Barriers of and facilitators to physician recommendation of colorectal cancer screening

Oncologist-Reported Barriers and Facilitators to Offering Cancer Clinical Trials to Their Patients

NCCN guidelines indicate that cancer clinical trials (CCTs) are the best management for patients with cancer. However, only 5% of patients enroll in them. We examined oncologists' perceived barriers and facilitators to discussing CCTs. This qualitative study was part of the ASCO-ACCC Initiative to Increase Racial and Ethnic Diversity in Clinical Trials. Barriers and facilitators at the system, trial, provider, and patient levels were examined. To achieve triangulation, patient encounters were reviewed using chart-stimulated recall (CSR) methods, thereby obtaining a valid assessment of physician performance. Ten oncology providers participated in this study. Nine were oncologists, and one was a clinical research coordinator; five were female; four were White; three were Asian; and three were Black. Barriers to offering CCTs were a lack of trial availability; ineligibility; a lack of knowledge; assumptions about patient interest, benefits, or harms; patient's disease factors; and negative attitudes. Facilitators of offering CCTs were a physical space to discuss trials; greater trial availability; a systematic approach to offering trials; patient factors; patients seeking trials; a lack of comorbidities; patients being younger in age; patients being aware of, asking about, or hearing of trials from their surgeon; and higher levels of altruism. Many of the cited barriers are addressable with the cited facilitators. A larger study is needed to generalize and validate these findings.

The Framing Effect of Digital Textual Messages on Uptake Rates of Medical Checkups: Field Study

BACKGROUND

Health care authorities often use text messages to enhance compliance with medical recommendations. The effectiveness of different message framings has been studied extensively over the past 3 decades. Recently, health care providers have begun using digital media platforms to disseminate health-related messages.

OBJECTIVE

This study aimed to examine the effectiveness of some of the most widely used message framings on the uptake rates of medical checkups.

METHODS

This study used a large-scale digital outreach campaign conducted by Maccabi Healthcare Services (MHS) during 2020-2021, involving a total of 113,048 participants. MHS members aged 50-74 years were invited to take their recommended medical actions from the following list: human papillomavirus (HPV), mammography, abdominal aortic aneurysm, fecal occult blood test (FOBT), and pneumococcal vaccination. Each member was randomly assigned to receive 1 of 6 message framings: control (neutrally framed; n=20,959, 18.5%), gains (benefits of compliance; n=20,393, 18%), losses (negative consequences of noncompliance; n=15,165, 13.4%), recommendation (a recommendation by an authoritative figure, in this context by a physician; n=20,584, 18.2%), implementation intentions (linking potential outcomes to future reactions; n=20,701, 18.3%), and empowerment (emphasizing personal responsibility for maintaining good health; n=15,246, 13.5%). The time frames for measuring a successful intervention were 14 days for scheduling screenings (ie, HPV, mammography, or abdominal aortic aneurysm), 30 days for performing the FOBT, and 60 days for receiving pneumococcal vaccination. We also examined the effectiveness of media channels (text message or email) on uptake rates and whether the subject-line length is correlated with message-opening rates.

RESULTS

No significant effect of message framing on uptake rates of medical checkups was observed. The rates of appointments for screening ranged from 12.9% to 14.1% across treatments. Based on a chi-square test, there was no evidence to reject the null hypothesis that these compliance rates are independent of the treatments (P=.35). The uptake rates for the FOBT and pneumococcal vaccination ranged from 23.3% to 23.8% across treatments, and we could not reject the hypothesis that they are independent of the treatments (P=.88). We also found that emails are more effective than text messages (P<.001) and that the subject-line length is negatively correlated with message-opening rates.

CONCLUSIONS

No evidence was found for an effect of the 5 message framings on uptake rates of medical checkups. To enhance compliance rates, public health officials may consider alternative framings. Furthermore, media channels and the subject-line length should be given careful consideration in the planning stages of health care campaigns.

TRIAL REGISTRATION

AEA RCT Registry AEARCTR-0006317; https://www.socialscienceregistry.org/trials/6317/history/201365.

The Development and Use of a New Visual Tool (REVISIT) to Support Participant Recall: Web-Based Interview Study Among Older Adults

BACKGROUND

Qualitative health services research often relies on semistructured or in-depth interviews to develop a deeper understanding of patient experiences, motivations, and perspectives. The quality of data gathered is contingent upon a patient's recall capacity; yet, studies have shown that recall of medical information is low. Threats to generating rich and detailed interview data may be more prevalent when interviewing older adults.

OBJECTIVE

We developed and studied the feasibility of using a tool, Remembering Healthcare Encounters Visually and Interactively (REVISIT), which has been created to aid the recall of a specific telemedicine encounter to provide health services research teams with a visual tool, to improve qualitative interviews with older adults.

METHODS

The REVISIT visual appointment summary was developed to facilitate web-based interviews with our participants as part of an evaluation of a geriatric telemedicine program. Our primary aims were to aid participant recall, maintain focus on the index visit, and establish a shared understanding of the visit between participants and interviewers. The authors' experiences and observations developing REVISIT and using it during videoconference interviews (N=16) were systematically documented and synthesized. We discuss these experiences with REVISIT and suggest considerations for broader implementation and future research to expand upon this preliminary work.

RESULTS

REVISIT enhanced the interview process by providing a focus and catalyst for discussion and supporting rapport-building with participants. REVISIT appeared to support older patients' and caregivers' recollection of a clinical visit, helping them to share additional details about their experience. REVISIT was difficult to read for some participants, however, and could not be used for phone interviews.

CONCLUSIONS

REVISIT is a promising tool to enhance the quality of data collected during interviews with older, rural adults and caregivers about a health care encounter. This novel tool may aid recall of health care experiences for those groups for whom it may be more challenging to collect accurate, rich qualitative data (eg, those with cognitive impairment or complex medical care), allowing health services research to include more diverse patient experiences.

A Qualitative Study of Barriers and Facilitators to Integrating Medications for Opioid Use Disorder and HIV Preexposure Prophylaxis for Adolescents and Young Adults

BACKGROUND

The syndemic of substance use and human immunodeficiency virus (HIV) is a well-recognized global phenomenon that threatens to undermine the priorities outlined by the National Institutes of Health "Ending the HIV Epidemic" initiative. There are few published studies on preexposure prophylaxis (PrEP) for adolescents and young adults (AYAs) with opioid use disorder (OUD) despite increasing availability of biomedical prevention options and Centers for Disease Control and Prevention recommendations to offer PrEP to this group.

METHODS

Healthcare providers who previously prescribed medications for OUD (MOUDs) and/or PrEP for AYA were purposively sampled. Audio-recorded in-depth individual interviews were conducted using chart-stimulated recall to explore barriers and facilitators to integrated MOUD and HIV prevention services. Interviews were double-coded, and qualitative analysis was performed using a modified grounded theory.

RESULTS

Of 19 providers sampled, most were physicians (63%). All recommended HIV screening at varying intervals; however, few counseled on (19%) or prescribed (11%) PrEP to patients on MOUD. Barriers to PrEP prescriptions included patient-level (ie, stigma surrounding PrEP use, adherence challenges, and competing social or mental healthcare needs), provider (perception of low risk, lack of training/experience), and system-level factors (including restricted visit types). Facilitators of PrEP prescriptions included patient-initiated requests, electronic health record system reminders, and the availability of consistent support staff (ie, navigators, certified recovery specialists).

CONCLUSIONS

Our study confirms that discussions about HIV prevention and PrEP prescriptions may be rare for AYA patients receiving MOUD. Further research is needed to develop interventions that increase the integration of PrEP delivery within the context of OUD care among this key AYA population.

Colorectal cancer screening completion by patients due or overdue for screening after reminders: a retrospective study

BACKGROUND

Patient and clinician reminders were implemented as part of an adherence improvement project at University of Florida (UF) Internal Medicine Clinics. We sought to assess colorectal cancer (CRC) screening completion rates among patients not up-to-date with screening following distribution of reminders and to identify characteristics correlated with screening outcomes.

METHODS

Retrospective chart review was performed for patients not up-to-date with CRC screening for whom at least one reminder (patient and/or clinician) was issued in June 2018. The primary endpoint, the completion of a CRC screening test, is characterized as the ratio of completed screening tests to the number of patients not up-to-date with screening. All analyses were performed using R 4.0 software.

RESULTS

Of the 926 patients included, 403 (44%; 95% CI, 0.40-0.47) completed a CRC screening test within 24 months following a reminder. Family history of CRC (relative risk (RR) 1.33; P = 0.007), flu immunization within two years of the reminder (RR 1.23; P = 0.019), and receiving a patient reminder either alone (RR 1.62; P < 0.001) or in combination with a clinician reminder (RR 1.55; P = 0.006) were positively associated with CRC screening completion. Reporting being divorced, separated, or widowed was negatively associated with screening completion (RR 0.70; P = 0.004).

CONCLUSION

Reminders, in particular patient reminders, seem to be an effective method to enhance screening among patients not up-to-date with CRC screening. This study suggests that reminder efforts should be focused at the level of the patients and provides insight on target populations for practical interventions to further increase CRC screening adherence.

