Comparative effectiveness of audit-feedback versus additional physician communication training to improve cancer screening for patients with limited health literacy

BACKGROUND

We designed a continuing medical education (CME) program to teach primary care physicians (PCP) how to engage in cancer risk communication and shared decision making with patients who have limited health literacy (HL).

OBJECTIVE

We evaluated whether training PCPs, in addition to audit-feedback, improves their communication behaviors and increases cancer screening among patients with limited HL to a greater extent than only providing clinical performance feedback.

DESIGN

Four-year cluster randomized controlled trial.

PARTICIPANTS

Eighteen PCPs and 168 patients with limited HL who were overdue for colorectal/breast/cervical cancer screening.

INTERVENTIONS

Communication intervention PCPs received skills training that included standardized patient (SP) feedback on counseling behaviors. All PCPs underwent chart audits of patients' screening status semiannually up to 24 months and received two annual performance feedback reports.

MAIN MEASURES

PCPs experienced three unannounced SP encounters during which SPs rated PCP communication behaviors. We examined between-group differences in changes in SP ratings and patient knowledge of cancer screening guidelines over 12 months; and changes in patient cancer screening rates over 24 months.

KEY RESULTS

There were no group differences in SP ratings of physician communication at baseline. At follow-up, communication intervention PCPs were rated higher in general communication about cancer risks and shared decision making related to colorectal cancer screening compared to PCPs who only received performance feedback. Screening rates increased among patients of PCPs in both groups; however, there were no between-group differences in screening rates except for mammography. The communication intervention did not improve patient cancer screening knowledge.

CONCLUSION

Compared to audit and feedback alone, including PCP communication training increases PCP patient-centered counseling behaviors, but not cancer screening among patients with limited HL. Larger studies must be conducted to determine whether lack of changes in cancer screening were due to clinic/patient sample size versus ineffectiveness of communication training to change outcomes.

Assessing needs and assets for building a regional network infrastructure to reduce cancer related health disparities

Significant cancer health disparities exist in the United States and Puerto Rico. While numerous initiatives have been implemented to reduce cancer disparities, regional coordination of these efforts between institutions is often limited. To address cancer health disparities nation-wide, a series of regional transdisciplinary networks through the Geographic Management Program (GMaP) and the Minority Biospecimen/Biobanking Geographic Management Program (BMaP) were established in six regions across the country. This paper describes the development of the Region 3 GMaP/BMaP network composed of over 100 investigators from nine institutions in five Southeastern states and Puerto Rico to develop a state-of-the-art network for cancer health disparities research and training. We describe a series of partnership activities that led to the formation of the infrastructure for this network, recount the participatory processes utilized to develop and implement a needs and assets assessment and implementation plan, and describe our approach to data collection. Completion, by all nine institutions, of the needs and assets assessment resulted in several beneficial outcomes for Region 3 GMaP/BMaP. This network entails ongoing commitment from the institutions and institutional leaders, continuous participatory and engagement activities, and effective coordination and communication centered on team science goals.

Abstract A11: Health information needs and predictors of cancer screening status among patients with limited health literacy

Background: Primary care physician (PCP) recommendation for cancer screening is a strong predictor of adherence to screening; however, patients with limited health literacy (HL) may have difficulty understanding information about screening. We implemented a continuing medical education program to train PCPs in cancer risk communication with limited HL patients. Our main study objective is to determine whether changes in PCP communication improve patients’ adherence to cancer screening. We examined baseline patient characteristics to assess whether patients’ cancer screening information needs vary across levels of limited HL and determine which factors may influence adherence to different types of cancer screening tests.

Methods: This study is part of a 4-year randomized controlled trial of a communication skills training program targeting PCPs (11 intervention vs. 8 control) who practice in safety-net clinics in New Orleans, LA and their patients with limited HL (Rapid Estimate of Adult Literacy in Medicine [REALM] score < 60). For each PCP, we recruited 10 patients (men [age 50–75]; women [age 40–75]) who were overdue for at least one cancer screening test (mammography; pap smears; FOBT/ endoscopy/barium enema). We conducted baseline interviews to obtain socio-demographics, cancer knowledge, cancer screening status and ratings of physician communication style (Perceived Involvement in Care Scale). We conducted baseline chart reviews to confirm cancer screening status.

Results: Of 871 clinic patients screened to date, 164 met eligibility criteria (target sample size: 180). The most common reasons for exclusion were HL too high (37%), up-to-date on cancer screening (20%), or new patients to the PCP (12%). Most eligible patients are African American (90%), female (77%), insured (61%) and read at the 7th-8th grade level (67%). Only 35% of the study sample was up-to-date by chart review on mammography, 34% on pap smears, and 29% on colorectal cancer screening. Patient ratings of the level of information exchange with their PCPs varied by level of HL with patients with < 3rd grade reading level rating their PCPs significantly lower (mean [SD]: 2.9 [1.4]) than patients with higher reading levels (7th-8th grade: 3.4 [1.0]; 5th-6th grade: 3.7 [0.6]). Overall, less than 1/3 of patients knew the age at which to start breast/cervical/CRC screening. Knowledge about the cancer screened for by mammography and the tests available for CRC screening varied significantly by level of HL (7th-8th grade vs. 5th-6th grade vs. <3rd grade: Breast, 83% vs. 69% vs. 41%; CRC, 51% vs. 32% vs. 12%). Only 10% of patients knew that pap smears screen for cervical cancer. There was no significant difference in cancer screening status by level of HL, cancer screening knowledge or perceptions of involvement in care. For mammography, the odds of being up-to-date increased with having insurance (OR, 95% CI: 3.2 [1.4–7.5]) and emotional/informational support (1.6 [1.2-2.2]) whereas receiving care in a community health center reduced the odds (0.42 [0.2-0.9]). For CRC screening, family history of CRC increased the odds of being up-to-date (5.7 [1.3-23.8]) whereas emotional/informational support reduced the odds (0.63 [0.5-0.9]). There were no significant factors that influenced cervical cancer screening status.

Although patients’ perceptions of health information exchange and cancer screening knowledge may depend on their level of health literacy, psychosocial, familial and health system related factors may ultimately influence adherence to cancer screening. Message framing for cancer risk communication should take these factors into consideration.

Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A11.

Cancer risk communication with low health literacy patients: a continuing medical education program

BACKGROUND

Low health literacy (HL) is an important risk factor for cancer health disparities.

OBJECTIVE

Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.

DESIGN

Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.

PARTICIPANTS

Eighteen PCPs and 73 low HL patients overdue for cancer screening.

INTERVENTION

Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.

MAIN MEASURES

Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.

RESULTS

Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as "very good". SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as "satisfactory". Clinic patients rated their doctor's facilitation of involvement in care and information exchange as "good". However, they rated their participation in decision-making as "poor".

DISCUSSION

The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.