A "sludge audit" for health system colorectal cancer screening services.

OBJECTIVES: "Sludge," or the frictions or administrative burdens that make it difficult for people to attain what they want or need, is an unexplored health care delivery factor that may contribute to deficiencies in colorectal cancer (CRC) screening. We piloted a method to identify and quantify sludge in a southeastern US health system's delivery of CRC screening services. STUDY DESIGN: Mixed methods sludge audit. METHODS: We collected and analyzed quantitative (insurance claims, electronic health record, and administrative files) and qualitative (stakeholder interviews and process observations) data associated with CRC screening for instances of sludge. Because they contribute to sludge and reduce system capacity for high-value screening, we also evaluated low-value CRC screening processes. RESULTS: Although specific results were likely amplified by effects of the COVID-19 pandemic, the sludge audit revealed important areas for improvement. A 60.4% screening rate was observed. Approximately half of screening orders were not completed. The following categories of sludge were identified: communication, time, technology, administrative tasks, paperwork, and low-value care. For example, wait times for screening colonoscopy were substantial, duplicate orders were common, and some results were not accessible in the electronic health record. Of completed screenings, 32% were low-value and 38% were associated with low-value preoperative testing. There was evidence of a differential negative impact of sludge to vulnerable patients. CONCLUSIONS: Our sludge audit method identified and quantified multiple instances of sludge in a health system's CRC screening processes. Sludge audits can help organizations to systematically evaluate and reduce sludge for more effective and equitable CRC screening.

The not-so-lazy days of summer: experimental interventions to increase college entry among low-income high school graduates.

Despite decades of policy intervention to increase college entry among low-income students, substantial inequalities in college going by family income remain. Policy makers have largely overlooked the summer after high school as an important time period in students' transition to college. During the post-high school summer, however, students must complete a range of financial and informational tasks prior to college enrollment, yet no longer have access to high school counselors and have not engaged yet with their college community. Moreover, many come from families with little college-going experience. Recent research documents summer attrition rates ranging from 10 to 40 percent among students who had been accepted to college and declared an intention to enroll in college as of high school graduation. Encouragingly, several experimental interventions demonstrate that students' postsecondary plans are quite responsive to additional outreach during the summer months. Questions nonetheless remain about how to maximize the impact and cost effectiveness of summer support. This chapter reports on several randomized trials to investigate the impact of summer counselor outreach and support as well as the potential roles for technology and peer mentoring in mitigating summer attrition and helping students enroll and succeed in college. The authors conclude with implications for policy and practice.