Reducing disparities and achieving health equity in colorectal cancer screening

Increases in colorectal cancer screening are linked to the declining incidence of the disease over the past three decades. These favorable trends, however, are not observed in marginalized racial and ethnic populations with disproportionately lower rates of screening, higher disease incidence, and increased mortality despite advances in health technology and policy. This review describes the differences in screening uptake and test selection amongst racial and ethnic groups, discusses known obstacles and facilitators that impact screening, and highlights existing frameworks developed to achieve health equity in colorectal cancer screening.

The effect of physician density on colorectal cancer stage at diagnosis: causal inference methods for spatial data applied on regional-level data

BACKGROUND

The early detection of colorectal cancer (CRC) through regular screening decreases its incidence and mortality rates and improves survival rates. Norway has an extremely high percentage of CRC cases diagnosed at late stages, with large variations across municipalities and hospital catchment areas. This study examined whether the availability of physicians related to CRC primary diagnosis and preoperative investigations, or physician density, contributes to the observed geographical differences in late-stage incidence rates.

METHOD

Municipality-level data on CRC stage at diagnosis were obtained from the Cancer Registry of Norway for the period 2012-2020. Physician density was calculated as the number of physicians related to CRC investigations, general practitioners (GPs) and specialists per 10,000 people, using physician counts per municipality and hospital areas from Statistics Norway. The relationship was examined using a novel causal inference method for spatial data-neighbourhood adjustment method via spatial smoothing (NA approach)-which allowed for studying the region-level effect of physician supply on CRC outcome by using spatially referenced data and still providing causal relationships.

RESULTS

According to the NA approach, an increase in one general practitioner per 10,000 people will result in a 3.6% (CI -0.064 to -0.008) decrease in late-stage CRC rates. For specialists, there was no evidence of a significant correlation with late-stage CRC distribution, while for both groups, GPs and specialists combined, an increase of 1 physician per 10,000 people would be equal to an average decrease in late-stage incidence rates by 2.79% (CI -0.055 to -0.001).

CONCLUSION

The study confirmed previous findings that an increase in GP supply will significantly improve CRC outcomes. In contrast to previous research, this study identified the importance of accessibility to both groups of physicians-GPs and specialists. If GPs encounter insufficient workforces in hospitals and long delays in colonoscopy scheduling, they will less often recommend colonoscopy examinations to patients. This study also highlighted the efficiency of the novel methodology for spatially referenced data, which allowed us to study the effect of physician density on cancer outcomes within a causal inference framework.

Exploration of Malaysian Stakeholders View on Barriers to and Facilitators of Colorectal Cancer Screening Among Older Population

According to the Malaysian National Cancer Registry (MNCR), more than 70% of colorectal cancer (CRC) cases in Malaysia are presented in the advanced stages of the disease, leading to poor survival rates while taxing the health care system. This study aims to explore the barriers to and facilitators of CRC screening uptake in the perspectives of the general population, health care providers, and policymakers. In-depth, semi-structured interviews were conducted with 25 purposively sampled respondents comprising general population above the age of 40, health care providers, and policymakers. Commonly reported barriers to CRC screening included psychological, poor knowledge and awareness, lack of physicians' recommendation, and inadequate implementation of CRC-related campaigns at systemic level. Facilitating factors for CRC screening included family support and family history of CRC. A comprehensive understanding of barriers and facilitators is relevant for designing an effective intervention and policy to increase CRC screening rates in Malaysia.

Modifications in Primary Care Clinics to Continue Colorectal Cancer Screening Promotion During the COVID-19 Pandemic

COVID-19 caused significant declines in colorectal cancer (CRC) screening. Health systems and clinics, faced with a new rapidly spreading infectious disease, adapted to maintain patient safety and address the effects of the pandemic on healthcare delivery. This study aimed to understand how CDC-funded Colorectal Cancer Control Program recipients and their partner health systems and clinics may have modified evidence-based intervention (EBI) implementation to promote CRC screening during the COVID-19 pandemic; to identify barriers and facilitators to implementing modifications; and to extract lessons that can be applied to support CRC screening, chronic disease management, and clinic resilience in the face of future public health crises. Nine recipients were selected to reflect the diversity inherent among all CRCCP recipients. Recipient and clinic partner staff answered unique sets of pre-interview questions to inform tailoring of interview guides that were developed using constructs from the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) and Consolidated Framework for Implementation Research (CFIR). The study team then interviewed recipient, health system, and clinic partner staff incorporating pre-interview responses to focus each conversation. We employed a rapid qualitative analysis approach then conducted virtual focus groups with recipient representatives to validate emergent themes. Three modifications that emerged from thematic analysis include: (1) offering mailed fecal immunochemical test (FIT) kits for CRC screening with mail or drop off return; (2) increasing the use of patient education and engagement strategies; and (3) increasing the use of or improving automated patient messaging systems. With improved tracking and automated reminder systems, mailed FIT kits paired with tailored patient education and clear instructions for completing the test could help primary care clinics catch up on the backlog of missed screenings during COVID-19. Future research can assess the effectiveness and cost-effectiveness of offering mailed FIT kits on maintaining or improving CRC screening, especially among people who are medically underserved.

Lung Cancer Screening Knowledge, Attitudes, and Practice Patterns Among Primary and Pulmonary Care Clinicians

BACKGROUND

Lung cancer screening has the potential to identify lung cancer at an early stage when more treatment options exist. However, discussions with and referrals of screening-eligible patients remain unacceptably low. We need to better understand clinician knowledge, attitudes, and practice patterns to identify strategies to improve lung cancer screening uptake. Prior studies have focused on understanding these factors from physicians only. Nevertheless, many patients receive primary care from nurse practitioners and physician assistants where prevention and early detection conversations are most likely to occur. Therefore, we must engage the full range of clinicians treating screening-eligible patients.

OBJECTIVES

The aim of this study was to describe attitudes, beliefs and referral practice patterns, lung cancer screening knowledge, and concordance with lung cancer screening guidelines among nurse practitioners, physicians, and physician assistants in the United States.

METHODS

A descriptive, cross-sectional study was performed using survey methodology with clinical vignettes to examine clinician factors and concordance with U.S. Preventive Services Task Force lung cancer screening guidelines.

RESULTS

Participants scored low on attitudes toward shared decision-making, high on the importance of shared decision-making in lung cancer screening, and low on barriers to lung cancer screening referral. In addition, midrange scores on empathy toward patients with smoking history were noted. Lung cancer screening knowledge was low regardless of clinician specialty; the most endorsed response when presented with a hypothetical patient was to refer for lung cancer screening using a chest X-ray.

DISCUSSION

Findings demonstrate that most clinicians are nonconcordant with U.S. Preventive Services Task Force guidelines, erroneously believing a chest X-ray is appropriate for lung cancer screening. Clinicians must follow evidence-based practice guidelines, highlighting the need for targeted continuing education about lung cancer screening for clinicians who treat screening-eligible patients.

Examining colorectal cancer screening uptake and health provider recommendations among underserved middle aged and older African Americans

Background: The purpose of this study is to determine whether underserved middle-aged and older African Americans are receiving a colorectal cancer (CRC) screening test (sigmoidoscopy or colonoscopy) and if recommended by their provider. Additionally, we examined correlates of both provider recommendation and uptake of CRC screening. Methods: Seven hundred forty African American individuals, aged 55 and older, participated in this local community cross-sectional survey. We used a multivariate technique of logistic regression. Results: One out of three participants reported that they never received a sigmoidoscopy or colonoscopy for CRC screening. More than 31% indicted that their providers never suggested CRC testing. However, participants who indicated that their providers recommended sigmoidoscopy/colonoscopy were almost 49 times (odds ratio [OR]: 48.9, 95% confidence interval [CI]: 29.5-81.2) more likely to obtain it compared to their counterparts who were not advised to have these procedures. Our data suggest that African American men were significantly less likely than women to receive recommendations from their providers (OR: 0.70, 95% CI: 0.50-0.91). Furthermore, controlling for other variables, the following factors: 1) living arrangement (OR: 1.44, 95% CI: 1.02-2.04), 2) health maintenance organization (HMO) membership (OR: 1.84, 95% CI: 1.28-2.67), 3) number of providers (OR: 1.15, 95% CI: 1.01-1.32), 4) satisfaction with access to and quality of care (OR: 1.24, 95% CI: 1.03-1.51), 5) depressive symptoms (OR: 0.92, 95% CI: 0.86-0.98), and 6) gastrointestinal conditions (OR: 1.73, 95% CI: 1.16-2.58) were associated with obtaining a sigmoidoscopy or colonoscopy test. Conclusion: Our findings suggest that the absence of a provider recommendation is the primary barrier preventing underserved older African Americans from obtaining CRC screening. In addition, our data revealed significant association between obtaining CRC screening and some of the predisposing characteristics of participants, satisfaction with access to and quality of care, and physical and mental health. These findings are consistent with this notion that disparities in health care for African Americans can be traced back to four primary factors: patients, healthcare providers, the healthcare system, and society as a whole, and emphasize the need for establishing theory-driven, culturally-sensitive, and cost-effective CRC screening interventions that recognize and address the constraints to cancer screening experienced by this segment of population.

