The Impact of the Affordable Care Act on Colorectal Cancer Incidence and Mortality: the case of Kaiser Permanente of Northern California

AbstractBackgroundThe Patient Protection and Affordable Care Act (ACA) eliminated cost sharing for preventive services, including colorectal cancer (CRC) screening for individuals aged 50 to 75 with private health insurance. The present study is the first to examine the impact of the no-cost CRC screening due to the ACA on CRC incidence and mortality.MethodsWe modeled trends in CRC incidence and CRC-related mortality in an open cohort of 2,113,283 Kaiser Permanente Northern California (KPNC) members aged 50 years and older between 2003 and 2016 using an interrupted time series design. Individual-level data were analyzed at the month-level. Analyses were adjusted for age, race/ethnicity and sex. As a sensitivity analysis, we considered a controlled approach, with a comparison group of KPNC members covered by health plans with pre-ACA zero cost-sharing for CRC screening.ResultsA total of 178,582,512 person-months were used in the analysis of CRC incidence, of which 48% occurred in the period before the ACA was passed into law (1/1/2003-3/31/2010) and 52% after (4/1/2010-12/31/2016). In primary analyses, the model for CRC incidence indicated a drop in the trend coinciding with the passage of the ACA (change in level incidence rate ratio, IRR: 0.83, 95% CI: 0.77-0.90, p-value < 0.0001), followed by a decrease in trend (change in slope IRR: 0.97/year, 95% CI: 0.93-1.00, p-value = 0.05). Results for CRC-related mortality were similar. Our controlled results indicate that free screening due to the ACA was associated with greater improvements in CRC outcomes among members previously covered by health plans with out-of-pocket costs for screening, compared to health plans with zero cost sharing for screening before the ACA went into effect.ConclusionsWe found that free CRC screening due to the ACA was associated with a decrease in age-, race/ethnicity- and sex-adjusted CRC incidence and CRC-related mortality, after accounting for contemporaneous competing interventions. Furthermore, these findings were robust to the addition of a comparison group with zero cost sharing both pre- and post-ACA.

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Is Colorectal Cancer Screening Appropriate in Nigeria?

Journal of Global Oncology ◽

10.1200/jgo.19.00035 ◽

2019 ◽

pp. 1-10

Author(s):

Gregory C. Knapp ◽

Olusegun I. Alatise ◽

Olalekan O. Olasehinde ◽

Ademola Adeyeye ◽

Omobolaji O. Ayandipo ◽

...

Keyword(s):

Colorectal Cancer ◽

Parasitic Infection ◽

Molecular Profile ◽

Future Research ◽

Middle Income ◽

Crc Screening ◽

Middle Income Countries ◽

Incidence And Mortality ◽

Prospective Trials ◽

The Impact

PURPOSE The global burden of colorectal cancer (CRC) will continue to increase for the foreseeable future, largely driven by increasing incidence and mortality in low- and middle-income countries (LMICs) such as Nigeria. METHODS We used the Wilson-Jungner framework (1968) to review the literature relevant to CRC screening in Nigeria and propose areas for future research and investment. RESULTS Screening is effective when the condition sought is both important and treatable within the system under evaluation. The incidence of CRC is likely increasing, although the exact burden of disease in Nigeria remains poorly understood and access to definitive diagnosis and treatment has not been systematically quantified. In high-income countries (HICs), CRC screening builds on a well-known natural history. In Nigeria, a higher proportion of CRC seems to demonstrate microsatellite instability, which is dissimilar to the molecular profile in HICs. Prospective trials, tissue banking, and next-generation sequencing should be leveraged to better understand these potential differences and the implications for screening. Fecal immunochemical test for hemoglobin (FIT) is recommended for LMICs that are considering CRC screening. However, FIT has not been validated in Nigeria, and questions about the impact of high ambient temperature, endemic parasitic infection, and feasibility remain unanswered. Prospective trials are needed to validate the efficacy of stool-based screening, and these trials should consider concomitant ova and parasite testing. CONCLUSION Using the Wilson-Jungner framework, additional work is needed before organized CRC screening will be effective in Nigeria. These deficits can be addressed without missing the window to mitigate the increasing burden of CRC in the medium to long term.

