beaber EF, Tiro J, et al. Variation in screening abnormality rates and follow-up of breast, cervical and colorectal cancer screening within the PROSPR Consortium. J Gen Intern Med 2016;31:372–9.
The authors thank Stephen Taplin, MD, MPH, for his insightful review of the manuscript and Beth Syat for her support of this project.
This work was supported by the National Institutes of Health (NIH) Common Fund, through a cooperative agreement (U54 AT007748) from the Office of Strategic Coordination within the Office of the NIH Director.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
The views presented here are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.
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Raman, S.R., Brown, J.S., Curtis, L.H. et al. Cancer Screening Results and Follow-up Using Routinely Collected Electronic Health Data: Estimates for Breast, Colon, and Cervical Cancer Screenings. J GEN INTERN MED 34, 341–343 (2019). https://doi.org/10.1007/s11606-018-4697-y