Examining the relationship between household wealth and colorectal cancer screening behaviors among U.S. men aged 45-75

Colorectal cancer (CRC) is the third leading cause of cancer-related death among men in the United States (U.S.), particularly among men aged 45 years and older. Early-detection screening remains a key method of decreasing CRC-related deaths, yet socioeconomic barriers exist to planning and completing CRC screening. While accumulating evidence shows income disparities in CRC screening prevalence, a dearth of research has investigated wealth disparities. This study aimed to determine whether household wealth was associated with CRC screening uptake and future screening intent. In February 2022, we sent an online survey to potential participants; U.S. men aged 45–75 years were eligible to participate. We examined four CRC screening behaviors as outcomes: ever completing a stool-based or exam-based screening test, current screening status, and future screening intent. Household net wealth, determined by self-reported household wealth and debt, was the primary predictor. We used logistic regression to estimate odds ratios (ORs) and their 95% confidence interval (CI). Of the study participants (N = 499), most self-identified as Non-Hispanic White, were aged 50–64 years, and had previously completed a CRC screening test. Results revealed that, among men aged 45–49 years, higher net wealth decreased the odds of ever completing a stool- or exam-based test (OR = 0.58, 95% CI: 0.33, 0.98; OR = 0.55, 95% CI: 0.31, 0.94, respectively). By contrast, among men aged 50–75 years, higher net wealth increased the odds of being current with CRC screening (OR = 1.40, 95% CI: 1.03, 1.92). Net wealth was unassociated with CRC screening intent. These findings suggest that household net wealth, rather than income, is an important socioeconomic factor to consider in relation to uptake of CRC early-detection screening. The financial and social cognitive mechanisms linking household wealth to CRC screening behaviors merit future research and intervention.

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Wealth was associated with U.S men's adherence to screening for colorectal cancer.

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Age modified the association between wealth and colorectal cancer screening uptake.

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Wealth reduced the odds of past colorectal screening completion for men 45–49 years.

Colorectal cancer and potential predictors of never screened for faecal occult blood test: a narrative review

Colorectal cancer (CRC) is a major public health threat. Therefore, CRC screening uptake has been a focus with the established precancerous lesion and the strong association of early detection with staging and survival of the disease. However, CRC screening is relatively low in many countries. This article briefly discussed the current situation of CRC, recommendations, and current uptake of CRC screening in various countries. Besides that, this article also highlights the potential factors that help to predict the CRC screening uptake worldwide. Identification of those factors could guide policymakers to develop an effective strategy to improve the CRC screening uptake and ultimately improve the health outcome of the population.

Understanding User Acceptance of Clinical Decision Support Systems to Promote Increased Cancer Screening Rates in a Primary Care Practice

OBJECTIVE

Clinical decision support systems (CDDSs) in the electronic medical record (EMR) have been implemented in primary care settings to identify patients due for cancer screening tests, while functioning as a real time reminder system. There is little known about primary care providers (PCPs) perspective or user acceptance of CDSS. The purpose of this study was to investigate primary care provider perceptions of utilizing CDSS alerts in the EMR to promote increased screening rates for breast cancer, cervical cancer, and colorectal cancer.

METHODS

An electronic survey was administered to PCPs in a Midwest Health Institution community internal medicine practice from September 25, 2019 through November 27, 2019.

RESULTS

Among 37 participants (9 NP/Pas and 28 MD/DOs), the NP/PA group was more likely to agree that alerts were helpful (50%; P-value = .0335) and the number of alerts (89%; P = .0227) in the EMR was appropriate. The NP/PA group also was more likely to find alerts straightforward to use (78%, P = .0239). Both groups agreed about feeling comfortable using the health maintenance alerts (MD/DO = 79%; NP/PA = 100%).

CONCLUSION

CDSSs can promote and facilitate ordering of cancer screening tests. The use of technology can promptly identify patients due for a test and act as a reminder to the PCP. PCPs identify these alerts to be a beneficial tool in the EMR when they do not interrupt workflow and provide value to patient care. More work is needed to identify factors that could optimize alerts to be even more helpful, particularly to MD/DO groups.

Overcoming constraints of the model minority stereotype to advance Asian American health

Asian Americans are the fastest growing U.S. immigrant group, projected to become the largest immigrant group by 2065, but the quantity of research on Asian Americans' health has not mirrored changing demographics. Asian Americans have been understudied for more than 25 years, with only 0.17% of National Institutes of Health (NIH) expenditures allocated to projects including Asian American, Native Hawaiian, and Pacific Islander populations (Ðoàn et al., 2019). This disproportionality may result in part from the model minority stereotype (MMS) being extended to health, perpetuating the ideas that Asian Americans are well-positioned with regard to health status and that associated research is not essential. Accordingly, the aims for this article are threefold: (a) bring attention to the inadequate representation of the Asian American population in health-related science, (b) question the MMS in health, and (c) outline potential pathways through which the MMS limits what is knowable on Asian American health issues and needs. We discuss the limited meaningfulness of nonrepresentative aggregated statistics purporting the model minority image and provide counterexamples. We also present a stereotype-constraints model with the MMS contributing to a bottleneck for Asian American health-related knowledge, accompanied by present-day circumstances (e.g., sparse data, few psychologists/behavioral medicine scientists focused on Asian American health). We conclude with initial recommendations for addressing MMS-associated constraints in psychology and more broadly. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Intention for Screening Colonoscopy among Previous Non-Participants: Results of a Representative Cross-Sectional Study in Germany

Early detection of colorectal cancer has the potential to reduce mortality at population level. Colonoscopy is the preferred modality for colon cancer screening and prevention, but attendance rates are low. To exploit colonoscopy's preventive potential, it is necessary to identify the factors influencing uptake, especially among previous non-participants. This analysis of cross-sectional data involved 936 non-participants in screening colonoscopy aged 55 years or older in Germany. Differences between non-participants with and without future participation intentions were investigated in terms of socio-demographic factors, health status, attitudes and beliefs, and medical counselling. Logistic regression models were fitted to estimate associations between intention to participate and selected factors. Intention to participate was lower among women than among men. For both genders, intention to participate was positively associated with younger age. For women, higher socioeconomic status and counselling were positively associated with intention to participate. Men showed a positive association with favouring joint decision-making. The results draw attention to starting points for improving acceptance of and participation in screening colonoscopy. This includes good medical counselling and successful physician-patient communication, for which the information and communication skills of both medical professions and the general public should be strengthened. Gender differences should be considered.

Breast Cancer Screening Practices in a Tertiary Care Center in the State of Qatar: A Cross-Sectional Survey

Introduction

Breast cancer is the most common cancer in females. In Qatar, mortality related to breast cancer came in third after lung cancer and leukemia. In this study, we aim to comprehensively evaluate the rate of internal medicine residents and faculty compliance with breast cancer screening in Hamad Medical Corporation (Doha, Qatar), as well as to identify barriers and facilitators that could potentially augment changes to enhance physician-led cancer screening.

Methods

A cross-sectional web-based survey was distributed among internal medicine physicians between December 2018 and March 2019 at a tertiary medical centre. It focused on the knowledge, attitude, and practice of physicians regarding breast cancer screening guidelines and explored potential barriers and proposed solutions. Chi-square and t-test statistics were used to draw conclusions where appropriate.

Results

A total of 158 physicians responded to the survey, with a response rate of 61%. 75.9% were postgraduate trainees. Around three-quarters of the physicians mentioned that they would recommend breast cancer screening for their age-appropriate average-risk patients. There was a statistically significant difference between the trainees, consultants, and specialists regarding the modality of choice, where the majority of the trainees opted mammogram every 2 or 3 years while 44.4% of the consultants indicated yearly self-breast exam (p<0.001). The percentage of survey participants who rarely to never offer breast cancer screening in the outpatient settings was 37.8%. Unclear pathway (40%) and lack of time in clinic/ward rounds (26.5%) were the major reported barriers for cancer screening.

Conclusion

In the current era of personalized medicine, physicians should be more oriented to local guidelines to provide optimal care to their patients. While the attitude towards breast cancer screening is positive, the overall compliance with the national recommendations is sub-optimal. Further initiatives and intervention programs are required to promote the breast cancer screening in Qatar.

Perspectives of family physicians towards access to lung cancer screening for individuals living with low income - a qualitative study

BACKGROUND

Individuals living with low income are less likely to participate in lung cancer screening (LCS) with low-dose computed tomography. Family physicians (FPs) are typically responsible for referring eligible patients to LCS; therefore, we sought to understand their perspectives on access to lung cancer screening for individuals living with low income in order to improve equity in access to LCS.

METHODS

A theory-informed thematic analysis was conducted using data collected from 11 semi-structured interviews with FPs recruited from three primary care sites in downtown Toronto. Data was coded using the Systems Model of Clinical Preventative Care as a framework and interpretation was guided by the synergies of oppression analytical lens.