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A FEW FOR-PROFIT BUSINESSES’ BATTLE OVER THE AFFORDABLE CARE ACT’S PREVENTATIVE SERVICES MANDATE

Journal of Law and Commerce ◽

10.5195/jlc.2014.64 ◽

2014 ◽

Vol 32 (2) ◽

pp. 381-400

Author(s):

Leigh Argentieri Coogan

Keyword(s):

Affordable Care Act ◽

Cost Sharing ◽

Religious Organizations ◽

District Court ◽

Health Plans ◽

For Profit ◽

Patient Protection ◽

The Supreme Court ◽

Regulation Changes ◽

Preventative Services

Under the Patient Protection and Affordable Care Act (ACA), employers are required to provide employees with health plans, which must include FDA, approved contraceptives with no cost sharing. While Health and Humans Services (HHS) revised the regulation to allow for a compromise among religious organizations and non-profits run by religious organizations, private for profit businesses must comply with the ACA even if the business asserts to be founded on religious principles. Several for profit business have sued in district court for an injunction against the requirements. However, a circuit split exists among courts granting preliminary injunctions against the ACA pending a granting of appeal. This note will focus on whether the federal government can compel secular, for profit organizations to provide employee health plans that include contraceptives, the morning after pill and sterilization under the Religious Freedom Restoration Act. Unless the statute or regulation changes, the Supreme Court will likely need to grant certiorari to resolve the issue.

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The impact of affordable care act on the treatment disparities for stage-IV colorectal cancer: A contemporary analysis.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.15_suppl.e19082 ◽

2020 ◽

Vol 38 (15_suppl) ◽

pp. e19082-e19082

Author(s):

Thejus Thayyil Jayakrishnan ◽

Veli Bakalov ◽

Zena Chahine ◽

Gene Grant Finley ◽

Dulabh K. Monga ◽

...

Keyword(s):

Socioeconomic Factors ◽

Affordable Care Act ◽

Stage Iv ◽

P Value ◽

Primary Therapy ◽

Vulnerable Group ◽

Enrollment Rate ◽

Enrollment Rates ◽

Rate Ratios ◽

The Impact

e19082 Background: Patients with advanced cancers are among the most vulnerable group of patients. We sought to analyze the impact of Affordable Care Act on the interaction of socioeconomic factors with treatment enrollement and survival in patients with metastatic colorectal cancers. Methods: We queried the National Cancer Database (NCDB) for patients with Stage-IV colon (C-Ca) and rectal cancers (R-Ca) diagnosed from 2004-2015 and excluded those who did not receive any therapies within 6 months of diagnosis. Enrollment rates were calculated as receipt of primary therapy as the incident-event (numerator) over time-to-initiation of therapy (denominator) and used to calculate incident-rate ratios that was further analyzed using Poisson regression analysis- reported as enrollment-rate ratios (ER, < 1 indicating lower enrollment rate). Multivariate Cox-proportional hazard model was performed for survival analysis and reported as calculate Hazard Ratios (HR). Results: We identified 59,211 C-Ca and 4,818 R-Ca for the analysis. Median ages were 64 years vs. 60 years and included 52% vs. 60% males respectively. For C-Ca enrollment to primary therapies were significantly associated (p-value < 0.05) with gender, race, insurance status, educational status and treatment facility. HR < 1 was associated with high-income vs. low-income group- 0.90(0.87-0.94),p-value < 0.005. The HR for non-Hispanic Blacks (NHB) vs. Whites (NHW) improved from 1.1(1.03-1.11),p-value < 0.005 to no-significant difference post-ACA. For R-Ca, the enrollment rates were favorable for NHB vs. NHW and ER improved from 1.15(1.0-1.32),p-value = 0.054) to 1.29(1.06-1.58),p-value = 0.013 post-ACA. Despite this, the HR for mortality were unfavorable - 1.19(1.06-1.33),p-value = 0.003 that persisted through the post-ACA period. The HR was favorable for the insured group in both cancer groups (0.84 for R-Ca,0.86 for C-Ca). Conclusions: Socioeconomic factors influence outcomes for this vulnerable group of patients in terms of enrollment to therapies and survival. The Affordable Care Act appears to have had a positive impact overall but more needs to be done including broadening insurance coverage.