RESULTS

Four overarching themes describe FP perspectives on access to LCS for individuals living with low income: the degree of social disadvantage that influences lung cancer risk and opportunities to access care; the clinical encounter, where there is often a mismatch between the complex health needs of low income individuals and structure of health care appointments; the need for equity-oriented health care, illustrated by the neglect of structural origins of health risk and the benefits of a trauma-informed approach; and finally, the multiprong strategies that will be needed in order to improve equity in health outcomes.

CONCLUSION

An equity-oriented and interdisciplinary team based approach to care will be needed in order to improve access to LCS, and attention must be given to the upstream determinants of lung cancer in order to reduce lung cancer risk.

Knowledge, Attitude and Practice of Physicians Regarding Screening of Colorectal Cancer in Qatar: A Cross-Sectional Survey

PURPOSE

The aim of this study was to evaluate the rate of internal medicine residents' and faculties' (specialists and consultants) compliance to colorectal cancer screening in Hamad Medical Corporation (Doha, Qatar) and to identify barriers as well as facilitators that will assist in drawing up changes that would enhance physician-related cancer screening.

METHODS

A cross-sectional web-based survey was distributed among internal medicine physicians at three component hospitals of Hamad Medical Corporation (HMC); focusing on knowledge and practice of colorectal cancer screening, its barriers and facilitators. Chi-square and t-test statistics were used to draw conclusions where appropriate.

RESULTS

The response rate for the survey was 91% and over 75% of the survey respondents were post-graduate trainees. The majority (90.6%) of the physicians (n=144) mentioned that they would recommend colorectal cancer screening for their asymptomatic patients, though trainees tend to choose the correct modality of screening compared to the consultants, 86.21% vs 40.74%. Only 43.4% of the survey participants always to usually recommend screening to their patients in their clinics while only 29.4% do so for their inpatients. Even though there was no statistically significant difference among the frequency of outpatient colorectal cancer screening among trainees, specialists or consultants (p=0.628), there was a clear increase in the reported referrals as the training years or the years of experience increases (p=0.049 for trainees and p=0.009 for faculty). Unclear pathway was reported as the main obstacle to outpatient cancer screening by 30.2% (n= 48) and 54% (n=87) pointed out that an easy and clear pathway for cancer screening would facilitate the same.

CONCLUSION

While the attitude towards colorectal cancer screening is positive, the actual practice of recommendation is sub-optimal. Further initiatives are required to facilitate awareness and compliance to colorectal cancer screening.

A Survey of Provider Attitudes, Beliefs, and Perceived Barriers Regarding a Centralized Direct-Mail Colorectal Cancer Screening Approach at Community Health Centers

Background: Colorectal cancer screening (CRC) rates are low, particularly among individuals with low socioeconomic status. Organized CRC screening programs have demonstrated success in increasing screening rates. Little is known about provider attitudes, beliefs, and practices related to CRC screening or how they are influenced by an organized CRC screening program. Methods: In 2014 and 2016, providers from 26 safety net clinics in Oregon and Northern California were invited to complete baseline and follow-up online surveys for the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) study. The provider survey link was sent electronically to primary care providers serving adult patients. Providers were sent reminders every 2 weeks via email to complete the survey, up to 3 reminders total. In this article, we describe learnings about provider attitudes, beliefs, and practices related to CRC screening after implementation of the STOP CRC program. Results: A total of 166 unique providers completed baseline and/or follow-up surveys, representing 228 responses. Main themes included (1) favorable shifts in attitude toward fecal immunochemical test (FIT) and direct-mail cancer screening programs, (2) changes in provider perception of key barriers, and (3) growing interest in centralized automated systems for identifying patients due for CRC screening and eligible for population-based outreach. Discussion: Providers are interested in improved information systems for identifying patients due for CRC screening and delivering population-based outreach (ie, to distribute FIT kits outside of the clinic visit) to help reduce health system- and patient-level barriers to screening. Trial Registration: National Clinical Trial (NCT) Identifier NCT01742065.

Outcomes associated with use of the Cancer Risk Intake System among primary care safety-net patients identified as needing colorectal cancer screening

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Guideline-based CRC screening is low among average- and elevated-risk individuals.

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Cancer Risk Intake System (CRIS) generates tailored CRC screening recommendations.

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44% of elevated- and 90% of average-risk patients received guideline-based orders.

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Only about half of elevated-risk group underwent guideline-concordant colonoscopy.

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Half of the average-risk group received guideline-concordant screening.

Despite demonstrated primary and secondary prevention benefits, screening for colorectal cancer (CRC) is sub-optimal. We implemented the Cancer Risk Intake System (CRIS) among a convenience sample of patients presenting for primary care in Dallas County safety-net clinics. CRIS, which assesses individuals’ CRC risks and generates guideline-based screening recommendations for them and their providers, had been found in a randomized trial to facilitate risk-based screening, compared to usual care. Here, of 924 patients ages ≥50 who used CRIS, 699 were identified as needing screening, with 39.2% needing colonoscopy rather than FIT. However, following use of CRIS and patients’ and providers’ receipt of guideline-concordant recommendations, 20.9% elevated-risk patients received no screening orders, only 44.1% received guideline-concordant colonoscopy orders, and less than half of these (48.4%) completed colonoscopy. Guideline-concordant screening orders were more common for average-risk patients (62.5% received orders for FIT and 26.6% for colonoscopy). However, like their elevated-risk counterparts who received screening orders, more than half of average-risk patients in each order group (52.3% for FIT and 52.8% for colonoscopy) did not complete screening. We found no correlates for receiving screening orders, but higher comorbidity scores were associated with less screening completion among the average-risk group. We had hoped CRIS would facilitate risk-based screening but, although orders for and receipt of colonoscopy were more common for elevated- than average-risk patients, they were still suboptimal in this clinical setting with a “FIT-first” strategy. A stronger intervention may be necessary to increase guideline-concordant recommendations and screening among patients 50 and older.

Integration of physical abuse clinical decision support at 2 general emergency departments

OBJECTIVE

The study sought to develop and evaluate an electronic health record-based child abuse clinical decision support system in 2 general emergency departments.

MATERIALS AND METHODS

A combination of a child abuse screen, natural language processing, physician orders, and discharge diagnoses were used to identify children <2 years of age with injuries suspicious for physical abuse. Providers received an alert and were referred to a physical abuse order set whenever a child triggered the system. Physician compliance with clinical guidelines was compared before and during the intervention.

RESULTS

A total of 242 children triggered the system, 86 during the preintervention and 156 during the intervention. The number of children identified with suspicious injuries increased 4-fold during the intervention (P < .001). Compliance was 70% (7 of 10) in the preintervention period vs 50% (22 of 44) in the intervention, a change that was not statistically different (P = .55). Fifty-two percent of providers said that receiving the alert changed their clinical decision making. There was no relationship between compliance and provider or patient demographics.

CONCLUSIONS

A multifaceted child abuse clinical decision support system resulted in a marked increase in the number of young children identified as having injuries suspicious for physical abuse in 2 general emergency departments. Compliance with published guidelines did not change; we hypothesize that this is related to the increased number of children identified with suspicious, but less serious injuries. These injuries were likely missed preintervention. Tracking compliance with guidelines over time will be important to assess whether compliance increases as physician comfort with evaluation of suspected physical abuse in young children improves.

Using Chart-Stimulated Recall to Identify Barriers and Facilitators to Routine HIV Testing Among Pediatric Primary Care Providers

PURPOSE

Adolescents account for one in five new HIV infections in the U.S. Yet, only 25% of sexually active adolescents report HIV testing, and testing rates have not improved over time. In this study, the primary aim was to identify barriers and facilitators to routine HIV testing in the pediatric primary care setting.

METHODS

Practices within a large pediatric network were stratified by higher and lower rates of HIV testing. Providers were purposively sampled across practices, and chart-stimulated recall was used to explore HIV testing knowledge and practices by having providers review actual adolescent well visit records. Interviews were audio-recorded and transcribed. Qualitative content analysis identified categories of barriers and facilitators to HIV testing among higher and lower performing sites.

RESULTS

Of participants (n = 31), 52% were from higher performing clinics, and 48% from lower performing clinics, and mean number of years in practice was 16.9 (standard deviation 10.8). Provider-identified barriers at lower-performing sites included lack of knowledge of testing guidelines, inadequate sexual risk assessment, concerns about damaging patient/caregiver relationships, and competing priorities, whereas both high- and low-performing cites reported concerns about confidentiality. Identified facilitators at higher performing sites included availability of on-site resources (Title X funding; laboratory).

CONCLUSIONS

Several distinct barriers and facilitators to routine HIV screening were identified at lower and higher performing sites. These findings can inform the development of multilevel interventions to improve HIV testing rates in pediatric primary care.

Development of an electronic medical record-based child physical abuse alert system

Objective

Physical abuse is a leading cause of pediatric morbidity and mortality. Physicians do not consistently screen for abuse, even in high-risk situations. Alerts in the electronic medical record may help improve screening rates, resulting in early identification and improved outcomes.

Methods

Triggers to identify children < 2 years old at risk for physical abuse were coded into the electronic medical record at a freestanding pediatric hospital with a level 1 trauma center. The system was run in "silent mode"; physicians were unaware of the system, but study personnel received data on children who triggered the alert system. Sensitivity, specificity, and negative and positive predictive values of the child abuse alert system for identifying physical abuse were calculated.

Results

Thirty age-specific triggers were embedded into the electronic medical record. From October 21, 2014, through April 6, 2015, the system was in silent mode. All 226 children who triggered the alert system were considered subjects. Mean (SD) age was 9.1 (6.5) months. All triggers were activated at least once. Sensitivity was 96.8% (95% CI, 92.4-100.0%), specificity was 98.5% (95% CI, 98.3.5-98.7), and positive and negative predictive values were 26.5% (95% CI, 21.2-32.8%) and 99.9% (95% CI, 99.9-100.0%), respectively, for identifying children < 2 years old with possible, probable, or definite physical abuse.

Discussion/Conclusion

Triggers embedded into the electronic medical record can identify young children with who need to be evaluated for physical abuse with high sensitivity and specificity.

Identification of barriers, facilitators and system-based implementation strategies to increase teleophthalmology use for diabetic eye screening in a rural US primary care clinic: a qualitative study

OBJECTIVE

Teleophthalmology for diabetic eye screening is an evidence-based intervention substantially underused in US multipayer primary care clinics, even when equipment and trained personnel are readily available. We sought to identify patient and primary care provider (PCP) barriers, facilitators, as well as strategies to increase teleophthalmology use.

DESIGN

We conducted standardised open-ended, individual interviews and analysed the transcripts using both inductive and directed content analysis to identify barriers and facilitators to teleophthalmology use. The Chronic Care Model was used as a framework for the development of the interview guide and for categorising implementation strategies to increase teleophthalmology use.

SETTING

A rural, US multipayer primary care clinic with an established teleophthalmology programme for diabetic eye screening.

PARTICIPANTS

We conducted interviews with 29 participants (20 patients with diabetes and 9 PCPs).

RESULTS

Major patient barriers to teleophthalmology use included being unfamiliar with teleophthalmology, misconceptions about diabetic eye screening and logistical challenges. Major patient facilitators included a recommendation from the patient's PCP and factors related to convenience. Major PCP barriers to referring patients for teleophthalmology included difficulty identifying when patients are due for diabetic eye screening and being unfamiliar with teleophthalmology. Major PCP facilitators included the ease of the referral process and the communication of screening results. Based on our results, we developed a model that maps where these key patient and PCP barriers occur in the teleophthalmology referral process. Patients and PCPs also identified implementation strategies to directly address barriers and facilitators to teleophthalmology use.

CONCLUSIONS

Patients and PCPs have limited familiarity with teleophthalmology for diabetic eye screening. PCPs were expected to initiate teleophthalmology referrals, but reported significant difficulty identifying when patients are due for diabetic eye screening. System-based implementation strategies primarily targeting PCP barriers in conjunction with improved patient and provider education may increase teleophthalmology use in rural, US multipayer primary care clinics.

A blueprint for cancer screening and early detection: Advancing screening's contribution to cancer control

From the mid-20th century, accumulating evidence has supported the introduction of screening for cancers of the cervix, breast, colon and rectum, prostate (via shared decisions), and lung. The opportunity to detect and treat precursor lesions and invasive disease at a more favorable stage has contributed substantially to reduced incidence, morbidity, and mortality. However, as new discoveries portend advancements in technology and risk-based screening, we fail to fulfill the greatest potential of the existing technology, in terms of both full access among the target population and the delivery of state-of-the art care at each crucial step in the cascade of events that characterize successful cancer screening. There also is insufficient commitment to invest in the development of new technologies, incentivize the development of new ideas, and rapidly evaluate promising new technology. In this report, the authors summarize the status of cancer screening and propose a blueprint for the nation to further advance the contribution of screening to cancer control.

The Chinese and Korean American immigrant experience: a mixed-methods examination of facilitators and barriers of colorectal cancer screening

OBJECTIVE

Among Asian Americans, colorectal cancer (CRC) is the second leading cause of cancer deaths. Despite strong evidence that screening can reduce CRC-related mortality, fewer Chinese and Koreans receive screening as compared to non-Hispanic whites and blacks. The objective of this study was to examine facilitators and barriers as well as strategies to promote CRC screening in this population.

DESIGN

This study employed a mixed-methods design. We conducted 17 key informant interviews and 12 focus groups in the Washington, D.C. metropolitan area. 120 Chinese and Korean focus group participants, aged 50 to 85, also provided quantitative data through self-administered surveys. All participants were asked to discuss facilitators and barriers of CRC screening, including in relation to culture.

RESULTS

Participants who had a regular physician and doctor's recommendation for CRC screening were more likely to ever receive a colonoscopy (adjusted odds ratio (aOR) = 3.51; 95% confidence interval (CI): 1.26, 9.79 and aOR = 6.61; 95% CI: 2.63, 16.65, respectively). A doctor's recommendation was also significantly associated with receipt of a fecal occult blood test (FOBT) (aOR = 4.00; 95% CI: 1.43, 11.15). In terms of barriers, those who reported having no time and not having symptoms were less likely to have a colonoscopy (aOR = 0.15; 95% CI: 0.03, 0.82 and aOR = 0.02; 95% CI: 0.002, 0.23, respectively) than those who had time and symptoms. Preventive healthcare was often not viewed as a priority, particularly for those living the'immigrant life,' who gave precedence to work. Cultural barriers to CRC screening included language (e.g. limited English proficiency and low health literacy); fear of finding CRC and burdening the family especially children; fatalism; and stigma towards cancer.

CONCLUSIONS

Future interventions and programs aiming to increase CRC screening among Chinese and Korean Americans should address both cultural and non-cultural factors that influence CRC screening uptake.

The Effect of Educational Intervention Based on Health Belief Model and Social Support on the Rate of Participation of Individuals in Performing Fecal Occult Blood Test for Colorectal Cancer Screening

Background and Aim:

Among the screening tests for colorectal cancer, fecal occult blood test (FOBT) is important in comparison other methods due to its ease of use and low cost.The aim of this study is to survey the effect of educational intervention based on health belief model and social support on the rate of participation of individuals in performing fecal occult blood test for colorectal cancer screening among men who referred to the health centers in FasaCity, Fars province, Iran.

Materials and Methods:

In this quasi-experimental study, 200 men (100 in experimental group and 100 in control group) in FasaCity, Fars province, Iranwere selected in 2017. A questionnaire consisting of demographic information, knowledge, HBM constructs (perceived susceptibility, severity, benefits, barriers, self- efficacy and cues to action) and social support was used to measure the rate of participation of individuals in performing Fecal Occult Blood Test for colorectal cancer screening before and three months after the intervention. Data were analyzed using SPSS22 viadescriptive and inferential statistics, paired t-test, Mann-Whitney, Chi-square, and independent t-test at a significance level of 0.5.

Results:

The mean age of the men was 63.18 ± 8.25 years in the experimental group and 65.11 ± 7.66 years in the control group. Three months after the intervention, the experimental group showed a significant increase in the knowledge, perceived susceptibility, perceived severity, perceived benefits, Self-efficacy, cues to action, social support and the level of referrals (participation) of subjects for FOBTcompared to the control group.

Conclusion:

This study showed the effectiveness of HBM constructs and social support in adoption of the level of participation of subjects for FOBTin men. Hence, these models can act as a framework for designing and implementing educational interventions for undergoing FOBT.

Understanding Pediatric Caretakers' Views on Obtaining Medical Care for Low-acuity Illness

BACKGROUND

A significant proportion of low-acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low-acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers' perspectives. The objective of this study was to explore caretaker decision-making processes, values, and priorities when deciding to seek care.

METHODS

We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing.

RESULTS

Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision-making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low-acuity care was well received by caretakers.

CONCLUSIONS

Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low-acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.

Have we increased our efforts to identify strategies which encourage colorectal cancer screening in primary care patients? A review of research outputs over time

Globally, colorectal cancer (CRC) screening rates remain suboptimal. Primary care practitioners are supported by clinical practice guidelines which recommend they provide routine CRC screening advice. Published research can provide evidence to improve CRC screening in primary care, however this is dependent on the type and quality of evidence being produced. This review aimed to provide a snapshot of trends in the type and design quality of research reporting CRC screening among primary care patients across three time points: 1993-1995, 2003-2005 and 2013-2015. Four databases were searched using MeSH headings and keywords. Publications in peer-reviewed journals which reported primary data on CRC screening uptake among primary care patients were eligible for inclusion. Studies meeting eligibility criteria were coded as observational or intervention. Intervention studies were further coded to indicate whether or not they met Effective Practice and Organisation of Care (EPOC) study design criteria. A total of 102 publications were included. Of these, 65 reported intervention studies and 37 reported observational studies. The proportion of each study type did not change significantly over time. The majority of intervention studies met EPOC design criteria at each time point. The majority of research in this field has focused on testing strategies to increase CRC screening in primary care patients, as compared to research describing rates of CRC screening in this population. Further research is needed to determine which effective interventions are most likely to be adopted into primary care.