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The impact of colorectal cancer screening on incidence and stage IV disease in the Netherlands.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.3531 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 3531-3531

Author(s):

Myrtle F Krul ◽

Marloes AG Elferink ◽

Niels FM Kok ◽

Evelien Dekker ◽

Iris Lansdorp-Vogelaar ◽

...

Keyword(s):

Colorectal Cancer ◽

The Netherlands ◽

Local Treatment ◽

Stage Iv ◽

Stage I ◽

Crc Screening ◽

Stage Distribution ◽

Incidence And Mortality ◽

Stage Iv Disease ◽

The Impact

3531 Background: Population-based screening for colorectal cancer (CRC) aims to decrease incidence and mortality due to precancerous polyp removal, early detection and early treatment of CRC. In the Netherlands, phased introduction of a biennial fecal immunochemical hemoglobin test started in 2014 for individuals aged 55-75. This evaluation of the national data focuses on the initial effect of CRC screening on incidence and stage distribution and the impact on stage IV disease. Methods: All CRC patients diagnosed in the Netherlands between 2009 and 2018 were selected from the Netherlands Cancer Registry (NCR). Patients were linked to the Dutch national pathology registry (PALGA) to identify screen-detected tumors. Results: The NCR identified 137,717 CRC patients between 2009 and 2018. The incidence within screening age (55-75 yr) of all CRC stages showed an initial peak after introduction of screening in 2014, followed by a continuous decrease for all stages. CRC incidence outside the screening age did not show these explicit changes between 2009 and 2018. In 2018, the incidence of stage IV CRC within screening age was lower than the level at the start of the screening program. Stage distribution within screening age shifted towards earlier stages in the screening period (2014-2018) compared to the period before screening (2009-2012) (stage I: 31% vs. 18%, stage II: 22% vs. 26%, stage III: 29% vs. 31%, Stage IV: 18% vs. 25%, respectively). In the period 2014-2018 and within screening age, the ratio of screen-detected and symptom-detected tumors was highest in stage I (47%:53%) and lowest in stage IV (9%:91%). Screen-detected compared to symptom-detected stage IV patients diagnosed in the period 2014-2018 and within screening age had more frequently single organ metastases (74.5% vs 57.4%, p < 0.001), higher resection rate of the primary tumor (57.5% vs. 41.3%; p < 0.001) and higher local treatment rate of metastases (40.0% vs. 23.4% p < 0.001). The median overall survival of screen-detected stage IV patients was significantly longer than that of symptom-detected stage IV patients (31.0 months (95% CI: 27.7 – 34.3) vs. 15.0 months (95% CI: 14.5 – 15.5), p < 0.001). Conclusions: The initial results of the introduction of CRC screening in the Netherlands showed a favorable trend on CRC incidence and stage distribution. Screen-detected patients with stage IV disease had less extensive disease, resulting in better treatment options and improved survival.

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Race/Ethnicity, Gender, Weight Status, and Colorectal Cancer Screening

Journal of Obesity ◽

10.1155/2011/314619 ◽

2011 ◽

Vol 2011 ◽

pp. 1-6 ◽

Cited By ~ 2

Author(s):

Heather Bittner Fagan ◽

Ronald E. Myers ◽

Constantine Daskalakis ◽

Randa Sifri ◽

Arch G. Mainous ◽

...

Keyword(s):

Colorectal Cancer ◽

Weight Status ◽

Normal Weight ◽

Crc Screening ◽

Interview Survey ◽

Multivariable Analyses ◽

Race Ethnicity ◽

And Gender ◽

Ethnicity And Gender ◽

The Impact

Background. The literature on colorectal cancer (CRC) screening is contradictory regarding the impact of weight status on CRC screening. This study was intended to determine if CRC screening rates among 2005 National Health Interview Survey (NHIS) respondent racial/ethnic and gender subgroups were influenced by weight status.Methods. Univariable and multivariable logistic regression analyses were performed to determine if CRC screening use differed significantly among obese, overweight, and normal-weight individuals in race/ethnic and gender subgroups.Results. Multivariable analyses showed that CRC screening rates did not differ significantly for individuals within these subgroups who were obese or overweight as compared to their normal-weight peers.Conclusion. Weight status does not contribute to disparities in CRC screening in race/ethnicity and gender subgroups.