Decision-making and socioeconomic disparities in colonoscopy screening in African Americans

BACKGROUND

Socioeconomic status (SES) disparities in colorectal cancer screening are persistent. Lower education and income are both associated with lower screening rates. Both cognitive (e.g., perceived barriers) and affective (e.g., disgust, fear) decision-making constructs are known determinants of colorectal cancer screening behavior. This study tests the hypotheses that SES may be related to decision-making constructs and that this SES-decision-making construct relation may contribute to explaining the SES-screening behavior disparity.

METHOD

Surveys assessing perceived benefits and barriers to screening, self-efficacy, positive and negative affective associations with colonoscopy, fear of colonoscopy, colorectal cancer knowledge, past screening behavior, and demographics including education and income were completed by 2,015 African American participants ages 50 and older. Both univariable and multivariable relations of SES to decision-making constructs were examined, as were univariable and multivariable models of the indirect effect of SES on screening via decision-making constructs.

RESULTS

Socioeconomic status was related to both screening compliance and the decision-making constructs. Bootstrap modeling of the indirect effect showed that the total effect of the SES-screening behavior relation included an indirect effect via social cognitive decision-making constructs.

CONCLUSION

These findings suggest that cognitive and affective decision-making constructs account for at least some of the SES disparities in colorectal cancer screening behavior. As such, more research is needed to explore the intra individual-level influences of disparities in colorectal cancer screening. In addition, work is needed to develop effective intervention approaches to address the relation of SES to decision-making constructs. (PsycINFO Database Record

Faecal occult blood testing (FOBT)-based colorectal cancer screening trends and predictors of non-use: findings from the South Australian setting and implications for increasing FOBT uptake

Objective The present study used data from three South Australian population health surveys to examine trends in knowledge, recent use and reasons for use or non-use of faecal occult blood testing (FOBT) for colorectal cancer (CRC) screening from 2011 to 2014. Screening awareness and demographic factors related to non-use were also examined. Methods FOBT trends were examined for respondents aged 50–75 years across survey years (n ~ 1000). Logistic regression analyses were undertaken to determine predictors of non-use and reasons for non-use of FOBT based on latest data. Results The proportion of respondents reporting recent FOBT use has trended up, whereas the proportion reporting non-use has trended down. Awareness of screening recommendations has increased. Respondents who were aware of screening recommendations and those aged 65–69 years were significantly less likely to report non-use. The most commonly reported reasons for FOBT use were as part the national screening program or routine examination, whereas reasons for non-use were not having symptoms and doctor not advising to have the test. Conclusions FOBT screening trends are indicative of the positive effect of the continued expansion of the national screening program. FOBT uptake may be increased by addressing salient barriers, as indicated by persisting reasons for non-use of FOBT. What is known about the topic? Australia has one of the highest age-standardised incidence rates of CRC (or bowel cancer) in the world. Population screening using non-invasive stool-based FOBT was implemented in Australia in 2006 with the introduction of the National Bowel Cancer Screening Program (NBCSP). To date, the NBCSP has been extended to only a small proportion of the target population and FOBT screening rates remain well below desired levels to effect changes in CRC outcomes at the population level. There is a recognised need for more robust data on CRC screening practices to inform interventions aimed at increasing FOBT uptake, beyond the scope of the NBCSP. What does this paper add? The study provides valuable insights into trends of FOBT screening indicators over time in the South Australia, drawing on data from population state health surveys undertaken from 2011 to 2014. A particular advantage of the dataset was that it included data on reasons for use and non-use of FOBT. These data are not routinely assessed in population-level studies of FOBT uptake, although such information would be beneficial for tracking implementation of the national program and identifying salient barriers to FOBT uptake in low-participation groups. Thus, the study also describes factors related to non-use and reasons for non-use of FOBT among the target population for CRC screening. What are the implications for practitioners? Results suggest that there have been considerable shifts in community knowledge and FOBT screening participation rates from 2011 to 2014, reflecting the positive effect of the NBCSP. Reliance on physician recommendation to screen, as well as knowledge deficits related to screening frequency and the perceived relevance of screening remain prominent barriers to FOBT uptake. Recommendations for increasing FOBT uptake are made in view of salient barriers and identified segments of the population less likely to report FOBT use.

A scoping review of the potential for chart stimulated recall as a clinical research method

BACKGROUND

Chart-stimulated recall (CSR) is a case-based interviewing technique, which is used in the assessment of clinical decision-making in medical education and professional certification. Increasingly, clinical decision-making is a concern for clinical research in primary care. In this study, we review the prior application and utility of CSR as a technique for research interviews in primary care.

METHODS

Following Arksey & O'Malley's method for scoping reviews, we searched seven databases, grey literature, reference lists, and contacted experts in the field. We excluded studies on medical education or competence assessment. Retrieved citations were screened by one reviewer and full texts were ordered for all potentially relevant abstracts. Two researchers independently reviewed full texts and performed data extraction and quality appraisal if inclusion criteria were met. Data were collated and summarised using a published framework on the reporting of qualitative interview techniques, which was chosen a priori. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines informed the review report.

RESULTS

From an initial list of 789 citations, eight studies using CSR in research interviews were included in the review: six from North America, one from the Netherlands, and one from Ireland. The most common purpose of included studies was to examine the influence of guidelines on physicians' decisions. The number of interviewees ranged from seven to twenty nine, while the number of charts discussed per interview ranged from one to twelve. CSR gave insights into physicians' reasoning for actions taken or not taken; the unrecorded social and clinical influences on decisions; and discrepancies between physicians' real and perceived practice. Ethical concerns and the training and influence of the researcher were poorly discussed in most of the studies. Potential pitfalls included the risk of recall, selection and observation biases.

CONCLUSIONS

Despite the proven validity, reliability and acceptability of CSR in assessment interviews in medical education, its use in clinical research is limited. Application of CSR in qualitative research brings interview data closer to the reality of practice. Although further development of the approach is required, we recommend a role for CSR in research interviews on decision-making in clinical practice.

Testing the Effectiveness of a Primary Care Intervention to Improve Uptake of Colorectal Cancer Screening: A Randomized Controlled Trial Protocol

BACKGROUND

Screening for colorectal cancer (CRC) significantly reduces mortality associated with this disease. In Australia, the National Bowel Cancer Screening Program provides regular fecal occult blood tests (FOBT) for those aged 50 to 74 years, however, participation rates in the program have plateaued at 36%. Given low uptake in the National Bowel Cancer Screening Program, it is necessary to explore alternate methods to increase CRC screening rates. Primary care is a promising adjunct setting to test methods to increase CRC screening participation. Primary care guidelines support the recommendation and provision of CRC screening to primary care patients. Those in the National Bowel Cancer Screening Program target age range frequently present to their primary care provider.

OBJECTIVE

This study tests the effect that a multicomponent primary care-based intervention has on CRC screening uptake when compared to usual care.

METHODS

Primary care patients presenting for an appointment with their primary care provider complete a touchscreen survey to determine eligibility for the trial. Those aged 50 to 74 years, at average risk of CRC, with no history of CRC or inflammatory bowel disease, who have not had an FOBT in the past 2 years or a colonoscopy in the past 5 years are eligible to participate in the trial. Trial participants are randomized to the intervention or usual care group by day of attendance at the practice. The intervention consists of provision of an FOBT, printed information sheet, and primary care provider endorsement to complete the FOBT. The usual care group receives no additional care.

RESULTS

The primary outcome is completion of CRC screening 6 weeks after recruitment. The proportion of patients completing CRC screening will be compared between trial groups using a logistic regression model.

CONCLUSIONS

CRC screening rates in Australia are suboptimal and interventions to increase screening participation are urgently required. This protocol describes the process of implementing a multicomponent intervention designed to increase CRC screening uptake in a primary care setting.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12616001299493; https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371136&isReview=true (Archived by WebCite at http://www.webcitation.org/6pL0VYIj6). Universal Trial Number U1111-1185-6120.

Understanding type 2 diabetes mellitus screening practices among primary care physicians: a qualitative chart-stimulated recall study

Background

Early diagnosis and treatment of prediabetes and type 2 diabetes mellitus (T2DM) can prevent future health problems, yet many individuals with these conditions are undiagnosed. This could be due, in part, to primary care physicians’ (PCP) screening practices, about which little is known. The objectives of this study were to identify factors that influence PCPs’ decisions to screen patients for T2DM and to characterize their interpretation and communication of screening test results to patients.

Methods

We conducted semi-structured chart-stimulated recall interviews with 20 University of Michigan Health System (UMHS) primary care physicians. PCPs were asked about their recent decisions to screen or not screen 134 purposively sampled non-diabetic patients who met American Diabetes Association criteria for screening for T2DM. Interviews were audio-recorded, transcribed, and analyzed using qualitative directed content analysis. Data on patient demographic characteristics and comorbidities were abstracted from the electronic health record.