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Nutritional Immunity, Zinc Sufficiency, and COVID-19 Mortality in Socially Similar European Populations

Frontiers in Immunology ◽

10.3389/fimmu.2021.699389 ◽

2021 ◽

Vol 12 ◽

Author(s):

Samer Singh ◽

Amita Diwaker ◽

Brijesh P. Singh ◽

Rakesh K. Singh

Keyword(s):

Standard Of Care ◽

Protective Role ◽

Vulnerable Groups ◽

P Value ◽

Negative Effects ◽

Nutritional Immunity ◽

Incidence And Mortality ◽

Standard Of Care Treatment ◽

The Impact ◽

European Populations

The impact of zinc (Zn) sufficiency/supplementation on COVID-19-associated mortality and incidence (SARS-CoV-2 infections) remains unknown. During an infection, the levels of free Zn are reduced as part of “nutritional immunity” to limit the growth and replication of pathogen and the ensuing inflammatory damage. Considering its key role in immune competency and frequently recorded deficiency in large sections of different populations, Zn has been prescribed for both prophylactic and therapeutic purposes in COVID-19 without any corroborating evidence for its protective role. Multiple trials are underway evaluating the effect of Zn supplementation on COVID-19 outcome in patients getting standard of care treatment. However, the trial designs presumably lack the power to identify negative effects of Zn supplementation, especially in the vulnerable groups of elderly and patients with comorbidities (contributing 9 out of 10 deaths; up to >8,000-fold higher mortality). In this study, we have analyzed COVID-19 mortality and incidence (case) data from 23 socially similar European populations with comparable confounders (population: 522.47 million; experiencing up to >150-fold difference in death rates) and at the matching stage of the pandemic (March 12 to June 26, 2020; first wave of COVID-19 incidence and mortality). Our results suggest a positive correlation between populations’ Zn-sufficiency status and COVID-19 mortality [r (23): 0.7893–0.6849, p-value < 0.0003] as well as incidence [r (23):0.8084–0.5658; p-value < 0.005]. The observed association is contrary to what would be expected if Zn sufficiency was protective in COVID-19. Thus, controlled trials or retrospective analyses of the adverse event patients’ data should be undertaken to correctly guide the practice of Zn supplementation in COVID-19.

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Estimating the impact of differential adherence on the comparative effectiveness of stool-based colorectal cancer screening using the CRC-AIM microsimulation model

PLoS ONE ◽

10.1371/journal.pone.0244431 ◽

2020 ◽

Vol 15 (12) ◽

pp. e0244431

Author(s):

Andrew Piscitello ◽

Leila Saoud ◽

A. Mark Fendrick ◽

Bijan J. Borah ◽

Kristen Hassmiller Lich ◽

...

Keyword(s):

Colorectal Cancer ◽

Real World ◽

Base Case ◽

Fecal Occult Blood ◽

Microsimulation Model ◽

Crc Screening ◽

Life Years ◽

Incidence And Mortality ◽

Screening Strategies ◽

The Impact

Background Real-world adherence to colorectal cancer (CRC) screening strategies is imperfect. The CRC-AIM microsimulation model was used to estimate the impact of imperfect adherence on the relative benefits and burdens of guideline-endorsed, stool-based screening strategies. Methods Predicted outcomes of multi-target stool DNA (mt-sDNA), fecal immunochemical tests (FIT), and high-sensitivity guaiac-based fecal occult blood tests (HSgFOBT) were simulated for 40-year-olds free of diagnosed CRC. For robustness, imperfect adherence was incorporated in multiple ways and with extensive sensitivity analysis. Analysis 1 assumed adherence from 0%-100%, in 10% increments. Analysis 2 longitudinally applied real-world first-round differential adherence rates (base-case imperfect rates = 40% annual FIT vs 34% annual HSgFOBT vs 70% triennial mt-sDNA). Analysis 3 randomly assigned individuals to receive 1, 5, or 9 lifetime (9 = 100% adherence) mt-sDNA tests and 1, 5, or 9 to 26 (26 = 100% adherence) FIT tests. Outcomes are reported per 1000 individuals compared with no screening. Results Each screening strategy decreased CRC incidence and mortality versus no screening. In individuals screened between ages 50–75 and adherence ranging from 10%a-100%, the life-years gained (LYG) for triennial mt-sDNA ranged from 133.1–300.0, for annual FIT from 96.3–318.1, and for annual HSgFOBT from 99.8–320.6. At base-case imperfect adherence rates, mt-sDNA resulted in 19.1% more LYG versus FIT, 25.4% more LYG versus HSgFOBT, and generally had preferable efficiency ratios while offering the most LYG. Completion of at least 21 FIT tests is needed to reach approximately the same LYG achieved with 9 mt-sDNA tests. Conclusions Adherence assumptions affect the conclusions of CRC screening microsimulations that are used to inform CRC screening guidelines. LYG from FIT and HSgFOBT are more sensitive to changes in adherence assumptions than mt-sDNA because they require more tests be completed for equivalent benefit. At imperfect adherence rates, mt-sDNA provides more LYG than FIT or HSgFOBT at an acceptable tradeoff in screening burden.