Results

The most common reasons PCPs gave for not screening 63 patients for T2DM were knowledge of a previously normal screening test (49%) and a visit for reasons other than a health maintenance examination (48%). The most common reasons PCPs gave for screening 71 patients for T2DM were knowledge of a previously abnormal screening test (49%), and patients’ weight (42%) and age (38%). PCPs correctly interpreted 89% of screening test results and communicated 95% of test results to patients. Among 24 patients found to have prediabetes, PCPs usually (58%) recommended weight loss and increased physical activity but never recommended participation in a Diabetes Prevention Program or use of metformin.

Conclusions

Previous screening test results, visit types, and patients’ weight and age influenced PCPs’ decisions to screen for T2DM. When patients were screened, test results were generally correctly interpreted and consistently communicated. Recommendations to patients with prediabetes could better reflect evidence-based strategies to prevent T2DM.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0623-3) contains supplementary material, which is available to authorized users.

General practitioners' perceptions of population based bowel screening and their influence on practice: a qualitative study

Background

Although largely preventable, Australia has one of the highest rates of bowel cancer in the world. General Practitioners (GPs) have an important role to play in prevention and early detection of bowel cancer, however in Australia this is yet to be optimised and participation remains low. This study sought to understand how GPs’ perceptions of bowel screening influence their attitudes to, and promotion of the faecal occult blood test (FOBT), to identify opportunities to enhance their role.

Methods

Interviews were conducted with 31 GPs from metropolitan and regional New South Wales (NSW), Australia. Discussions canvassed GPs’ perceptions of their role in bowel screening and the national screening program; perceptions of screening tests; practices regarding discussing screening with patients; and views on opportunities to enhance their role. Transcripts were coded using Nvivo and thematically analysed.

Results

The study revealed GPs’ perceptions of screening did not always align with broader public health definitions of ‘population screening’. While many GPs reportedly understood the purpose of population screening, notions of the role of asymptomatic screening for bowel cancer prevention were more limited. Descriptions of screening centred on two major uses: the use of a screening ‘process’ to identify individual patients at higher risk; and the use of screening ‘tools’, including the FOBT, to aid diagnosis. While the FOBT was perceived as useful for identifying patients requiring follow up, GPs expressed concerns about its reliability. Colonoscopy by comparison, was considered by many as the gold standard for both screening and diagnosis. This perception reflects a conceptualisation of the screening process and associated tools as an individualised method for risk assessment and diagnosis, rather than a public health strategy for prevention of bowel cancer.

Conclusion

The results show that GPs’ perceptions of screening do not always align with broader public health definitions of ‘population screening’. Furthermore, the way GPs understood screening was shown to impact their clinical practice, influencing their preferences for, and use of ‘screening’ tools such as FOBT. The findings suggest emphasising the preventative opportunity of FOBT screening would be beneficial, as would formally engaging GPs in the promotion of bowel screening.

Increasing referral rate for screening colonoscopy through patient education and activation at a primary care clinic in New York City

OBJECTIVE

Colorectal cancer could be prevented through regular screening. Individuals age 50 and older are recommended to get screened via colonoscopy. Because physician referral is a major predictor of colonoscopy completion, two low-cost, evidence-based interventions were tested to increase referrals by activating patients to self-advocate.

METHODS

This study compared the impact of a pre-visit educational handout that prompts patients to discuss colonoscopy with their physician with the handout plus brief counseling through exit interviews and chart reviews. The main outcome was physician referral.

RESULTS

Medical charts were reviewed for eligibility: 130 control patients (Arm 1), 45 patients who received the educational handout and health counseling (Arm 2), and 50 patients who received only the handout (Arm 3). Colonoscopy referral rates increased from 24.6% in Arm 1 to 44.4% and 52.0% in Arms 2 and 3, respectively (p=0.001). The proportion of exit interview participants who discussed colonoscopy with their doctor increased from 68.8% in Arm 1 to 76.5% and 88.9% in Arms 2 and 3, respectively.

CONCLUSIONS

Results indicate that both interventions are effective at increasing colonoscopy referrals.

PRACTICAL IMPLICATIONS

Results suggest that an educational handout alone is sufficient in prompting patient-initiated discussions about colonoscopy.

Barriers to Colorectal Cancer Screening in Primary Care Settings: Attitudes and Knowledge of Nurses and Physicians

Objective:

Healthcare providers (HCPs) play a critical role in reducing colorectal cancer (CRC) related morbidity and mortality. This study aimed at exploring the attitudes and knowledge of nurses and physicians working in primary care settings regarding CRC screening.

Methods:

A total of 142 HCPs (57.7% nurses and 42.3% physicians) participated in a cross-sectional survey. Data were collected using a Self-administered Questionnaire. The participants were clinically experienced (mean = 9.39 years; standard deviation [SD] = 6.13), regularly taking care of adults eligible for CRC screening (62%) and had positive attitudes toward CRC screening (83.1%). Most participants (57%) had low levels of knowledge about CRC screening (mean = 3.23; SD = 1.50). The participants were most knowledgeable about the recommended age for initiating screening (62.7%) and the procedures not recommended for screening (90.8%).

Results:

More than 55% did not know the frequency of performing specific screening procedures, the upper age limit at which screening is not recommended, and the patients at high-risk for CRC. There were no significant differences between nurses’ and physicians’ attitudes and knowledge. The participants’ perceptions about professional training (odds ratio [OR] = 2.17, P = 0.003), colonoscopy (OR = 2.60, P = 0.014), and double-contrast barium enema (OR = 0.53, P = 0.041), were significantly associated with knowledge about CRC screening.

Conclusions:

The inadequate knowledge levels among nurses and physicians may be one of the barriers affecting CRC screening. Enhancing HCPs knowledge about CRC screening should be considered a primary intervention in the efforts to promote CRC screening and prevention.

Comparison Study of Uptake of Colorectal Cancer Testing between Ethnic Minorities and the General Population in Hong Kong

BACKGROUND

Colorectal cancer (CRC) is one of the most common cancers. This study aimed to compare the uptake of CRC testing in the general public and in ethnic minorities in Hong Kong.

MATERIALS AND METHODS

This cross-sectional survey covered 2,327 South Asian and Chinese adults aged over 50, recruited from two separate studies. A structured questionnaires were administered by research staff over the telephone or in face- to-face interviews.

RESULTS

The uptake rate of CRC testing among South Asians was significantly lower than that of the general population in Hong Kong. Factors associated with the uptake rate were health professional's recommendation, perception of regular visits to doctor, use of complementary therapy, ethnicity, perceived susceptibility to cancer, presence of chronic illness, and education level. In addition, a significant interaction (p<0.05) between ethnicity and health professionals' recommendations was found, after adjustment for the main independent factors identified.

CONCLUSIONS

Older people with lower educational attainment, without chronic illness and those have lower perceived susceptibility to cancer may be targeted for CRC testing promotion in the society. In addition, health professionals can play a highly influential role in promoting such testing, particularly among ethnic minorities.

Acceptability of Physician Directed Academic Detailing to Increase Colorectal Cancer Screening: an Application of the RESPECT Approach

BACKGROUND

In developing effective interventions to increase colorectal cancer (CRC) screening in at risk populations, a necessary first requirement is feasibility. This paper describes how the RESPECT approach to health education guided the conceptualization and implementation of physician-directed academic detailing (AD) to increase practice-wide CRC screening uptake.

METHODS

Physician-directed AD was one intervention component in a large educational randomized controlled trial to increase CRC screening uptake. Study participants, primarily urban minority, were aged 50 or older, insured for CRC screening with no out-of-pocket expense and out of compliance with current screening recommendations. The trial was conducted in the New York City metropolitan area. Participants identified their primary care physician; 564 individuals were recruited, representing 459 physician practices. Two-thirds of the physician practices were randomized to receive AD. The RESPECT approach, modified for AD, comprises: 1) Rapport, 2) Educate, but don't overwhelm, 3) Start with physicians where they are, 4) Philosophical orientation based on a humanistic approach to education, 5) Engagement of the physician and his/her office staff, 6) Care and show empathy, and 7) Trust. Feasibility was assessed as rate of AD delivery.

RESULTS

The AD was delivered to 283 (92.5%) of the 306 practices assigned to receive it; 222/283 (78.4%) delivered to the doctor.

CONCLUSION

The AD was feasible and acceptable to implement across a range of clinical settings. The RESPECT approach offers a framework for tailoring educational efforts, allowing flexibility, as opposed to strict adherence to a highly structured script or a universal approach.

Colorectal cancer screening at community health centers: A survey of clinicians' attitudes, practices, and perceived barriers

Objective

Colorectal cancer (CRC) screening rates remain lower among some racial/ethnic groups and individuals with low income or educational attainment who are often cared for within community health centers (CHCs). We surveyed clinicians in a network of CHCs to understand their attitudes, practice patterns, and perceived barriers to CRC screening.

Methods

A clinician survey was conducted in 2013 within the Community Health Applied Research Network (CHARN).

Results

180 clinicians completed the survey (47.9% response rate). Participants had an average of 11.5 (SD: 9.8) years in practice, 62% were female, and 57% were physicians. The majority of respondents somewhat agreed (30.2%) or strongly agreed (57.5%) that colonoscopy was the best screening test. However, only 15.8% of respondents strongly agreed and 32.2% somewhat agreed that colonoscopy was readily available for their patients. Fecal immunochemical testing (FIT), a type of fecal occult blood test (FOBT), was viewed less favorably; 24.6% rated FIT as very effective.

Conclusions

Although there are no data showing that screening colonoscopy is superior to FIT, CHC clinicians believe colonoscopy is the best CRC screening test for their patients, despite the high prevalence of financial barriers to colonoscopy. These attitudes could be due to lack of knowledge about the evidence supporting long-term benefits of fecal occult blood testing (FOBT), lack of awareness about the improved test characteristics of FIT compared to older guaiac-based FOBT, or the absence of systems to ensure adherence to regular FOBT screening. Interventions to improve CRC screening at CHCs must address clinicians' negative attitudes towards FIT.

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We surveyed primary care clinicians in a nationwide network of Community Health Centers.

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The vast majority believed that colonoscopy was the best screening test for colorectal cancer.

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However, less than half agreed that colonoscopy was readily available for their patients.

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Fecal occult blood testing was viewed far less favorably than colonoscopy.

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These attitudes and barriers must be overcome to improve screening and reduce disparities.

How many individuals will need to be screened to increase colorectal cancer screening prevalence to 80% by 2018?

BACKGROUND

A recent study estimates that 277,000 colorectal cancer (CRC) cases and 203,000 CRC deaths will be averted between 2013 and 2030 if the National Colorectal Cancer Roundtable goal of increasing CRC screening prevalence to 80% by 2018 is reached. However, the number of individuals who need to be screened (NNS) to achieve this goal is unknown. In this communication, the authors estimate the NNS to achieve 80% by 2018 nationwide and by state.

METHODS

The authors estimated the NNS by subtracting adults aged 50 to 75 years who would need to be screened to achieve an 80% CRC screening prevalence from the number who are currently guideline-compliant from population estimates for this age group. The 2013 National Health Interview Survey and the 2012 Behavioral Risk Factor Surveillance System were used to estimate CRC screening prevalence and data from the US Census Bureau were used to estimate population projections. The NNS were age-standardized and sex-standardized.

RESULTS

Nationwide, 24.39 million individuals (95% confidence interval, 24.37-24.41 million) aged 50 to 75 years will need to be screened to achieve 80% by 2018. By state, the NNS ranged from 45,400 in Vermont to 2.72 million in California. The majority of individuals who need to be screened are aged 50 to 64 years and the largest subgroup is privately insured.

CONCLUSIONS

The authors estimated that at least 24.4 million additional individuals in the United States will need to be screened to achieve the National Colorectal Cancer Roundtable goal of increasing CRC screening prevalence to 80% by 2018. To reach this goal, improving facilitators of CRC screening, including physician recommendation and patient awareness, is needed.

Racial and Ethnic Disparities in Colonoscopic Examination of Individuals With a Family History of Colorectal Cancer

BACKGROUND & AIMS

Guidelines recommend that persons with a high-risk family history of colorectal cancer (CRC) undergo colonoscopy examinations every 5 years, starting when they are 40 years old. We investigated factors associated with colonoscopy screening of individuals with a family history of CRC, focusing on race and ethnicity.

METHODS

In a retrospective study, we analyzed data from the 2009 California Health Interview Survey on persons 40-80 years old with a first-degree relative (mother, father, sibling, or child) with CRC who had visited a physician within the past 5 years. Our study included an unweighted and population-weighted sample of 2539 and 870,214 individuals with a family history of CRC, respectively. We performed a survey-weighted logistic regression analysis to adjust for relevant demographic and socioeconomic variables and used estimates to calculate relative risks and 95% confidence intervals (CIs) for colonoscopy examination within the past 5 years.

RESULTS

In the weighted sample, 60.0% of subjects received a colonoscopy within the past 5 years. A physician recommendation for CRC screening increased the odds that an individual would undergo colonoscopy examination (relative risk, 1.89; 95% CI, 1.61-2.24). Latinos were 31% less likely to receive colonoscopies than whites (95% CI, 7%-55%). Among individuals 40-49 years old, blacks were 71% less likely to have had a colonoscopy than whites (95% CI, 13%-96%).

CONCLUSION

On the basis of an analysis of data from the California Health Interview Survey, less than two-thirds of individuals with a family history of CRC reported receiving guideline-recommended colonoscopy examinations within the past 5 years. We observed racial and ethnic disparities in colonoscopy screening of this high-risk group; Latinos and blacks were less likely to have had a colonoscopy than whites.

Characterizing Online Narratives About Colonoscopy Experiences: Comparing Colon Cancer "Screeners" Versus "Survivors"

Effective screening can reduce colorectal cancer mortality; however, screening uptake is suboptimal. Patients' stories about various health topics are widely available online and in behavioral interventions and are valued by patients. Although these narratives may be promising strategies for promoting cancer screening behavior, scant research has compared the influence of different role models. This study involving content analysis of online stories aimed to (a) describe the content of online experiential narratives about colonoscopy; (b) compare narratives from individuals who had a colonoscopy and either had colon cancer (survivors) or did not have colon cancer (screeners); and (c) generate hypotheses for future studies. The authors identified 90 narratives eligible for analysis from 15 websites. More stories were about White patients, men, and routine (vs. diagnostic) colonoscopy. A higher-than-expected number of narratives reported a family history of colorectal cancer or polyps (20%) and a colorectal cancer diagnosis (47%). Colorectal cancer survivor (vs. screener) stories were longer, mentioned symptoms and diagnostic reasons for getting a colonoscopy more often, and described the colonoscopy procedure or referred to it as easy or painless less often. Future studies should examine the effects of the role model's personal characteristics and the colonoscopy test result on reader's perceptions and intentions to have a colorectal cancer screening.

Heterogeneous demographic and cultural profiles of Chinese American patients nonadherent to colorectal cancer screening: a latent class analysis

BACKGROUND

Colorectal cancer (CRC) is one of the leading causes of cancer death in Chinese Americans, but their CRC screening rates remain low.

OBJECTIVE

We examined subgroups of Chinese American patients nonadherent to CRC screening guidelines to better inform clinical practices to effectively promote screening.

METHODS

Using latent class analysis of data from 327 participants recruited from 18 primary care clinics, we classified nonadherent patients based on sociodemographics, screening barriers, and attitudinal and clinical factors for CRC screening.

RESULTS

The best-fitting latent class analysis model described 3 distinctive classes: Western healthcare class (36%), Eastern healthcare class (18%), and mixed healthcare class (46%). Western healthcare class patients were highly educated, with average US residency of 20 years, a high level of English proficiency, the least Eastern cultural views of care, and the greatest exposure to physician recommendations, but reported having no time for screenings. Eastern healthcare class patients were highly educated seniors and recent immigrants with the least CRC knowledge and the most Eastern cultural views. Mixed healthcare class patients had low level of education, resided in the United States for 20 years, and half had sought services of their physicians for at least 3 years, but their knowledge and cultural views were similar to those of Eastern healthcare class patients.

CONCLUSIONS

Nonadherent Chinese American patients are heterogeneous. It is essential to have future intervention programs tailored to address specific screening beliefs and barriers for subtypes of nonadherent patients.

IMPLICATIONS FOR PRACTICE

Training primary care physicians to recognize patients' different demographic characteristics and healthcare beliefs may facilitate physicians' communication with patients to overcome their barriers and improve screening behaviors.

Colorectal Cancer Identification Methods Among Kansas Medicare Beneficiaries, 2008-2010

Introduction

Population-based data are limited on how often colorectal cancer (CRC) is identified through screening or surveillance in asymptomatic patients versus diagnostic workup for symptoms. We developed a process for assessing CRC identification methods among Medicare-linked CRC cases from a population-based cancer registry to assess identification methods (screening/surveillance or diagnostic) among Kansas Medicare beneficiaries.

Methods

New CRC cases diagnosed from 2008 through 2010 were identified from the Kansas Cancer Registry and matched to Medicare enrollment and claims files. CRC cases were classified as diagnostic-identified versus screening/surveillance-identified using a claims-based algorithm for determining CRC test indication. Factors associated with screening/surveillance-identified CRC were analyzed using logistic regression.

Results

Nineteen percent of CRC cases among Kansas Medicare beneficiaries were screening/surveillance-identified while 81% were diagnostic-identified. Younger age at diagnosis (65 to 74 years) was the only factor associated with having screening/surveillance-identified CRC in multivariable analysis. No association between rural/urban residence and identification method was noted.

Conclusion

Combining administrative claims data with population-based registry records can offer novel insights into patterns of CRC test use and identification methods among people diagnosed with CRC. These techniques could also be extended to other screen-detectable cancers.