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Investigation of an ethnic predisposition to developing brain metastases (BM) in Asian patients with colorectal cancer (CRC).

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.e15023 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. e15023-e15023

Author(s):

Kerri McGovern ◽

Teresa Rodriguez ◽

Melissa H Smith ◽

Antonia Maloney ◽

Wasif M. Saif

Keyword(s):

Overall Survival ◽

Molecular Markers ◽

Ethnic Disparities ◽

The United States ◽

Treatment Modalities ◽

Increased Risk ◽

Incidence And Mortality ◽

Race Ethnicity ◽

The Impact ◽

Hispanic White

e15023 Background: CRC, the third most common cancer in the United States, carries racial/ethnic disparities in both incidence and mortality. With availability of effective systemic therapies, the life of CRC patients can be prolonged which thereby increases the risk of metastases at uncommon sites, such as the brain. We report our investigation into the impact of race/ethnicity on the incidence of BM in CRC patients using retrospective data (2010 – 2018) at a single institution. Methods: We retrospectively reviewed patients diagnosed with CRC and collected data on age, race/ethnicity, stage, treatment modalities, metastatic sites, and survival. Race and ethnicity were defined in accordance with federal standards set by the U.S. Census. Following this, race/ethnicity was self-declared and/or based on the primary language declared and categorized as non-Hispanic White, Hispanic White, non–Hispanic Black, Asian, or Unknown/Other. CRC location was classified as right-sided, left-sided or rectal. Results: We identified 264 CRC patients (median age: 61; range: 38 - 99). Among them 123 identified as non-Hispanic white, 28 non-Hispanic black, 26 Hispanic white, and 9 declared Other. There were 76 (29%) who identified as Asian. Of those 76 patients, 5 (7%) developed BM. All 5 patients were male and stage IV at initial diagnosis. BM was a late stage phenomenon with rectal primary and lung metastases seemly associated with an increased risk in the specific cohort. Molecular markers such as KRAS were available in 3 patients without clear association. Median time to development of BM was 29 months (range: 26 - 33). Median overall survival after BM diagnosis was 5.5 months (range: 4 - 11). Overall survival was longest for the patient who had both radiation and surgery. Conclusions: Our study showed an incidence of BM of 7% in the Asian sub-population compared to the historical control of 0.6 – 3.2% in the overall population. These results at the least warrant further investigation in a larger patient population of BM in CRC patients with emphasis on molecular markers. Recognition of BM in CRC patients is clinically relevant secondary to multiple lines of therapy as mentioned earlier and its grave impact on outcome.

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Adverse Pregnancy Outcomes in Women with Sickle Cell Trait

American Journal of Perinatology Reports ◽

10.1055/s-0039-1695743 ◽

2019 ◽

Vol 09 (04) ◽

pp. e346-e352

Author(s):

Whitney L. Wellenstein ◽

Shannon Sullivan ◽

Jeanne Darbinian ◽

Miranda L. Ritterman Weintraub ◽

Mara Greenberg

Keyword(s):

Sickle Cell ◽

Pregnancy Outcomes ◽

Sickle Cell Trait ◽

Adverse Pregnancy Outcomes ◽

P Value ◽

Kaiser Permanente ◽

Multivariable Analyses ◽

Race Ethnicity ◽

Adverse Pregnancy ◽

Racial Ethnic

Objective To compare adverse pregnancy outcomes between women with sickle cell trait (SCT) and women with normal hemoglobin. Study Design A retrospective cohort study of women who delivered within Kaiser Permanente Northern California between 2006 and 2013. Using hemoglobin electrophoretic profiles, we defined women with hemoglobin AS (HbAS) as having SCT and those with hemoglobin AA (HbAA) as having normal hemoglobin. Outcomes were pregnancy-induced hypertension (PIH), small for gestational age (SGA), gestational diabetes (GDM), and preterm delivery (PTD). Demographic and pregnancy outcome variations were assessed in bivariate analyses. Multivariable logistic regression modeling was used to estimate odds ratios for the association between primary outcomes and selected characteristics. Results Of 31,840 eligible women, 868 (2.7%) had SCT. Women with SCT were more likely to have PIH (15.6% vs. 12.2%, p value = 0.003) and SGA (8.3% vs. 6.1%, p value = 0.008), less likely to have GDM (6.8% vs. 9.8%, p value = 0.003) and had similar PTD prevalence (8.1% vs. 7.6%, p value = 0.600). In multivariable analyses, SCT was not an independent predictor of these outcomes. Racial/ethnic minorities had higher adjusted odds of PIH, SGA, and GDM. Conclusion SCT alone does not appear to be associated with adverse pregnancy outcomes. Race/ethnicity is a risk factor for adverse pregnancy outcomes.

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Quantifying the impact of adherence to screening on colorectal cancer incidence and mortality

European Journal of Public Health ◽

10.1093/eurpub/ckz185.054 ◽

2019 ◽

Vol 29 (Supplement_4) ◽

Author(s):

E D’Andrea ◽

D J Ahnen ◽

D A Sussman ◽

M Najafzadeh

Keyword(s):

Colorectal Cancer ◽

Cancer Incidence ◽

Fecal Occult Blood ◽

Substantial Impact ◽

Dna Test ◽

Crc Screening ◽

Life Years ◽

Incidence And Mortality ◽

Screening Strategies ◽

The Impact

Abstract Background Current recommendations of The US Preventive Services Task Force (USPSTF) on colorectal cancer (CRC) screening strategies are based on models that assume 100% adherence to screening. Since adherence can largely affect the outcomes of a screening modality, we aimed to assess the comparative effectiveness of CRC screening strategies under published rates of actual adherence. Methods We developed an individual-level simulation model and validated it against landmark trials and USPSTF models. Then we assessed the effectiveness of colonoscopy (COL), flexible sigmoidoscopy (FS), high-sensitivity guaiac fecal occult blood test (HS-gFOBT), fecal immunochemical test (FIT), multitarget stool DNA test (FIT-DNA), computed tomography colonography (CTC), and methylated SEPT9 DNA test (SEPT9) in reducing CRC incidence and mortality. For each strategy, we also estimated the incremental life-years gained, number of colonoscopies, and adverse events. Results Assuming 100% adherence, FIT-DNA, FIT, HS-gFOBT, and SEPT9 averted 58 to 59 CRC cases and 28 CRC deaths; COL and CTC strategies 56 cases and 27 deaths, while FS averted 39 cases and 19 deaths per 1,000 individuals. Life-years gained were similar across FIT-DNA, FIT, HS-gFOBT, SEPT9, CTC, and COL strategies. The total number of colonoscopies was highest with COL (3,567), followed by SEPT9 (3,231), HS-gFOBT (2,584), FIT-DNA (2,079), FIT (2,067), CTC (1,691) and FS (1,538) strategies. Assuming actual adherence, SEPT9 averted 54 CRC cases and 26 CRC deaths, followed by COL with 49 cases and 24 deaths, and FIT-DNA, FIT, CTC and HS-gFOBT with approximately 36 to 41 cases and 18 to 21 deaths averted per 1000 individuals screened. Life-years gained reflected the effectiveness of each strategy in reducing CRC cases and deaths. Conclusions Adherence is a key factor in determining the effectiveness of CRC screening and strategies with higher expected adherence rates have the potential to reduce cancer incidence and mortality. Key messages Adherence has a substantial impact on screening outcomes, such as cancer incidence and mortality, and may influence selection of optimal screening strategies. Strategies with higher expected adherence rates can lead to clinically meaningful benefits compared to strategies that may have better one-time sensitivity and/or specificity.

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